Tissue is traditionally grasped with forceps
or a rigid suction head (upper left corner). To reduce suction
pressure required for tissue attachment, we developed
devices with flexible sealing clamps (lower left corner). Less
suction pressure relates to less tissue injury while the
tissue remains more firmly and securely attached. An electronic device is
available for monitoring secure tissue attachment. When the
device is turned, e.g. by 90°, the tissue is lifted, i.e.
AttachLifter. This approach is used for accessing the normal
pericardial sac, where the pericardium is very close to the
underlying epicardium and where there is a high risk of
puncturing the epicardium with the inherent risk of fatal
pericardial tamponade, i.e. the risk inherent in the
conventional needle technique.
The devices can be used stand-alone or in a working
channel of an endoscope. The applications are manifold.
Pericardial access for
pericardiocentesis, epicardial ablation, stem cell
delivery and intrapericardial therapy
Currently, the example of pericardial access is described
in detail. The pericardium is lifted away from the
epicardium using a suction head with flexible clamps
followed by insertion of a needle into the pericardial
cavitiy. Without the flexible clamps, turning of the
suction head can be associated with loss of vacuum due to
the irregular tissue structure of the pericardium with
subsequent failure of accessing the pericardial cavitiy.
pericardial effusion and intrapericardial drug therapy
implantation for cardiac resynchronization therapy (CRT)
Intrapericardial procedures for
cardiac regeneration by stem cells.
Need for minimal invasive
access (AttachLifter) to the normal pericardial cavity.
(available as personal copy to Heinz Rupp)
H. Rupp, T.P. Rupp, P. Alter, N. Jung, S. Pankuweit, B.
In view of the only modest functional and anatomical
improvements achieved by bone marrow-derived cell
transplantation in patients with heart disease, the question
was addressed whether the intracoronary, transcoronary-venous,
and intramyocardial delivery routes are adequate. It is
hypothesized that an intrapericardial delivery of stem cells
or activators of resident cardiac stem cells increases
therapeutic benefits. From such an intrapericardial depot,
cells or modulating factors, such as thymosin β4 or Ac-SDKP,
are expected to reach the myocardium with sustained kinetics.
Novel tools which provide access to the pericardial space even
in the absence of pericardial effusion are, therefore,
described. When the pericardium becomes attached to the
suction head (monitored by an increase in negative pressure),
the pericardium is lifted from the epicardium
(“AttachLifter”). The opening of the suction head (“Attacher”)
is narrowed by flexible clamps which grab the tissue and
improve the vacuum seal in the case of uneven tissue. A ridge,
i.e.,“needle guidance”, on the suction head excludes injury to
the epicardium, whereby the pericardium is punctured by a
needle which resides outside the suction head. A fiberscope
can be used to inspect the pericardium prior to puncture.
Based on these procedures, the role of the pericardial space
and the presence of pericardial effusion in cardiac
regeneration can be assessed.
Fixation point for flexible
The flexible clamps provide also a long sought tool for
providing a fixation point required in all endoscopy work. The
fixation point providing a stable operating environment
is one of the advantages of rigid endoscopy but is absent in
conventional flexible endoscopy. The stable
operating environment is particularly important for
intra-luminal surgery where surgery is performed with an
endoscope inserted through a natural body orifice (NOTES).
This aspect has been pointed out e.g. in "Stabilizing
for the performing of endoscopic surgical procedures".
Some stabilization can be
provided by pushing the side of the endoscope against the body
conduit or gastrointestinal wall, but this technique does not
adequately allow a surgeon to manipulate the tissue of an
internal body lumen to perform precise surgical procedures. A
fixation point is essential for intra-luminal surgery using an
endoscope because, without it, the risks of inadvertent
perforation, uncontrolled bleeding, and unacceptable surgical
margins are high. A fixation point can be provided by the
suction head(s) with flexible clamps. For example, biopsy of
the stomach wall or other manipulation as part of a NOTES
procedure can be performed after fixation of the device (e.g.
AttachGuider) with flexible clamps. In the most simple
approach, the device has a "working channel" with a
conventional flexible endoscope with small diameter which
after fixation is used for the tissue manipulation. Without a
suction head with flexible clamps, the conventional endoscope
could not be properly positioned. It appears that the suction
head with flexible clamps according to Rupp et al. provides a
major breakthrough in flexible endoscopic surgery.
A possible application
is also in Transanal Endoscopic Microsurgery (TEM) which is a
minimally invasive technique for the local resection of rectal
tumours. TEM was developed in 1983 by Professor Dr. Gerhard
Buess in Tuebingen, Germany and is used now worldwide,
e.g. in over 100 US sites. For details on the procedure, see Burghardt
and Buess G, Floyd
and Saclarides TJ or Dana R
While in TEM the size of the suction head is not critical, a
smaller size is required for a regular endoscope when the
suction head is within the working channel or remains outside
and is used "in tandem" with the endoscope (as described in
principle for our AttachGuider). Irrespective of the design,
the suction head could also be used for biopsy or resection of flat polyps or adenomas
Resection, EMR). Very flat polyps can be impossible to snare and
even after submucosal saline injection cannot be snared.
Currently, there are at least two approaches available: a
snare which can dig into the mucosa such as the barbed snare
or the "cap with suction" technique. Using a cap with
suction (see e.g. Fig.
of ERBE), flat polyps can be grasped, lifted and snared.
The advantage of the AttachLifter device over conventional
vacuum grabbers is the greater grasping force despite a lower
suction pressure. The flexible clamps have a sealing function,
thereby preventing loss of vacuum when uneven tissue is
attached to the head. The tissue grabbing is not lost when the
suction head is slightly tilted since the captured tissue is
kept within the suction head also by mechanical forces, i.e.
tissue is "behind" the sealing clamps and cannot easily
"escape" from behind the sealing clamps.
Upcoming applications for the
AttachLifter in gynecology
removal of uterine fibroids)
Transurethral resection of the prostate
has been taken to protect the claims from possible
competition from other technologies (including
inferior ones). Inlicencing enquiries are welcome. The
patent applications can be downloaded as PDFs: Attacher.pdf,
covering aspects of the AttachLifter and AttachGuider
covering aspects of the AttachGuider:
covering aspects of the AttachLifter:
The AttachLifter and associated devices have
been developed at the Department of Internal Medicine
and Cardiology of the Heart Center and the Technical
Development Plant of the Medical Center
and Medical Faculty of the Philipps
The team involved
in the production of the AttachLifter and related
devices: Prof. Dr. Heinz Rupp, Prof. Dr. Bernhard
Maisch, Dr. Thomas P. Rupp MD
Rupp, Michael Koch, Ekkehard Schüler, Hermann Schön.
application and marketing is in cooperation with TransMIT
works at the interface between universities and
businesses. TransMIT assists scientists in protecting
their inventions and provides assistance in the marketing of
technologies and developments. For information on the patent of the
AttachLifter and follow-up devices, please contact Dr. Peter Stumpf, Managing
Director, TransMit or Heinz Rupp.
on the AttachLifter and other devices, please contact Heinz
For information on
the use of the AttachLifter in general surgery, please contact
Dr. Thomas P. Rupp, M.D.
Copyright © 2008 H. Rupp