MXPA99007599A - Extracorporeal pneumoperitoneum enclosure and method of use - Google Patents

Abstract

Surgical apparatus for providing extracorporeal pneumoperitoneum. One embodiment provides a reversely-turned fluid and gas impermeable fingerless sleeve (14) with a quick connect and disconnect assembly around the cuff of the sleeve (14) for sealing around an abdominal incision to allow hand-assisted minimally invasive surgery under conditions of pneumoperitoneum. A dome-shaped enclosure (62) is provided for use with the quick connect and disconnect assembly to seal around an abdominal incision and maintain pneumoperitoneum during interruptions in a surgical procedure. Another embodiment incorporates a fingerless sleeve (14) which is adhesively secured directly to a patient's skin around an incision. The sleeve is applied over a pre-gloved surgeon's hand, and an outer surgical glove (18) is applied over the sleeve (14) in the region where the fingers and thumb protrude before the sleeve (14) is reversely turned on itself for connection to a patient.

Description

COVER OF THE EXTRACORPORAL NEUMOPERITONEOUS AND METHOD OF USE FIELD OF THE INVENTION The present invention relates generally to an apparatus and method suitable for maintaining the extracorporeal pneumoperitoneum in an abdominal fenestration during surgery, and more particularly to a quick connect and disconnect cover and method for insertion of instruments or a hand of the surgeon within the body cavity through a fenestration to access the organs and instruments inside the cavity without the loss of insufflation pressure.

BACKGROUND OF THE INVENTION Laparoscopy and endoscopy have become a preferred surgical procedure since it does not invade the patient's body greatly and, in many cases, can be performed in facilities for rapid procedures with minimal trauma and a significantly reduced recovery time. In some cases, a new procedure has been used in relation to manually assisted laparoscopy or endoscopy, in which a small incision is made in muscle separation long enough to allow the surgeon's hand inside the abdominal cavity to allow palpation of organs and manipulation of surgical instruments, and to provide biophysical feedback. Visual feedback is usually provided through an endoscope and a television monitor. Many medical devices have been developed, which makes it possible to carry out assisted laparoscopy manually in the abdominal cavity although under pneumoperitoneum conditions. A device, for example, of Patrick F. Leahy and others described in Patent Application E.U.A S.N. 08 / 300,346 issued March 29, 1995 (International Application PCT / US95 / 04202 published October 29, 1995) provides a gas-tight sleeve that communicates with the abdominal cavity through an incision allowing the hand of the surgeon access through the entry and exit openings at opposite ends of the sleeve. The outlet opening is sealed around the incision by means of a flange adhesively attached to the external surface of the abdomen. After the hand is passed through the entry opening, the sleeve is sealed around the surgeon's forearm by means of an adjustable cuff. A duckbill check valve positioned between the inlet and outlet openings forms with the outlet opening a substantially gas-tight chamber that allows the surgeon to withdraw his hand from the insufflation cavity with only a slight decrease in gas pressure which can be restored quickly.

Another device described in the patent E.U.A. 5,480,410 to Cuschieri et al. Provides a gas-tight cover in which a flexible ring in an outlet opening is compressed by the hand into an oblong shape for insertion through the abdominal incision, subsequently allowing it to extend to its original shape under the edge of the incision to seal the peritoneum and cover for insufflation. At least one entry opening is provided for passing an instrument or the surgeon's hand to the cover. The cover may also include a surgical glove integrally sealed to the entry opening in a glove-box manner to allow sterile access of the surgeon's hand through the exit opening to the organs and instruments within the abdominal cavity. However, none of these devices satisfies the need for such a gas-tight cover that can be quickly disconnected and reconnected as often as needed during manually assisted laparoscopic or endoscopic surgery while the cover remains sealed in place around the surgeon's hand, and may maintain abdominal pneumoperitoneum during extended interruptions in an operation for other medical procedures.

OBJECTS OF THE INVENTION Accordingly, it is an object of the present invention to provide a cover of the gas-tight extracorporeal pneumoperitoneum used by the surgeon during manually assisted laparoscopic or endoscopic surgery, which can be rapidly disconnected from the patient as often as needed during the course of the operation. and reconnect while remaining sealed around the surgeon's hand, allowing the surgeon to manipulate or palpate organs and instruments from the inside of the abdominal cavity, and what provides biophysical feedback from the surgeon's hand under pneumoperitoneum conditions. Another object of the invention is to provide a surgical apparatus that can be continuously sealed around the hand and forearm of the surgeon and selectively connected around an open wound while maintaining the pneumoperitoneum during the course of a manually assisted laparoscopic or endoscopic operation, and that it will keep the pneumoperitoneum within the body cavity during any interruption for any other medical procedure during the course of an operation. A further object of the invention is to allow a surgery with a minimum of invasion, with a minimum of risk or damage to the immune system, and with a shorter healing time and with less recovery time in a hospital. A further object is to provide an available surgical device that is relatively simple in design and easy to use.

BRIEF DESCRIPTION OF THE INVENTION More specifically, in one embodiment, the cover of the extracorporeal pneumoperitoneum is a fluid and an elongate, gas-free fingers sleeve having an open proximal end and a distal end with holes placed to seal the base of the surgeon's thumb gas tightly. and each of the fingers. The intermediate ends of the sleeve section are reversed on themselves before their proximal end fits either directly or indirectly, on the patient's skin around the incision. Preferably, a quick connect and disconnect assembly at the proximal end of the sleeve is gas tightly sealed to the skin around an incision allowing the surgeon to interrupt and resume a manually assisted laparoscopic surgical procedure under pneumoperitoneum conditions as often as It is required without removing the sleeve of your hand. Along with the quick disconnect and connection assembly is a pressure release valve to prevent over insufflation. At least one instrument port is provided in the fist to admit, without loss of gas pressure, surgical instruments. In another embodiment of the extracorporeal pneumoperitoneum sheath, a hemispherical sheath impermeable to gas and fluid is hermetically sealed to the gas around the incision. A quick connect and disconnect assembly with an integral pressure release valve is secured around an open base to keep the abdominal cavity insufflated during interruptions in an operation. This modality also includes an instrument port capable of being sealed. The lower and upper stacking rings in both embodiments of the quick connect and disconnect assembly have mating interfaces respectively that allow the sleeve and jacket to be interchangeable without removing the lower stasis ring previously attached to the patient. The method for using the apparatus in a manually assisted laparoscopic operation is as follows. A lower stagnation ring of the quick connect and disconnect assembly is adhered to the patient's skin around the place where a muscle separation incision is made through the abdominal wall and the peritoneum. A wound liner and retractor can be inserted into the incision to protect the wound from contamination and expand to facilitate access. When using an inner surgical glove, the surgeon inserts his hand in the sleeve without fingers until the fingers extend completely through the holes and seal tightly around their bases. For further precaution against spillage, an outer surgical glove is then placed over the inner glove and sleeve without fingers. Later the sleeve is reversed on itself. An upper sealing ring of the quick connect and disconnect assembly is then connected around the glove grip in a sealable manner to the lower stacking ring and the abdomen and glove blown to the desired pressure either through a separate cannula or a port in the glove. The surgeon can then insert or remove his hand from the abdominal cavity as often as necessary during the laparoscopic procedure. The port on the sleeve allows the instruments to be inserted as often as required. Any increase in insufflated gas pressure, caused by a sudden reduction in volume when the hand is inserted, is prevented by the pressure release valve in the quick disconnect and connection assembly. Each time the surgeon wishes to interrupt a surgical procedure while holding the pneumoperitoneum, the sleeve is disconnected from the lower stacking ring, and instead the dome-shaped envelope with the upper stacking ring is connected to the stagnation ring lower than the left in the abdomen and the insufflation is restored. Other objects, advantages and novel features of the invention will be apparent from the following detailed description of the invention when considered in conjunction with the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS Figure 1 is an elevational view and a partial cross-section of a cover of the extracorporeal pneumoperitoneum or sleeve, in accordance with one embodiment of the invention, as applied in laparoscopically assisted manual surgery in the abdomen; Figure 2 is a perspective view of various components of the sleeve, or cover, of Figure 1 placed separately for assembly; Figure 3 is a more detailed view, partly in cross section, of a segment of a connection and disconnection assembly shown in the cover of Figure 1; Figure 4 is a cross-sectional view like Figure 3 but the assembly shown is partially disconnected; Figure 5 is a cross-sectional view of a top stagnation ring of the sleeve, or cover, taken along line 5-5 of Figure 2; Figure 6 is a plan view of the lower stacking ring with an integral safety valve; Figure 7 is a cross-sectional view of an instrument port shown in the cover of Figure 1; Figure 8 is a view of the instrument port of Figure 7 seen from inside the cover of Figure 1; Figure 9 is a view in elevation and partial cross section of an extracorporeal pneumoperitoneum cover according to another embodiment of the invention as applied during the interruption of a surgical procedure.

Figure 10 is a perspective view of a cover, or sleeve, similar to the embodiment of Figure 1, but using a simplified connection and disconnection assembly; and Figure 1 1 is a partially sectioned elevational view showing the cover, or sleeve, of Figure 10 reversed and in use in an operating position.

DETAILED DESCRIPTION Referring now to the drawings, Figure 1 illustrates an extracorporeal pneumoperitoneum cover 10 according to the invention applied to the anterior abdominal wall W of the patient. A surgeon's hand extends into the abdominal cavity through the small muscle separation incision that is protected against contamination of the wound by a wound guard / retractor 12 as described in US Pat. 5,524,644 to Berwyn M. Crook. In a preferred embodiment, the cover 10 includes a flexible sleeve impermeable to the elongate gas 14 of sufficient length to receive the surgeon's hand and forearm. The sleeve 14 has an intermediate section extending from the cuff section of the proximal end 14a to a section of the "fingerless" distal hand 14b where it ends with holes 15 positioned to receive the full length of the surgeon's thumb and fingers for sealing the sleeve tightly around the root of each of these as shown in Figure 2. As best seen in Figure 2, the sleeve 14 has an inner side 14c that faces outwardly in Figure 1 since , in use, the section of the middle fist is reversed, or reversed on itself, so that the interior faces outwards. An inner surgical glove 16, placed in direct contact with the hand, is located near the inner side 14c and an outer surgical glove 18, positioned to be secured against spills in the holes 15, covers an outer side 14d. Therefore, the distal end portion 14b of the sleeve 14 is sandwiched between the inner and outer surgical gloves 16 and 18 respectively and thereby secured in place. Sleeve 14 is made of a surgical grade flexible transparent material and a side designed to seal around the fingers of a small hand but will also tightly fit under deformation of plastic with residual elasticity to accommodate larger hands without contracting the circulation of the fingers. A suitable material is the 2 mm thick polyethylene film like the X-2000 from Pierson Industries. The preferred diameters of the holes 15, in centimeters, are the following: The thumb 2.49, the index 2.01, the middle finger 2.21, the annular 1.91 and the little finger 1.60. In the embodiments of Figures 1-9, an annular quick connect and disconnect coupling means assembly is permanently sealed around the proximal end of the cuff section 14a and removably sealed with an adhesive 22 to the skin. around the protector / retractor 12. With reference to Figures 3-6, the coupling assembly 20 includes interconnected upper and lower stagnation rings 20a and 20b, preferably molded by a slightly flexible thermoplastic rubber of medical grade of hardness 80A Shore as Santoprene® made by Advanced Elastomer Systems. The upper ring 20a defines an annular collar 24 permanently sealed around the periphery of the section of a cuff 14a with an upwardly facing annular sphere 26 concentrically positioned around the collar 24. The lower ring 20b includes an annular flange 28 having a adhesive 22 to secure the ring 20b to the skin of a patient during surgery. A removable strip (Fig.2) covers the adhesive until the ring is applied to the skin of the abdomen. A preferred adhesive is IT8-59-A from Tolas Health Care Packaging of Feasterville, Pennsylvania. An annular member 32 sealed around its lower part to the flange 28 extends upwards and terminates in an annular downwardly-directed groove 33 formed to interfere with a seal with the sphere 26 of the upper ring 20a. An annular latch 34 extends radially from the sphere 26 and is split in two within an annular groove 36 on the inner surface of the member 32 when the sphere 26 and the slot 33 are engaged as shown in Figure 3. The pull tabs 38 that extend inwardly from the cylinder 24 allow the surgeon's fingers to push the latch 34 inward and disengage it from the slot 36, thereby releasing the upper ring 16a of the lower ring 20b as shown in Figure 4. The ring lower 20b further includes a normally closed gas pressure release valve 40 for limiting increases in pressure in the abdominal cavity such as could be caused when the surgeon inserts his hand and displaces the sleeve 14. Valve 40 comprises an integrally molded seat 42 in the periphery of the lower ring 20b, a layer 44 a bar valve 46, and a helical spring 48. The layer 44 is secured to the ring 16b by rotating it about the cylindrical axis until the tabs 43a at the lower edge engage with the slots 43b around the seat 42. An opening 44a in the upper part of the cover 44 guides the shank 46a of the piston 46 within the seat 42 thus as also serves as a passage for the release of insufflation gas through the valve 40. The spring 48, around the rod 46a between the top of the lid 44 and the head 46b of the piston 46, diverts the valve 40 to a normally closed position. A recess 43 in the surface below the seat 42b forms a channel 47 with the flange 28 to communicate continuously between the valve 40 and the abdominal cavity when the lower stasis ring 20b adheres to the surface of the abdomen. If the pressure of the cavity exceeds a safety limit for the pneumoperitoneum, such as for example 30 mm Hg, the piston 46 rises from the seat 42 against the force of the spring 48 to release the gas to the ambient atmosphere. The construction materials for the lid 44 and the piston 46 are preferably thermoplastic polycarbonate of hardness 80C Shore. Figures 10 and 1 1 illustrate simplified annular assembly means 70 for securing the sleeve 14 directly to a patient. The assembly 70 includes an annular flange 72 of flexible plastic permanently heat sealed or bonded around the proximal end of the cuff section of the sleeve 14a. An adhesive 74 is covered on the underside of the flange 72 to be applied either directly to the patient's skin, or to a surgical fold, around the incision site. The complementary peel strips 76 around the respective halves of the flange cover the adhesive until the glove is ready to join the skin or fold. A protrusion, which can be mounted either in the pressure relief valve 40, as previously described, or provide a sealed instrument port 50, as will be described later, can be provided in the sleeve 14 adjacent the proximal end as shown in FIG. shown in Figure 10. A preferred material for flange 72 is a 4 mm plastic sheet of EVA / Surlyn® / EA, and a preferred adhesive is IT8-59-A supra. The sleeve 14 includes an instrument port 50 located near the proximal end of the cuff section 14a to provide an optional entry into the abdominal cavity for instruments such as fasteners, clippers, clip appliers, extensions, etc. With reference to Figures 7 and 8, port 50 includes a general cylindrical housing 52 with a flanged base 52a at one end secured to inner side 14a of fist section 14b the other end defines a cone-shaped wall 52b tapering along its conical axis within the housing to a circular hole 54 at the small end which is measured to slidably receive an instrument without spillage. A duckbill check valve 56 prevents pressure loss when no instrument is present in port 50. This comprises a flanged base 56a at one end secured to the inner part of housing 52 adjacent wall 52b. The other end tapering to a normally closed slot 56b separated below the hole 54 in a plane transverse to the conical axis of the wall 50b. The housing 50 and the insert 52 have sufficient flexibility for the wall 50b to form a gas-tight seal around the surface of the instrument and to ensure that the slot 56a closes tightly after the instrument is removed. A suitable material found for this purpose is a thermoplastic rubber molded as Santoprene® by Advanced Elastomer Systems. Figure 9 illustrates an alternative embodiment of an extended pneumoperitoneum cover 60 in accordance with the invention for use in the glove cover 10 place during interruptions in surgery conducted under pneumoperitoneum conditions. This comprises a hemispherical dome-shaped cover 62 of a thin transparent flexible polyethylene film and an upper stagnation ring 64 of similar construction as the upper stagnation ring 20a. The perimeter in the open base is sealed around the upper stacking ring 64 and is interconnected with the lower stacking ring 20b of the assembly 20. Obviously, the cover 60 may also include its own lower stagnation ring as used in Figures 10 and 11 of the embodiment. Access by means of surgical instruments is provided by an instrument port 66, similar port 50, secured to cover 62. A method according to the invention for performing manually assisted abdominal laparoscopic surgery using the extended pneumoperitoneum covers as described previously they will be described now. The place to make the incision is drawn precisely on the abdomen of the patient. In the embodiment of Figures 1-8, the stagnation ring 20b and the sleeve 14 are preferably separated from the upper stacking ring 20a and placed on the surgeon's hand before the ring 20a is attached to the abdomen to provide a view free clear of the layout. The release strip 30 covering the adhesive 22 in the lower ring 20b is removed and the ring adheres to the abdomen around the trace. Following the route, a small incision of muscle separation is made through the wall of the abdomen sufficient in size to allow the surgeon's hand to pass through it. The peritoneum affects approximately the same amount. The wound liner and retractor 12 are installed in the incision to protect the wound from contamination and expand to facilitate access by hand. The wall of the abdomen and peritoneum should also be punctured in other locations to receive an insufflator, a laparoscope, and other instruments. By using an inner surgical glove 16, the surgeon puts on the sleeve 14 by placing his hand inside the section of the fingerless hand 14b until the thumb and fingers extend completely through the holes 15 and are comfortably sealed in this. The section of the cuff 14a and the upper ring 20a (or assembly 70 of Figure 10) extend over the forearm exposing the outer side 14d of the fingerless section 14a. For additional protection against spills around the holes 15, an outer surgical glove 18 is preferably placed over the exposed finger portions of the inner glove 16 and the hand section 14a. If preferred, the surgeon can put on the sleeve 14 and join it to the lower ring 20b before making the incision in the abdomen. The sleeve 14 is subsequently reversed on itself with the reversed cuff section 14a and the upper annulus 20a is sealed in the lower annulus 16b by pressing the sphere 26 into the cavity 33 until the latch 36 of the upper ring 20a is break in two inside the groove 36 of the lower ring 20b. The abdominal cavity and annular cover formed by sleeve 14 can now be insufflated at the desired pressure either through a separate cannula or through port 50 in sleeve 14. The surgeon's hand thus covered subsequently enters and returns to enter the abdominal cavity as often as necessary during surgery without loss of pneumoperitoneum. Any increase in insufflation gas pressure, caused by a reduction in volume within the chamber formed by the sleeve surrounding the surgeon's forearm when the hand is inserted, is released by the pressure relief valve 40. A Extended interruption in a surgical procedure while still maintaining the pneumoperitoneum, the sleeve 14, attached to the upper stacking ring 20a, can be disconnected leaving in its place the lower stacking ring 20b. The dome-shaped roof 62, attached to the upper stacking ring 64, can subsequently be connected to the lower stacking ring 20b and restore insufflation. Of course, when the embodiment of Figures 10 and 11 is used, the surgeon should put on the sleeve 14, as described above, the peel-off strips 76 of the adhesive 74 and place the flange directly on the skin or surgical crease around the site. of incision after the wound liner and the retractor 12 were installed. Some of the many advantages and novel features of the invention will now be apparent. For example, a cover of the extracorporeal pneumoperitoneum that can be used continuously by the surgeon during manually assisted laparoscopic surgery under pneumoperitoneum conditions without loss of free movement and finger movement is provided. This allows the surgeon to quickly disconnect and reconnect the patient's cover when it remains stopped in his hand. An alternative modality provides a dome-shaped cover that can be replaced by the sleeve at any time that a prolonged interruption in a surgical procedure is necessary. This allows minimal invasive surgery to be performed and a minimal risk of damage to the patient's immune system. Due to the smaller incisions, a short healing time and a much shorter recovery time in the hospital is possible. The covers are also relatively simple in design and easy to use. It will be understood, of course, that various changes in the details, materials, steps and arrangements of the parts that have been described herein and illustrated to explain the nature of the invention may be made by those skilled in the art within the principles and scope of the invention as expressed in the appended claims.

Claims (34)

NOVELTY OF THE INVENTION CLAIMS

1. An apparatus for use in the provision of an extracorporeal pneumoperitoneum around a surgical incision in a patient, comprising: an elongate flexible sleeve (14) having a distal end portion (14b) to cover the hand of a surgeon, a portion intermediate to cover the forearm of the surgeon, and a proximal portion (14a) having an extreme opening that allows the introduction of the hand and forearm of the surgeon, and means for releasably and gas tightly securing said extreme opening of the portion proximal (14a) to the patient around the surgical incision and allowing said intermediate portion to reverse in order to extend along the surgeon's forearm when said sleeve (14) is operatively secured to the patient and insufflated.

2. An apparatus according to claim 1, further characterized in that said distal portion (14b) of said flexible sleeve (14) has a plurality of openings (15) for receiving the fingers and thumb of a surgeon.

3. An apparatus according to claim 2, further characterized in that said sleeve (14) is formed of a flexible plastic that molds, but does not fit continuously, around the bases of the fingers and thumb when the cover is installed and the surgeon's hand is closed.

4. An apparatus according to claim 3, further characterized in that said plastic material is a polyethylene film.

5. An apparatus according to claim 2, further characterized in that the diameters of said openings (15), in centimeters, are the following: thumb 2.49, index 2.01, middle finger 2.21, annular 1.91 and little finger 1.60.

6. An apparatus according to claim 1, further characterized in that said sealing means gas-tight (20) of the proximal end include ring means connected to said sleeve (14) and adapted to be adhesively secured to the patient around the incision.

7. An apparatus according to claim 6, further characterized in that said ring means include an annular base (20b) adhesively secured to the patient and an annular ring (20a) releasably coupled with said base (20b).

8. An apparatus according to claim 7, further characterized in that said annular ring (20a) coincidentally engages and internally said base (20b) in a gas-tight relationship therewith.

9. An apparatus according to claim 7, further including a pressure relief valve (40) carried by said annular base (20b) to release high pressures above about 30 mm Hg.

10. An apparatus according to claim 7, including a closure (60) having an annular ring (64) releasably engageable with said base (20b) providing a selective sealed connection thereto of said sleeve (14) or of said closure (60). 1.

An apparatus according to claim 10, further characterized in that said closure (60) includes a flexible hemispherical dome (62) covering said base ring (20b).

12. An apparatus according to claim 11, further characterized in that said closure (60) includes a port (66) having an internally open duck bill check valve (56) that provides passage of a surgical instrument within of the closure (60).

13. An apparatus according to claim 2, including an outer surgical glove (18) applied on said hand of a surgeon after being operatively inserted into the distal portion (14b) of said sleeve and through said openings. (15) to ensure the sealed closure of said openings (15).

14. An apparatus in accordance with Claim 13, which includes an interior surgical glove (16) placed in the surgeon's hand inwardly adjacent to the said distal sleeve portion (14b) for cooperating with the outer surgical glove (18) for sandwiching said distal sleeve end (14b) therebetween.

15. An apparatus for preventing overinflation of a body cavity during endoscopic surgery using a flexible sleeve (14) having an end portion (14a) sealingly and operaty connected to a patient around an incision and another end portion (14b) connected in a sealable and operatway to a surgeon, the apparatus comprises: a pressure release valve (40) having a gas communication inlet with the interior of said sleeve (14) and having an outlet to the ambient atmosphere, and means for bypassing said valve (40) in a closed position normally blocking the flow from the inlet to the outlet until a predetermined pressure level is reached within said sleeve (14), whereby overinflation can be prevented over the body cavity during the endoscopic surgical movements of the surgeon.

16. An apparatus according to claim 15, further characterized in that said pressure relief valve (40) includes a base (20b) that is releasably connected to the patient in proximity to the incision.

17. An apparatus according to claim 16, further characterized in that said base (20b) is formed integrally with a ring surrounding said incision and is adhesively insurable to the patient.

18. - An apparatus according to claim 15, further characterized in that said predetermined pressure is less than about 30 mm Hg.

19. An apparatus according to claim 17, including a closure (60) having a self-sealing instrument port (66), said closure (60) is releasably coupled to said ring (20b) to provide a coupling selective of said closure (60) or said sleeve (14) on said ring (20b).

20. An apparatus according to claim 15, further characterized in that said flexible sleeve (14) has an intermediate portion inversely turned on itself to form an annular chamber of variable volume around the surgeon's forearm.

21. An apparatus for providing an extracorporeal pneumoperitoneum around a surgical incision, comprising: a flexible gas impermeable cover (14) having a proximal section (14a) defining a proximal end opening, a distal section (14b) with holes (15) for receiving the fingers of a surgeon, and an intermediate section reversibly reversible around the forearm of the surgeon with the distal section (14b) telescopically movable within the proximal section (14a); and ring means (20) carried by said cover (14) around said proximal end opening to secure said cover (14) in sealed contact with the skin around the incision.

22. - An apparatus in accordance with the re-division 21, further characterized in that said ring means (20) include releasably and coincidently engageable rings (20a, 20b), one mounted on said proximal end of the cover and the other attachable in an adhesive manner to said skin.

23. An apparatus according to claim 22, including a closure (60) having a ring (64a), similar in structure to said ring, to enable said closure (60) to be mounted in a manner selective on said ring adhered to the skin.

24. An apparatus according to claim 23, including: a sphere (26) formed in said one ring around said proximal end opening of the cover; and a groove (33) formed in said other ring for interconnecting said sphere (26).

25. An apparatus according to claim 24, further comprising: retainer means (34, 36) formed in said rings to interlock when said sphere (26) and said slot (33) are fully engaged.

26. An apparatus according to claim 21, further comprising: pressure release valve means (40) carried by said ring (20b) to communicate with said cover (14) for venting blown gas when the pressure exceeds a preselected limit.

27. - An apparatus according to claim 26, further characterized in that said preselected pressure limit is about 30 mm Hg.

28. An apparatus according to claim 21, further comprising: port means (50) attached to said sleeve (14) and formed to admit a surgical instrument while maintaining the extracorporeal pneumoperitoneum.

29. An apparatus according to claim 28, further characterized in that said port means (50) further includes: a generally cylindrical housing (52) having a tapered wall (52b) tapered inwardly to form a circular hole (54) ) to slidably receive said surgical instrument; a duckbill check valve (56) secured to said housing (52) and having normally closed slots spaced below said hole (54) in a plane transverse to the conical axis of said wall (52b) to slidably receive to the instrument in series with said hole (54).

30. An apparatus according to claim 29, further characterized in that: said housing (52) has sufficient elasticity so that said hole (54) forms a gas-tight seal around the surface of the instrument; and said duckbill check valve (56) has sufficient elasticity for said slot to close forcefully on itself when the instrument is removed from it.

31. - An apparatus for surgery with a minimum of invasion and manually assisted under conditions of pneumoperitoneum, comprising: a flexible sleeve impermeable to gases (14) having a section of distal hand without fingers (14b) ending in holes (15) for receiving the thumb and fingers of a surgeon's hand, an intermediate cuff section extending from said distal hand section (14b), and a section of the proximal end (14a) terminating in an opening, said cuff section intermediate is inversely turned on itself to extend along the forearm of the surgeon when the opening of the proximal end (14a) is displaced towards the distal end (14b), and a removable adhesive ring (20b) carried by said sleeve (14). ) to make sealable contact with the skin around the abdominal incision; and means for releasably attaching said adhesive ring (20b) to said sleeve (14) around the opening of the proximal end.

32.- An apparatus according to claim 31, further characterized in that said releasable coupling means include a first ring (20a) sealed to said sleeve (14) around the opening of the proximal end to engage in a sealable and releasable manner in the inside said adhesive ring (20b).

33.- An apparatus according to claim 31, including pressure release valve means (40) carried by said adhesive ring (20b) to release the pressure above the predetermined level occurring within the reversely flipped sleeve (14). ).

34. An apparatus according to claim 31, including an outer surgical glove (18) that encloses the hand of the surgeon after insertion through the holes of the distal end (15) to produce a positive seal of the holes (15). ). 35.- An apparatus according to claim 34, including an inner surgical glove (16) that encloses the hand of the surgeon inside the sleeve (14) to wall the distal end of the sleeve (14b) between the inner and outer surgical gloves (16, 18).