WO2009000854A1

WO2009000854A1 - Surgical instrument

Info

Publication number: WO2009000854A1
Application number: PCT/EP2008/058078
Authority: WO
Inventors: Tahar Benhidjeb
Original assignee: Tahar Benhidjeb
Priority date: 2007-06-25
Filing date: 2008-06-25
Publication date: 2008-12-31
Also published as: DE102007029162A1

Abstract

The invention relates to a surgical instrument for a specific surgical procedure, especially the transoral resection of the thyroid.

Description

Surgical instrument

I. Field of application

The invention relates to a device and a surgical procedure for the gentle operation of, for example, the thyroid gland, the parathyroid gland, the salivary gland, the lymph nodes and other organs located in the same region.

II. Technical background

In surgery there is a general trend to make the surgical procedures as comfortable as possible for the patient, especially in the postoperative period, and to minimize the lasting effects on the patient, the patient's inpatient stay as far as possible for cost reasons and minimize the time and, if possible, the investment on the part of the surgeon / hospital as low as possible.

Since thyroid surgery is one of the most common operations in Germany, the following invention will be described using the example of thyroid surgery without limiting the invention thereto. In the past, after thyroid surgery was primarily performed via a cervical approach, most recently minimally invasive and video-assisted by the so-called MIVAT method, various extracervical approaches via the axilla and thoracic wall were introduced to avoid even these small scars in the anterior cervical region.

In order to create a sufficient operating room, gas insufflation, in particular CO ₂ insufflation, was already required.

The disadvantage, however, was that it was not possible to operate on both thyroid lobes at the same time, at least for the axilla access.

Access is via two skin inlays in the areolae mamma on both sides, and a third trocar parasternal right in the region of the mammary fold or infraclavicular. The latter incessions are still cosmetically unfavorable because they are visible.

Only the combined axilla and chest access - the latter exclusively via Areolae mammae - solved this problem, but the disadvantage of this so-called ABBA technique is a limitation to node sizes up to about 30 mm, wide access paths, etc.

IN THE. Presentation of the invention

a) Technical task

It is therefore the object of the invention to provide an operating device and an operating method which, despite short access paths, is subject to low operational restrictions and leaves no visible visible scars in the visible region. b) Solution of the task

This task is solved by a surgical procedure and a suitable surgical device in tube form, which penetrates through the anterior floor of the mouth to the thyroid gland, possibly even further.

Advantageous embodiments will be apparent from the dependent claims.

As is the case with many invasive procedures, a demanding step in the operation is the advance of the instrument to the surgical area.

To prepare for the operation, the patient is first positioned with both arms in the supine position, fixed and subjected to nasotracheal intubation anesthesia, and an endotracheal electrode tube is also placed for neuromonitoring.

In particular, the longitudinal axis of the oral cavity, the pharynx and the larynx is adjusted by raising the head in a common axial direction. Of course, before starting the operation, the usual disinfection, in this case the oral cavity.

In the present case, this penetration must be carried out with a tubular, but bendable, surgical instrument, the front end of which is formed blunt, for example, hemispherical.

The procedure is as follows:

First, a small incision is made at the level of the caruncula subungualis to open access to the floor muscles. This is then penetrated with a blunt aid, with which the muscle strands are each pushed aside to create the necessary passage space. Likewise, with a blunt instrument, in particular a separator of the skin muscle, which has advanced in front of the camera, is then advanced subplatysmal along the superficial fascia and thereby further in the direction of the suprasternal space, for example to the jugulum.

In this created penetration space, an endoscope cone (trocar) is first used so that it ends with his front end until just before the larynx.

When inserting the endoscope cone and therefore also in the previous preparation of the floor muscles and the Platysma care should be taken that this is strictly centered between left and right.

Subsequently, the surgical device is advanced with its front blunt end through the endoscope cone and pushed from the front end only by a few inches and then more and more and then started with the CO ₂ insufflation to increase the available work space.

The surgical device is advanced until it protrudes from the front end of the endoscope cone so far that the front articulation point of the body is pushed out of the front end of the endoscope cone for what a marker on the back of the end of the surgical device is present, which can be z. B. pushes to the rear end of the endoscope cone or a local countermark. Subsequently, the bending of the front region of the base body of the surgical device at the first joint point by about 20 to 40 degrees after, but this can be done only after the CO ₂ insufflation.

After the base body of the surgical device is located with its front end in the operating area, the main body with respect to a fixed point outside the patient, preferably at the operating table, both in terms his Vorschublage, the rotational position about its longitudinal axis and the bending position of its two joints fixed and - if this was not done before the insertion of the body - now more the individual instruments inserted into the guide channels of the body until they are right in the front end lie the base body or protrude from this.

It is important to ensure that the vocal cord nerve is not damaged during this process and also during the further advance.

Subsequently, with the help of the anterior blunt end of the operating device, the suprasternal tissue in the spatium is forced apart and the skin muscle is also detached from the straight neck muscles, from the region of the larynx to the interclavicular ligament. This must be up to Mm laterally. Sterocleidomastoideae take place.

In this way, a sufficiently large action space is created and the linea alba colli is thus visible, serves as a guide and can be bypassed with the surgical equipment.

This happens until the optionally present second joint of the main body is pushed out of the front end of the endoscope cone, and after the central region of the main body with respect to the rear region around this second joint by 20 to 30 degrees in the direction of the side and possibly even down was bent.

If there is only a first anterior joint, work continues forward.

The removal of the thyroid itself is then carried out with the following steps:

First, the dissection scissors of the ultrasonic scissors from the front end of the body pushed forward and thus the Mm. sternohyoideus as also the Mm. sternothyreoideus and also the trachea made visible by the linea alba colli is severed.

This is done partly by blunt, partly also sharp separation with the help of the section scissors, until the thyroid itself comes to light.

Subsequently, the connection of the two thyroid lobes is severed with the dissection scissors and the flap to be removed is cut free with the necessary separation of the gland proximal to the esophagus.

Depending on the scope, only a resection of the individual nodes to be removed or a subtotal current selection takes place.

Subsequently, the upper pole vessels are exposed and severed, as well as the Kocher side vein and the branches of the A. thyreoidea inferior. After the recurrent laryngeal nerve has been demonstrated, the actual thyroid resection occurs.

After completion of the resection, a check for dryness of blood is first carried out and, if appropriate, a drainage in (through one of the guide channels of the body or past the body) the thyroid lodge laid and transorally led out by the body is withdrawn after laying the drainage in their relative position to the body of the patient remains. This will usually be removed after about 24 hours.

The straight neck muscles are again brought together by means of a continuous suture and an absorbable suture, and the access incision in the area of the caruncula subungualis is also closed, preferably by suturing or by gluing. This operation is thus carried out with an operating device which, in contrast to the conventional gastroscope, not only allows sampling in addition to the observation of the field of view, but contains all necessary instruments for the operation, which in particular individually displaceable, possibly pivotable about a joint and actuated and also supplementary assistance such as irrigation and the like offers.

Such a tubular surgical device comprises a tubular base body by extending in the longitudinal direction of the main body guides, which are in particular spatially separated and / or circumferentially closed guide channels are located with the longitudinally displaceable instruments therein. The cross sections of the instruments, in particular the shanks of the instruments, are matched to the cross sections of the guide channels so that the instruments are guided by the respective guide channel in a form-fitting manner exactly in all transverse directions.

The surgical device further comprises a target device for deflecting the front end of the main body from the normal position and a fixing device for fixing the main body both in terms of the deflection of the pivot about the longitudinal axis and in terms of the axial feed position in the patient with respect to a fixed point, the located outside the patient and near the rear end of the body, in particular a fixation point on the operating table.

The front end face of the tubular operating device is convexly convex, in particular hemispherical. The outer surfaces of the main body including the front end faces consist of a non-porous, disinfectable material, in particular an antiseptic material.

The instruments can be pulled out of the guide channels of the body completely, in particular to the rear, so that the body then cleaned in the guide channels, disinfected and thus can be reused.

According to the necessary outer diameter of the individual instruments or other services such as rinsing, which must provide or accommodate the channels of the body, the diameter of the guide channels may be different. The channels preferably open in the front end face of the main body, however, special channels, such as the channel for insufflation, can end back from the front end of the end face in the lateral surface of the main body.

The main body itself has at least one, but better two joints in the course:

The optionally second joint is located approximately in the middle region of its longitudinal extension and is a one-dimensional joint, thus allowing the pivoting of the two adjacent regions of the base body only about a transverse axis and preferably only in one deflection direction.

The first, front joint is set back 2 cm to 3 cm from the front end of the body and is a three-dimensional joint, thus allowing the pivoting of the body about two intersecting, in particular perpendicular to each other, transverse axes, preferably in both directions of deflection.

The main body has a total length of at least 40 cm, better 45 cm or even 50 cm, and a maximum diameter of 20 mm, more preferably only 15 mm.

The first joint is pivotable by up to +/- 20 to 40 degrees, better up to 10 to 60 degrees with an accuracy of +/- 3 °, better +/- 2 °. The optional second joint +/- 15 degrees, better +/- 25 degrees.

In most of the guide channels of the body operating instruments are longitudinally displaceable insertable to use them leaked from the front end of the body in the operating area can. With regard to the axial position, rotational position with respect to the base body as well as in their deflection with respect to their own joints, the instruments or their shanks are fixable.

The following instruments are located in one of the guide channels of the basic body and are components of the surgical device:

A scissors instrument, in particular in the form of an ultrasonic dissecting scissors, that is to say with mechanical scissors and an integrated sclerosing instrument, which is made possible by applying electric current to the metallic scissors or a separate sclerosing head,

a clamping instrument comprising a clamp for clamping vessels, - a spatula instrument with a spatula for holding vessels or other parts of a suction irrigation instrument with a suction-irrigation tube, which is extendable from the corresponding guide channel and in the front end and in particular kinks has an integrated electrode at the front end of the flushing tube as a coagulation instrument.

In addition, for example, a channel for the gas is used to inflate the operating area and to create better room and visibility. The outlet opening of this channel can also be in the side wall, ie in the lateral surface of the body shortly before the front end, preferably on both sides. Another channel contains a cold light exit at the front end of a light instrument. The light instrument can be arranged axially displaceable or axially fixed in the corresponding channel, in the latter case then the cold light outlet at the free end of the guide channel.

A retractable from the guide channel and pivoting light instrument allows lighting, especially behind shadows that would otherwise be accepted by obstacles.

The light source is preferably attached to the rear end of the light instrument, ie outside the rear end of the base body and thus the patient and the light is transported to the front end of the light instrument via optical fibers routed in the shaft of the light instrument.

Combined in the same guide channel and in particular to form a common instrument is an optical instrument, that is to say an eyepiece, for viewing the space in front of the front end of the basic body. This optical instrument can either be arranged longitudinally in the guide channel and end at the front end thereof, or be a tubular optical instrument which can be pushed out of the front end of the guide channel and can also be pivoted laterally with the front region.

The optical instrument includes a wide-angle lens that either covers the entire surgical area or has a smaller viewing angle, and then looks in a direction different from the longitudinal direction. The optical instrument must then be rotatable about its longitudinal axis, preferably by a full 360 °.

Likewise, a guide channel contains a special Spülrohrinstrument exclusively for cleaning the optics and possibly even the light exit, so that the rinsing direction of the outlet opening of the Spülrohrinstrumentes either always directed to the optics and / or the light exit or at least can be directed there.

The rinsing tool for the optics and the general suction irrigation instrument can also be functionally combined.

Preferably, the optical instrument is duplicated, and the two optical instruments have the greatest possible distance from each other to mimic the three-dimensional view of the human eye, at the rear end for the two optical units each having an eyepiece, which corresponds to the distance of the human eyes ,

In order to imitate the three-dimensional vision of the human eyes, the two optical instruments can preferably be brought beyond the diameter of the base body to a distance which approximates the distance of the human eyes, wherein in this spaced position the two optical instruments are parallel, ie in the same direction, can look.

This can be achieved, for example, by the two optics from the front ends of their guide channels are pushed forward and then about two joints Z-shaped pivotally, so that each of the ends of the optical instruments is in each case outside the diameter of the body.

The actual instruments each sit on an instrument shaft, which essentially passes through and bridges the length of the main body, that is to say the guide channels.

Therefore, the rear region of the shaft can preferably be made flexible, in particular with limited flexibility, in order to be able to move the shanks over the joints. ke with kinked body away through the guide channels to push.

The front portion of the instrument shaft, in particular about 5 cm to 10 cm or 15 cm, however, must preferably be designed rigid and in this rigid front region at least one joint must be arranged to the up beyond this joint out pushed end of the instrument outside to pivot the body.

Depending on the instrument, two-dimensional or three-dimensional joints (ie pivoting about one or two transverse axes) are required. Preferred is a one-dimensional joint with pivoting in even only one deflection direction to keep the joint small.

The lengths from the instrument joint to the front end are 3 cm to 5 cm, while the length of the instrument shaft still rigid beyond the instrument joint is 2 cm to 5 cm or 10 cm, with which the instrument shaft should still sit in the guide channel of the body ,

The instrument joints allow a pivoting from the normal position in one direction by at least 50 °, better 70 °, better 80 °.

The shafts of the instruments project from the rear end of the main body.

There they run diagonally apart, so that at the rear ends of the shafts sufficient space for actuating the handles, which are arranged at the rear ends of the shafts and with which the surgeon operates the instruments. Alternatively, the shafts of at least 10 cm to 25 cm may be of different lengths, so that they are at the same far advanced front end, the rear handles are offset in the longitudinal direction to each other so far that they can easily grip the surgeon without mutual interference.

So that the individual instruments can be quickly and easily fixed in the position in which the surgeon once brought them, there is either an automatic locking device on each instrument which holds the instrument - again with regard to feed position, rotational position relative to the basic body, as well in terms of kinking of the joint or joints - fixed in the position that was last taken.

This can be done automatically by releasing the handle by the surgeon. In another case, an activation of the locking device is necessary, for. As a switch or button in the grip area of the hand of the instrument located hand of the surgeon.

In a preferred embodiment, the guide channels in the longitudinal direction offset from one another in the front, patient-side end of the main body 2 open, in part before and partly behind the front joint of the body.

c) embodiments

Embodiments according to the invention are described in more detail below by way of example. Show it:

1: the operating area,

2: the supply of the surgical device,

Fig. 3: the surgical instrument in different views. Figures 1 and 2 show the insertion and operation area 50 of the patient lying as it is adjusted on the operating table 21.

As described, the head is bent so far back that leads from the insertion point 7 to the operation area 50 as straight as possible within the body.

2, the operating device 1, which has the shape of a long thin rod or tube, is already in the operating position, so that it is in contact with the front, located in the patient end 1 a inside the patient, in the operating area 50, close to the organ to be operated, in this case the shield nozzle 53, located in front of the thyroid 53, while the rear end 1 b of the operating device 1 from the oral cavity 51 of the patient is located.

In FIG. 2, for reasons of simplification, only the basic body 2 of the operating device is shown, through which the individual instruments are inserted from the rear end 1 b, as will be explained with reference to FIGS.

FIG. 1b shows the oral cavity 51 of the patient with the mouth open and the tongue bent backwards, as they are fixed for the duration of the operation.

In this case, the penetration point 7 is marked centrally at the front end of the floor of the mouth 52, ie near the inside of the lower jaw in its middle area.

FIG. 1 c shows a cross-section through the patient's body in the operating region, ie approximately at the level of the thyroid gland 53.

From the point of penetration 7, in FIG. 2, the point at which the rear end 1b of the operating device 1 protrudes from the floor of the mouth 52, the operating system works. teur as described with the front end 1 b of the surgical instrument 1 first through the tissue of the floor and then the digastricus behind the jawbone past forward and then between the trachea and platysma further forward in the patient down until the operation unit 1 with his in the front end of the Base body 2 so close to or in the operating area 50, here the area around the thyroid gland 53, is that the instruments 5a, b, which are pushed forward from the front end 2a of the main body 2, are the organ to be operated on, in this case the thyroid gland 53 , reachable.

Ideal here is a position of the front end 2a just above or in front of the thyroid 53.

FIG. 2 also shows that, for the operation of further organs located in this region or somewhat deeper in the patient, the surgical device 1 also continues to move, for example. B. past the thyroid gland 53 could be pushed under the breastbone in order to achieve and operate under the breastbone lying organs and bodies.

As the cross section of Figure 1 shows c, the thyroid gland 53 is disposed on both sides of the air tube, so that under certain circumstances for resection of these two lobes of the thyroid 53, the front end of the surgical device 1, ie in particular the base body 2, in its position in each case corresponding side must be changed.

In the figures 3 the used operating device 1 is shown:

Such a surgical device 1, as shown in the overall view in Figure 3a in the side view, comprises on the one hand a tubular or tubular body 2 (which is shown individually in Figure 3b) in the interior in the longitudinal direction 10 extending a plurality of parallel and preferably separate guide channels 9a, b ... are present, as best seen in the cross-sectional view of Figure 3c. These guide channels have front and rear freely ending openings in which they open in the front end 2a and the rear end 2b of the tubular or tubular body 2.

As a result-as shown in FIG. 3a-thin, rod-shaped or shaft-shaped instruments 5a, b, the outer diameter of which is smaller than the inner diameter of the respective guide channel 9a, b, inserted from the rear end 2a, b in the base body 2 and through the entire guide channel 9a, b pushed so far forward that the front end of the respective instrument 5a, b projects from the front end 2a of the body and can be operated there in the operating area.

In order to be able to accurately position the front, patient-side end 2a of the base body 2 in the operating region, the basic body 2, which is otherwise substantially rigid about transverse axes, has at least one joint 6b, which is set back only about 2 cm to 5 cm from the front end 2a , while optionally further back, approximately in the central region of the length of the entire body 2, another joint 6a may be located.

Preferably, four guide channels 9a to d are located inside the generally circular cross-section of the main body 2, and not more so as to keep the diameter of the main body as small as possible, preferably less than 15 mm, as shown in FIG. 3c.

In principle, any operating device can be introduced at any time in each of the guide channels 9a to d at any time, provided that it has the correspondingly small diameter, which can also be changed at any time during the operation, that is to say while the main body 2 is partly inserted in the patient , For the purposes of the thyroid resection described in this application, preference is given to the following instrumentation:

The four channels need not each have the same diameter.

Shown is a solution in which in cross section through the guide tube according to Figure 3c in the cross arranged cross sections of the four guide channels 9a to d three of which, 9a to c, each having a diameter of 5 mm and the fourth channel 9d has a diameter of 3 mm ,

The assembly would then look like this:

In the channel 9a the combined cold light / camera instrument, in a second channel 9b only the scissors instrument, in particular the ultrasonic scissors, or optionally also a hook instrument, depending on current needs.

In the channel 9c a terminal instrument and in the channel 9d a suction device, in particular a Bipolarsauger and thus integrated flushing instrument, in turn, depending on the respective current need in the operating area.

Alternatively, an additional separate flushing channel in the base body 2 may be present.

The assignment of the instruments 5a, b ... in the cross section of the base body 2 is preferably chosen so that the suction instrument or the irrigation instrument the light / optical instrument are opposite and also lying at right angles to and opposite each other, the mechanically acting instruments, So scissors, hook, clamp instrument.

FIG. 3 a shows that each of the instruments 5 a, b protrudes with its shaft 22 out of the front end 2 a of the main body during use, to such an extent that the in each case in the front end region of the shank 22 instrument joint 8 is already before, that is outside of the front end 2a of the base body 2, so that the bendable front end 5 'of each of the instruments 5a, b is bent separately as needed by the surgeon.

This is controlled by the at the rear end of each shaft 22a, b arranged handles 23a, b, which serve the guidance and operation of the instrument by the surgeon.

The handles are as ergonomically as possible with a handle opening 56 for the four fingers of a hand without the thumb and a thumb opening 57 opposite the thumb, which must be moved by the surgeon against each other to operate the scissors / clamp, or one other function of the corresponding instrument.

In the handle also a dial 58 can be seen, by the rotation of the deflection of the front end 5 'of the corresponding instrument from the longitudinal axis of the shaft 22 is adjusted.

Also, the forward sliding or retraction of the respective shaft 22 and thus of the instrument 5a, b relative to the base body 2 by means of the respective handle 23 which is fixed axially fixed to the rear end of the respective shaft 22a, b and is rotatably attached thereto, so in that the handles 23, which project radially away from the extension of the shaft, rotate the instrument about its shaft longitudinal axis by rotation about the shaft longitudinal axis.

In this way, the handles can also be radially abstrebend with respect to the center of the body 2 in different directions - alternatively or in addition to the axial offset from each other, as seen in Figure 3a - to actuate the individual handles by the surgeon possible without mutual interference to carry out. In a preferred embodiment, the guide channels in the longitudinal direction offset from one another in the front, patient-side end of the main body 2 open, in part before and partly behind the front joint of the body.

Thus, Figure 3d shows a design in which the opposite guide channels 9a and 9d open in the foremost end face at the front end of the base body 2, which has in its front region for its purpose a narrower, for example oval, cross-section.

The other two, lying on a transverse axis to channels 9b, 9c open the other hand, offset backwards in a corresponding paragraph or bevel, over which the narrower front cross-section of the body 2 in the normal, z. B. round, cross section of the body 2 passes.

The front joint 8b is located in the front narrow cross-sectional area of the main body 2, so that it moves only the two local channels 9a and 9d, while in the other two channels 9b, 9c outstanding instruments - which are not shown in Figure 3d - are not affected by such a pivot.

LIST OF REFERENCE NUMBERS

1 operating device

C _Is 1 a front end

1 b rear end

2 main body

2a, b front / back end

Side wall

3 target device

4 front face

5a, b instrument

5 ¹ front end

6a, b joint

7 penetration point

8 instrument joint

9a, b guide channels

10, 10 'longitudinal direction

11 a, b transverse direction

12 light instrument

12a light emission

13 optical instrument

14 rinsing pipe instrument

14a flushing pipe

14b outlet opening

15 scissors instrument

16 clamp instrument

17 spatula instrument

18 suction flushing instrument

18a suction rinsing pipe

19 outlet opening

20 fixed point

21 operating table 22 shaft

22a, b front / rear area

23 handles

24 locking device

50 operating room

51 oral cavity

52 floor of the mouth

53 thyroid

54 larynx

55 vocal cord nerve

56 handle opening

57 thumb opening

58 setting wheel

59

60 endoscope cone

Claims

1. An endoscopic tubular operating device (1) for transoral operations, comprising a tubular base body (2) in which guides extending in the longitudinal direction (10), in particular spatially separate guide channels (9a, b), with individual instruments guided therein ( 5a, b), - a target device (3) for deflecting the front end of the main body from the normal position and fixing the base body (2) both in terms of deflection as the rotational position about the longitudinal axis, and the axial feed position with respect to a fixed point (20) outside the patient (2b) near the rear end of the base body (2), - wherein the front end face (4) of the base body (2) convex convex, in particular hemispherical rounded, and the outer surface of the base body (2) including the front end face (2a) of a non-porous, disinfectable material, in particular an antiseptic material, best ht.

2. Operating device according to claim 1, characterized in that the guide channels (9 a, b) circumferentially closed and to the side of the base body (2) are not open.

3. Operating device according to one of the preceding claims, characterized in that the channels (9a, b) have different diameters.

4. Operating device according to one of the preceding claims, characterized in that each instrument (5a, b) in the appropriate diameter with respect to the channel (9a ...) in the base body (2) in the longitudinal direction (10 ') moves to the Längsach - (10) rotated and its from the front end face (2a) of the base body (2) projecting end (5 ') from the longitudinal direction (10') of the instrument (5a ..) can be deflected.

5. Operating device according to one of the preceding claims, characterized in that each of the instruments (5a ...) in terms of axial position, rotational position and deflection from its normal longitudinal direction (10 ') fixable, in particular relative to the basic body (2) can be fixed.

6. Operating device according to one of the preceding claims, characterized in that the deflection of the or the front regions relative to the further back region of the base body (2) to defined joints (6a, b) takes place, of which one or more at defined axial positions are arranged in the basic body (2).

7. Operating device according to one of the preceding claims, characterized in that the base body has a first hinge point (6a) in the central region of its longitudinal extension and a second hinge point (6b) 2 cm to 3 cm from the front end (2a) of the base body (2) set back.

8. Operating device according to one of the preceding claims, characterized in that the first articulation point (6a) in the central region allows pivoting about only one transverse axis (11a) and / or the second articulation point (6b) allows a Pivoting of the base body (2) by two intersecting, in particular perpendicular to each other, transverse axes (11a, b) allows.

9. Operating device according to one of the preceding claims, characterized in that the stationary point (20) outside the patient is a stationary point on the operating table (21).

10. Operating device according to one of the preceding claims, characterized in that the base body (2) has a length of at least 40 cm, better at least 45 cm or even 50 cm, and has a diameter of a maximum of 20 mm, more preferably 15 mm.

11. Operating device according to one of the preceding claims, characterized in that the second joint (6a) in the central region of the base body (2) a deflection of up to +/- 20 ° to 40 °, in particular 10 ° to 60 °, allows a fine adjustment of +/- 3 °, in particular +/- 2 °.

12. Operating device according to one of the preceding claims, characterized in that the base body (2) contains at least the following instruments:

A cold light outlet (12a), in particular xenon light emission, at the front end of a light instrument (12), in particular extendable beyond the front end of the base body (2), in particular with built-Antinebelpumpe,

An optical instrument (eyepiece) (13) for viewing the space in front of the front end (2a) of the base body (2), in particular the front end of an optical instrument (13) and in particular advanceable over the front end (2a) of the base body (2 ), a Spülrohrinstrument (14) for cleaning in particular optics (13) and light outlet (12a), in particular in the form of one of the longitudinal channels (9a) of the base body (2) or as a separate in the longitudinal channel (9a) guided, vorschiebbares tube, - a scissors instrument ( 15), in particular a Ultraschalldissektionsschere consisting of scissors and integrated Verödungsinstrument using the electrical application of the scissors, a clamping instrument (16), a spatula instrument (17), - a suction flushing instrument (18) with a suction-flushing pipe (18) , in particular with integrated bipolar electrode at the front end of the flushing tube (18a) as Koagulationsinstrument, a channel for gas insufflation, in particular CO ₂ insufflation, in particular with an outlet opening (19) in the side wall (2 ') of the base body (2) yet in front of the front end (2a) of the main body (2), in particular laterally on both sides.

13. Operating device according to one of the preceding claims, characterized in that the light instrument (12) and the optical instrument (13) in the base body (2) in the longitudinal direction (10) fixed, but at most rotatable about its longitudinal direction (10 ') are arranged ,

14. Operating device according to one of the preceding claims, characterized in that two separate optical instruments (13a, b) with the greatest possible distance from each other on or in the base body (2) are present, in particular laterally movable beyond the cross-sectional area of the base body (2) and yet looking in the same direction.

15. Operating device according to one of the preceding claims, characterized in that the instrument shafts (22), sit on the front ends of the actual instruments, in its front region (22a) are formed rigid with an instrument joint (8) in the front region and the adjoining rear region (22b) of the shanks (22) is at least limitedly flexible, in particular so flexible that the instrument shafts can be inserted through the basic body (2) already bent at the joint points.

16. Operating device according to one of the preceding claims, characterized in that the length of the instrument in front of the instrument joint (8) to the front end is 3 cm to 5 cm and / or the length of the front, stable region of the instrument behind the instrument joint (8 ) Is 2 cm to 5 cm.

17. Operating device according to one of the preceding claims, characterized in that individual instruments, in particular the optical instrument (13), in particular the two optical instruments (13a, b) have two longitudinally spaced Instrumenten joints (8a, b), in particular in each other opposite directions for generating a Z-shaped crank are pivotable.

18. Operating device according to one of the preceding claims, characterized in that the instrument joints (8) are pivotable about only one transverse axis (11).

19. Operating device according to one of the preceding claims, characterized in that the pivoting of the aligned normal position of the instrument joints by at least 25 °, better at least 35 °, better at least 45 ° is possible.

20. Operating device according to one of the preceding claims, characterized in that the flushing pipe (14a) of the Spülrohrinstrumentes (14) for the optics (13) and the light exit (12) with its opening directly on the optical instrument (13) and the light exit (12a ), in particular the flushing pipe (14 a) for this purpose has a lateral outlet opening (14 b) and is not rotatable in its guide channel, but only axially displaceable, in particular longitudinally displaceable, in particular in the front end of the base body (2).

21. Operating device according to one of the preceding claims, characterized in that the shafts (22) from the rear end (2b) of the base body (2) protrude and run apart there at an angle to provide space on the individual shafts for handles (23). for actuating the instruments located at the front ends of the shafts (22).

22. Operating device according to one of the preceding claims, characterized in that the instruments (12, 13 ...) can be pulled out completely from the main body (2) and can be inserted from there, even in the case of kinked joints (6a, b ) of the main body (2).

23. Operating device according to one of the preceding claims, characterized in that the handles (23) at the rear end of the shafts (22) are designed so that

24. Operating device according to one of the preceding claims, characterized in that the handles (23) comprise a locking device (24), by means of which the feed position, rotational position and buckling position of the respective instrument is fixed in the current position and the locking device (24) in particular either automatically locked when the handle (23) is released or activated is arranged by the actuated an actuating element, in particular a pressure switch in the grip area, in particular of the user's thumb on the handle (23).

25. A method for operating in particular the thyroid, the parathyroid gland, the salivary gland and the lymph nodes, characterized in that the access to the surgical area (50) through the oral cavity (51) and the floor of the mouth (52) through a single tubular or tubular O. - Perationsgerätes done.

26. The method according to claim 25, characterized in that the penetration to the surgical area (50), in particular to the thyroid gland (53) with the following steps: small incision at the level of the caruncula subungualis, blunt preparation of the floor muscles, blunt preparation of the subplatysmal along the fascia colli superficialis in

Direction Spatium suprasternale, - Introduce the operating device (1) through an endoscope cone (60) to just before the larynx (54),

CO ₂ insufflation especially with a pressure of 4-6 mm Hg, dull distention of the connective tissue in the suprasternal space, - blunt detachment of the platysma from the straight neck muscles from cranial (larynx) to caudal (interclavicular ligament) and lateral (Mm. Sternocleidomastoideae) .

Creation of a sufficiently large room and representation of the Linea alba colli.

27. The method according to any one of the preceding claims, characterized in that during insertion of an endoscope cone (60) is used as a cavity through the floor muscles through the base body and in particular the endoscopic cone is placed strictly centrally (between left and right).

28. The method according to any one of the preceding claims, characterized in that the operation itself is carried out with the following steps: - the preparation begins with a dissection scissors, in particular an ultrasonic dissecting scissors,

Entered by Linea alba coli and representation of the Mm. sternohyoideus et sternothyreoideus, as well as the trachea, partly blunt, partly sharp separation of the Mm. sternohyoideus et sternothyroidus until the thyroid gland emerges,

Dissection of the insthmus and dissection of the affected lobe from cranial to caudal with successive thyroid-like severing of the sprouting vessels, depending on size and strategy, node resection or subtotal struma resection,

Presentation and transection of the upper pole vessels, presentation and transection of Kocher's lateral vein, presentation and ligature of the inferior artery, depiction of the recurrent laryngeal nerve, - Intraoperative neuromonitoring via the recurrent laryngeal nerve, in particular with the 5 mm probe, thyroid-like subtotal resection from cranial to caudal, specimen recovery, in particular by gripping with clamp and retracting the surgical device together with the preparation.

29. The method according to any one of the preceding claims, characterized in that for the preparation of operations, the following steps are carried out:

Surgical positioning of the patient with both arms outstretched, - nasotracheal intubation anesthesia with an endotracheal electrodentube for neuromonitoring,

The longitudinal axis of the oral cavity, pharynx and larynx are adjusted by raising the head in a common axis direction, disinfecting the oral cavity with a mucous membrane disinfectant.

30. The method according to any one of the preceding claims, characterized in that the following steps are carried out for operation follow-up:

Control of dryness of blood and insertion of a drainage, especially drainage of 8 in the thyroid box, which is led out transorally,

Approximation of the straight neck muscles by means of continuous suture (3x0, resorbable),

Mucosa suture in the area of the caruncula subungualis, removal of the drainage after 24 hours.