one or more illustrative embodiments of the concepts disclosed herein are presented below . not all features of an actual implementation are described or shown in this application for the sake of clarity . it is understood that the development of an actual embodiment , numerous implementation - specific decisions must be made to achieve the developer &# 39 ; s goals , such as compliance with system - related , business - related and other constraints , which vary by implementation and from time to time . while a developer &# 39 ; s efforts might be complex and time - consuming , such efforts would be , nevertheless , a routine undertaking for those of ordinary skill in the art having benefit of this disclosure . in general , the devices and methods herein provide tissue approximation and retraction that can quickly and easily be assembled , positioned , and repositioned in multiple planes and axes of motion . the devices and methods can present relatively little obstruction to the surgeon &# 39 ; s movement , protect the sterile field , diminish the risk of tissue trauma , and yet be stable enough to function adequately while reducing the need for assistance . fig1 is a schematic diagram of a tissue approximator - retractor elastic device . the tissue approximator - retractor elastic device 2 generally includes an elastic portion 4 with at least three or more coupling rings 6 , 8 , 10 spaced along the elastic portion . in at least one embodiment and without limitation , the elastic portion can be approximately 1 mm to 5 mm in diameter and the coupling rings can be about 3 mm in diameter . the length of the elastic portion 4 can vary as may be appropriate and generally would range between 1 cm to 10 cm . however , a key feature is that at least three coupling rings and generally four or more coupling rings are coupled to the elastic portion . the term “ ring ” is used broadly and includes a full or partial encircling element of any shape , such as circular , square , elliptical , segmented , trapezoidal , and so forth in two or three dimensions . the ring material can be plastic , rubber , metal , ceramic , magnetic , or other medically acceptable materials . the coupling ring 6 can be coupled to the elastic portion 4 on one end , the coupling ring 8 can be attached adjacent to the coupling ring 6 , and the coupling ring 10 can be attached adjacent to the ring 8 . other rings can also be coupled to the elastic portion 4 . in at least one embodiment , the coupling rings are spaced 0 . 5 cm from each other along the elastic portion . the elastic portion can be of any suitable elastomeric material , including surgical tubing , non - latex rubber tubing , nitriles , surgical grade rubbers , silicon , and other elastic materials . the present embodiment provides a significant amount of flexibility during the medical procedure to choose different rings to apply different contractile forces using the same elastic device 2 . in other words , the elastic device 2 can be anchored with a first ring , for example , to a tissue portion . after anchoring the first ring , a second ring , selected at the option of the medical personnel , can be pulled to a different tissue portion and anchored thereto . the contractile force can be varied by which ring is selected . further , the distance between the anchor points can vary not only upon initial setting , but can also be varied during the procedure by selecting other rings during the procedure , as may be beneficial to the particular circumstances . details are provided below fig2 is schematic diagram of another embodiment of the tissue approximator - retractor elastic device . the tissue approximator - retractor elastic device 2 can include an elastic portion 4 in which the coupling rings 6 , 8 , and 10 and other rings are at least partially embedded therein . thus , the rings form apertures or openings within the material of the elastic portion 4 . one or more tissue engagement members 12 , 14 are also shown in fig2 . the tissue engagement members 12 , 14 are broadly construed to include a variety of devices that can couple the elastic device 2 to a tissue portion . generally , such engagement members include “ clips ” as are known to those of ordinary skill in the art for attaching to tissue portions or closing tissue portion in close proximity to each other . the clips generally can be placed and actuated by a single instrument inserted into the area in which the medical procedure will be performed . sutures can also be used . staples and tissue adhesives can also be used . in general and as further described below , the engagement member 12 can anchor one portion of the elastic device 2 . the second engagement member 14 can engage one of the other rings at the discretion of the operator , such as ring 10 , to stretch or pull a portion of the elastic device 2 to a different tissue portion and be coupled thereto . the contractile force caused by the stretched portion is used in a variety of manners to approximate or retract tissues portions . fig3 - 8 are schematic diagrams illustrating an exemplary and nonlimiting procedure using the tissue approximator - retractor elastic device . the figures will be described in conjunction with each other . fig3 is a schematic diagram of exemplary tissue portions separated by a gap . the tissue portions can represent a number of tissues encountered by medical personnel on or in a body . thus , “ tissue ” is used broadly to include organ tissues , such as uterine , esophageal , intestinal , heart , lung , liver , stomach ; connective tissues such as ligaments , tendons , cartilage ; muscle tissues such as skeletal , smooth , cardiac , and others ; dermal tissues ; and the like . for example and without limitation , the tissue portions could be tissues separated by a wound which needs closure , or a surgical incision made for the purpose of carrying out a surgical procedure . in some circumstances , the gap 24 is larger than a typical clip inserted into the area can close . thus , a pre - closure procedure is generally beneficial to allow a more permanent suturing or other closure . the tissue approximator - retractor elastic device 2 disclosed herein can provide a great deal of flexibility in pre - closing the gap 24 . fig4 is a schematic diagram of the tissue portions separated by a gap with the tissue approximator - retractor elastic device of fig1 . an operator can provide and position a tissue approximator - retractor elastic device adjacent the tissue portions across the gap 24 . in general , one end of the elastic device 2 can be anchored to a first tissue portion 20 with a first tissue engagement member 12 coupled to a first coupling ring 6 . the operator can then choose between the remaining coupling rings to select a second coupling ring as suitable for the particular tissue involved , the size of the gap 24 , and the amount of contractile force to be exerted by the elastic device 2 . fig5 is a schematic diagram of the two tissue portions separated by the gap with at least two tissue engagement members coupled to the tissue approximator - retractor elastic device . a second tissue engagement member 14 can be inserted into a selected ring , such as ring 10 that is appropriate for the size of the gap 24 and the contractile force to be exerted by the elastic device 2 . fig6 is a schematic diagram of the tissue portions separated by the gap with the tissue approximator - retractor elastic device anchored on either side of the gap . the elastic portion 4 can be stretched across the gap 24 using the engagement member 14 in conjunction with the ring 10 ( or other selected ring ) and anchored to the second tissue portion 22 . thus , ring 6 is anchored at the first tissue portion 20 with the first engagement member 12 , and the ring 10 is anchored at the second tissue portion 22 with the second engagement member 14 . the operator can select another ring , such as ring 8 , to be coupled to the second tissue portion 22 , if additional contractile force is needed for the gap 24 . alternatively , a ring distal from the ring 6 can be chosen to reduce contractile forces . such a selection can be made without removing the tissue approximator - retractor elastic device 2 or inserting another elastic device into the area . fig7 is a schematic diagram of the tissue portions that have been approximated using the tissue approximator - retractor elastic device . the engagement members 12 , 14 and their respective rings 6 , 10 are anchored to the tissue portions 20 , 22 , and the elastic portion 4 exerts a contractile ( tension ) force on the tissue portions . the stretched portion of the elastic portion 4 can contract the gap 24 to a smaller dimension between the first and second tissue portions 20 , 22 . fig8 is a schematic diagram of an exemplary closure of the gap between the tissue portions . in a contracted position , the gap 24 can be sufficiently closed so that the additional tissue engagement members 28 , 30 can be placed along the gap 24 to secure the closure in the approximated position . such securing can occur through clips , sutures , and other medical devices known to those with ordinary skill in the art . the tissue approximator - retractor elastic device 2 can be removed if appropriate , or optionally can be allowed to remain for a period of time to help maintain the closure . in general , it is believed that at least one tissue engagement member 28 will be disposed on one side of the tissue approximator - retractor elastic device 2 and at least one tissue engagement member 30 will be disposed on a distal side of the elastic device 2 . fig9 - 14 are schematic diagrams illustrating another exemplary and nonlimiting procedure using the tissue approximator - retractor elastic device . the figures will be described in conjunction with each other . fig9 is a cross - sectional schematic diagram of tissue having a portion to be excised . a first tissue portion 20 , such as tumor , or other growth , is sometimes desired to be excised from a base tissue . when such procedures are done under limited viewing capabilities , such as endoscopically , laparoscopically , or other such restrictive procedures , it is advantageous to have a separate member that can pull the tissue to be excised away from the excision edge to facilitate better viewing and better procedures . the present disclosure can provide such capabilities . fig1 is a cross - sectional schematic diagram of the tissue of fig9 with a tissue approximator - retractor elastic device coupled thereto . a tissue approximator - retractor elastic device 2 can be provided to the area near the tissue portions 20 , 22 . for example , a first tissue portion 20 can include the tissue to be excised or otherwise treated . a second tissue portion 22 can be a tissue portion distally located to serve as an anchor point from the area to be excised . the elastic device 2 can include an elastic portion 4 and at least three coupling rings 6 , 16 , and 18 . the first ring 6 can be coupled to the first tissue portion 20 with a first tissue engagement member 12 . the elastic portion 4 can be stretched by choosing a remaining coupling ring , such as ring 18 , and coupling that ring to the second tissue portion 22 with a second tissue engagement member 14 . the contractile force exerted by the elastic portion 4 of the elastic device 2 can create a tension on the first tissue portion 20 , so that as it is excised or otherwise treated , it is pulled toward the second tissue portion 22 . thus , the first tissue portion is retracted away from the base tissue and toward the second tissue portion 22 . fig1 is a schematic cross - sectional diagram of the first tissue portion partially excised illustrating a retraction using the tissue approximator - retractor elastic device . a cutter 32 can be used to separate the first tissue portion 20 from a third tissue portion 26 , such as the base tissue . the elastic portion of the elastic device 2 is allowed to contract to adjust the location of the first tissue portion 20 relative to the second tissue portion 22 as the first tissue portion is excised . thus , the area of separation with the cutter 32 can be viewed and more readily accessed in the medical procedure . fig1 is a cross - sectional schematic diagram of fig1 illustrating a different coupling of a different ring to the tissue portion compared to the tissue approximator - retractor elastic device . as the separation between the first tissue portion 20 and third tissue portion 26 continues to occur , it may be advantageous to adjust the contractile force of the elastic portion 4 on the first tissue portion 20 . in some instances , another ring , such as ring 16 , can be coupled to the tissue portion 22 or another tissue portion , with a tissue engagement member 34 to increase the contractile force . alternatively , the engagement member 14 in the ring 18 can be moved to another location . further , the ring 18 can be uncoupled from the tissue portion 22 to reduce or eliminate the contractile force . fig1 is a diagram with a three dimensional perspective illustrating an option to vary an angle of the contractile force between tissue portions . it may be advantageous to change a retraction angle of the first tissue portion 20 during , before , or after the medical procedure . for example , it may be advantageous to concentrate on a certain portion of the first tissue portion 20 and thus retract it at a different angle . the flexible application of the presently disclosed tissue approximator - retractor elastic device 2 with multiple rings allows for a variance in the angle of contraction between the first tissue portion and the second tissue portion , even during the medical procedure . for example , the second ring 18 can be coupled with the second engagement member 14 to the tissue portion 22 . during the procedure , it may be advantageous to change the angle of retraction and / or the amount of contraction by coupling a coupling ring 16 with a tissue engagement member 34 to another location of the second tissue portion 22 and at an angle to the second ring 18 . in a similar fashion , the angle of approximation can also change when the two tissue partners are approximated . fig1 is a cross - sectional perspective diagram of the tissue portions to be excised with a plurality of tissue approximator - retractor elastic devices coupled thereto . the flexibility of the current tissue approximator - retractor elastic device 2 with multiple rings can allow attachment of other tissue approximator - retractor elastic devices to assist in the medical procedure . for example , a first tissue approximator - retractor elastic device 2 can be attached to the first tissue portion 20 and the second tissue portion 22 , as described above . if desired , a second segment of the first tissue portion 20 can also be coupled to a second tissue approximator - retractor elastic device 2 a . a coupling ring 36 on the second tissue approximator elastic device 2 a can be coupled to the first tissue portion 20 ( or other tissue portion as appropriate ) with a tissue engagement member 38 . the second tissue approximator - retractor elastic device 2 a can be coupled to either a separate tissue portion , similar to coupling the tissue portion with the first elastic device 2 , or the elastic device 2 a can be coupled to the first tissue approximator - retractor elastic device 2 by use of one of the rings on each of the elastic devices . for example , a ring 44 on the second tissue approximator - retractor elastic device 2 a can be coupled with the ring 16 on the elastic device 2 . the elastic device 2 a in its corresponding elastic portion can be stretched to make such coupling , as appropriate , to apply a contractile force on the tissue portion coupled to the ring 36 . further , if appropriate , the rings 44 and / or 16 can be coupled to another tissue portion 42 . the coupling can change the contractile force , the angle of contraction , or other aspects as appropriate . while the tissues are approximated or retracted , the intended medical procedure can be performed . after the medical procedure that created the desire for the tissue approximation or retraction has been accomplished , the tissue approximator - retractor elastic device or devices can be removed . an incision through which the elastic device was inserted and the medical procedure was performed can be closed in a conventional manner . alternatively , the elastic device or devices can remain for some time period as might be desired to maintain some amount of tissue approximation or retraction . the invention has been described in the context of various embodiments and not every embodiment of the invention has been described . apparent modifications and alterations to the described embodiments are available to those of ordinary skill in the art . the disclosed and undisclosed embodiments are not intended to limit or restrict the scope or applicability of the invention conceived of by the applicant , but rather , in conformity with the patent laws , applicant intends to protect all such modifications and improvements to the full extent that such falls within the scope or range of equivalent of the following claims . the various methods and embodiments of the invention can be included in combination with each other to produce variations of the disclosed methods and embodiments , as would be understood by those with ordinary skill in the art , given the understanding provided herein . also , various aspects of the embodiments could be used in conjunction with each other to accomplish the understood goals of the invention . also , the directions such as “ top ,” “ bottom ,” “ left ,” “ right ,” “ upper ,” “ lower ,” and other directions and orientations are described herein for clarity in reference to the figures and are not to be limiting of the actual device or system or use of the device or system . the term “ coupled ,” “ coupling ,” “ coupler ,” and like terms are used broadly herein and can include any method or device for securing , binding , bonding , fastening , attaching , joining , inserting therein , forming thereon or therein , communicating , or otherwise associating , for example , mechanically , magnetically , electrically , chemically , directly or indirectly with intermediate elements , one or more pieces of members together and can further include without limitation integrally forming one functional member with another in a unity fashion . the coupling can occur in any direction , including rotationally . unless the context requires otherwise , the word “ comprise ” or variations such as “ comprises ” or “ comprising ”, should be understood to imply the inclusion of at least the stated element or step or group of elements or steps or equivalents thereof , and not the exclusion of a greater numerical quantity or any other element or step or group of elements or steps or equivalents thereof . the device or system may be used in a number of directions and orientations . further , the order of steps can occur in a variety of sequences unless otherwise specifically limited . the various steps described herein can be combined with other steps , interlineated with the stated steps , and / or split into multiple steps . additionally , the headings herein are for the convenience of the reader and are not intended to limit the scope of the invention . further , any references mentioned in the application for this patent as well as all references listed in the information disclosure originally filed with the application are hereby incorporated by reference in their entirety to the extent such may be deemed essential to support the enabling of the invention . however , to the extent statements might be considered inconsistent with the patenting of the invention , such statements are expressly not meant to be considered as made by the applicant ( s ).
the present disclosure provides an improved method and device for approximation and retraction of tissue portions during a medical procedure . the disclosure includes a tissue approximator - retractor elastic device , comprising : an elastic portion having a contracted length and adapted to expand to a different length to exert a contractile force ; and at least three coupling rings spaced along the elastic portion for an operator to choose between the rings and couple at least two rings to at least two tissue portions to adjust a contractile force on the two tissue portions . the disclosure also discloses providing the device near the tissue portions ; coupling a first coupling ring to a first tissue portion ; choosing between the remaining coupling rings to select a second coupling ring ; engaging the second coupling ring and elastically pulling the elastic portion to the second tissue portion to attach to the second tissue portion .