 |
Description  |
|
|
BACKGROUND OF THE INVENTION
1. Field of the Invention
The present invention pertains to suturing of bodily tissue and, more
particularly, to methods, apparatus and systems for suturing tissue during
endoscopic procedures.
2. Discussion of the Prior Art
Suturing of bodily tissue is a time consuming part of most surgical
procedures including both open surgery and endoscopic or closed surgery.
By open surgery is meant surgery wherein the surgeon gains access to the
surgical site via a relatively large incision, and by endoscopic surgery
is meant surgery wherein the surgeon gains access to the surgical site via
one or more portals through which endoscopes are introduced to view the
surgical site and through which various instruments are introduced to the
surgical site. There are many common endoscopic surgical procedures,
including arthroscopy, laparoscopy (pelviscopy), gastroentroscopy and
laryngobronchoscopy, for example. In the past, suturing has been
accomplished with the use of a sharp metal suture needle attached to the
end of a length of suture material, the suture needle being caused to
penetrate and pass through the tissue pulling the suture material through
the tissue. Once the suture material has been pulled through the tissue,
the surgeon ties a knot in the suture material, the knotting procedure
allowing the surgeon to adjust the tension on the suture material to
accommodate the particular tissue being sutured and control approximation,
occlusion, attachment or other conditions of the tissue. The ability to
control tension is extremely important to the surgeon regardless of the
type of surgical procedure being performed; however, knotting of the
suture material is time consuming and tedious work, particularly in
microsurgery and endoscopic surgery. In microsurgery, suturing is
necessarily time consuming due to the small size of the suture needle and
the suture material and the concomitant difficult manipulation required to
pass the suture needle through the tissue and to tie a knot in the suture
material. With respect to endoscopic surgery, suturing and tying knots
represents an even more time consuming procedure due to the difficult
maneuvers required. Accordingly, while endoscopic surgery would be
preferred for most procedures, the advantages are often outweighed by the
disadvantages caused by the length of time required to complete the
endoscopic surgical procedure, which time is greatly extended due to the
time required for suturing.
There have been many attempts to provide devices to take the place of
conventional suturing with a suture needle and a length of suture
material; however, such prior art devices have essentially been staples,
clips or clamps not allowing any adjustment of tension by the surgeon.
French Patent No. 2,651,113 to Alain and U.S. Pat. Nos. 3,123,077 to
Alcamo, No. 3,570,497 to Lemole, No. 4,548,202 to Duncan, No. 4,592,355 to
Antebi, No. 4,730,615 to Sutherland et al, No. 4,935,028 to Drews, No.
4,950,285 to Wilk, No. 4,955,913 to Robinson and No. 5,123,913 to Wilk are
representative of prior art devices for use during open surgery to
adjustably hold tissue together similar to suturing and tying but fail to
provide the same feel and tension control as knotting a length of suture
material. U.S. Pat. No. 3,910,281 to Kletschka et al is representative of
suture anchors for facilitating tying.
Endoscopic surgery is preferred over open surgery due to the greatly
reduced trauma and wound healing time for the patient and due to
concomitant cost savings associated with shorter hospital stays and
performing surgery without general anesthesia and in non-hospital or
out-patient surgery sites. Accordingly, there has been much effort spent
to develop techniques for facilitating the suturing normally performed by
use of a suture needle and a length of suture material. Alternative
techniques proposed have included electrical coagulation, mechanical
devices such as clips, clamps and staples, and lasers; however, no well
accepted alternative has yet been found in that suturing and tying are
essential and vital parts of most surgical procedures. That is, to date
the proposed alternatives have had disadvantages, including increased risk
to the patient, while not providing the surgeon with the advantages of
suturing and tying and not being useful in a wide range of procedures to
allow expansion of the areas in which endoscopic surgery can be
effectively performed. Thus, there is a great need for suturing techniques
useful in endoscopic surgery to permit surgeons to suture with controlled
tension and approximation of tissue similar to that obtained by
conventional knot tying.
U.S. Pat. No. 3,775,825 to Wood et al discloses apparatus and method for
suturing wherein clips are secured on the free ends of a suture filament;
however, the apparatus and method are not practical for endoscopic
procedures.
U.S. Pat. Nos. 5,078,731 to Hayhurst and No. 5,171,251 to Bregen et al are
representative of clips for clamping suture material to eliminate knotting
during endoscopic procedures. European Patent Publication No. 0,477,020A
to Chen et al and U.S. Pat. Nos. 5,015,250 to Foster, No. 5,037,433 to
Wilk et al, No. 5,059,201 to Asnis, No. 5,084,058 to Li, No. 5,087,263 to
Li, No. 5,100,415 to Hayhurst, No. 5,100,421 to Christoudias, No.
5,144,961 to Chen, No. 5,147,373 to Ferzli, No. 5,152,769 to Baber and No.
5,163,946 to Li are representative of needle holders and apparatus for
suturing, knotting or ligating during endoscopic procedures which,
however, have the disadvantages of requiring complex instruments, of
requiring special suture devices, of being difficult to manipulate and/or
of not sufficiently reducing the time required for suturing.
U.S. Pat. Nos. 4,932,962, No. 4,981,149 and No. 5,074,874 to Yoon et al and
U.S. Pat. Nos. 4,935,027, No. 5,053,047 and No. 5,100,418 to Yoon disclose
methods and apparatus particularly useful for suturing during endoscopic
procedures to permit tissue approximation with controlled tension.
SUMMARY OF THE INVENTION
Accordingly, it is a primary object of the present invention to provide
methods, apparatus and systems for suturing tissue during endoscopic
procedures in a time efficient and precise manner.
Another object of the present invention is to form a suture stitch in
tissue by inserting a needle into the tissue to pass a portion of a length
of suture material through the tissue from a proximal entry point to a
distal exit point, forming a loop in the length of suture material at the
exit point, engaging the loop with an anchor of a size to resist passing
through the tissue, withdrawing or backing out the needle through the
tissue and tensioning the length of suture material to controllably
approximate the tissue. Additional stitches, as required, are formed in
the same manner either continuously with a single length of suture
material or a plurality of lengths of suture material.
A further object of the present invention is to suture tissue during an
endoscopic procedure by manipulating a suturing instrument passing through
a first portal in an anatomical cavity wall to reciprocate a needle
carrying a length of suture material through the tissue from an entry
point to an exit point and back to the entry point to form a loop at the
exit point and engaging the loop with an anchor carried by an anchor
applier instrument passing through a second portal in the anatomical
cavity wall whereby one or more stitches can quickly be placed in the
tissue with controlled tension and tissue approximation.
The present invention has another object in that a suturing instrument has
a needle formed as a component thereof or integrally therewith to
facilitate needle manipulation during endoscopic suturing, a mechanism to
permit adjustment of the needle orientation by movement of an elongate
operating member relative to a handle of the suturing instrument, an
electrical connection to allow use of the needle as a cautery and/or a
lumen permitting introduction of other instruments through the suturing
instrument.
An additional object of the present invention is to construct an anchor
applier instrument for use in suturing during an endoscopic procedure with
an anchor receiver having a tapered tip for insertion in a looped portion
of a length of suture material to position the looped portion around an
anchor.
Some of the advantages of the present invention over the prior art are that
controlled tissue approximation can be achieved to provide a "feel"
similar to suturing with knots in an expeditious manner thereby increasing
the variety of surgical procedures that can be performed endoscopically
without increasing the time required for suturing, and that suturing can
be accomplished using conventional, available instruments or specially
designed instruments of simple construction allowing the instruments to be
disposable or easily sterilized for reuse.
The present invention is generally characterized in a method for suturing
tissue in an anatomical cavity during an endoscopic procedure including
the steps of penetrating the tissue with a needle until a portion of a
length of suture material attached thereto has passed through the tissue,
engaging the portion of the suture material with an anchor, backing the
needle out of the tissue while the suture material is held by the anchor,
tensioning the suture material, and securing the suture material in the
tensioned position. The present invention is further characterized in a
system for suturing tissue in accordance with the above method including a
needle with a length of suture material attached thereto at a position
spaced from a proximal end thereof and an applier instrument carrying a
plurality of anchors. A suturing instrument for use in suturing tissue in
accordance with the present invention includes a needle body held by the
distal end of an elongate operating member having a length to extend
through a portal established in the wall of the anatomical cavity, a
handle at the proximal end of the operating member and a length of suture
material attached to the needle body having an enlarged proximal end. An
anchor applier instrument for use in suturing according to the present
invention includes a barrel housing a plurality of anchors and having a
length to extend through the portal in the anatomical cavity wall, a
handle receiving the proximal end of the barrel for manipulating the
anchor applier instrument and an anchor receiver positioned at the distal
end of the barrel for receiving anchors ejected therefrom, the anchor
receiver having a tapered tip for insertion in a looped portion of the
length of suture material to position the looped portion in engagement
with the anchor.
Other objects and advantages of the present invention will become apparent
from the following description of the preferred embodiments taken in
conjunction with the accompanying drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a broken side view, partly in section, of a needle with a length
of suture material attached thereto for use with the present invention.
FIG. 2 is a broken side view, partly in section, of an anchor applier
instrument for use with the present invention.
FIG. 3 is a broken perspective view, partly in section, illustrating
suturing according to the present invention during an endoscopic
procedure.
FIGS. 4, 5, 7 and 8 are broken perspective views showing suturing steps
according to the present invention looking at the needle entry side of the
tissue to be sutured.
FIGS. 6 and 9 are broken perspective views showing suturing steps according
to the present invention looking at the needle exit side of the tissue to
be sutured.
FIG. 10 is a plan view showing the arrangement of the length of suture
material and anchors shown in FIGS. 8 and 9.
FIGS. 11, 12, 13 and 14 are perspective views of alternative anchors for
use with the present invention.
FIG. 15 is a broken side view in section of an alternative distal end of an
applier instrument for the anchors of FIG. 11.
FIG. 16 is a side view, partly in section, of a suturing instrument for use
with the present invention in a protective position.
FIG. 17 is a broken, exploded, perspective view, of the distal end of the
suturing instrument of FIG. 16.
FIG. 18 is a side view of the suturing instrument of FIG. 16 in an
operative position.
FIGS. 19 and 20 are broken perspective views of suturing instrument
modifications for use with the present invention.
DESCRIPTION OF THE PREFERRED EMBODIMENTS
In accordance with the present invention, suturing is preferably
accomplished with a suture needle 10, as shown in FIG. 1, having a sharp
distal end or tip 12, a curved body 14 and a proximal end 16. A length of
suture material 18 has a distal end attached to the needle body at an
attachment position 19 spaced from the proximal end 16 by a distance
greater than the thickness of the tissue to be sutured. In order to
minimize the space required to accommodate protrusion of the needle tip
beyond the exit point in the tissue, it is desirable to make the
attachment position as close to the tip 12 as practical; however, as will
be understood from the following, the attachment position can be anywhere
along the body of the needle as long as the needle can be held at the
proximal end and passed through the tissue to cause the attachment
position to extend beyond the exit point to place a portion of the length
of suture material at the exit point. One manner in which the suture
material can be secured to the needle is to form a groove 22 in the convex
side of the needle leading to a blind hole 24 and to hold the distal end
of the suture material in the hole by friction, adhesive, wax, fusing or
the like.
The suture material has a length dependent upon the procedure being
performed and the number of stitches to be made, and the suture material
has an enlarged proximal end 26 having a transverse dimension greater than
the transverse dimension of needle 10 and suture material 18. The enlarged
proximal end 26 is shown in FIG. 1 as a cross member to produce a "T"
configuration and is shown in FIG. 3 as a sphere. The enlarged proximal
end 26 can be formed integrally with the suture material prior to starting
the suturing procedure and can have any desired configuration as well as
the illustrated cross member and sphere, or the enlarged end can be formed
by attaching a clip or other device to the proximal end of the suture
material or by tying a knot in the suture material either during or prior
to the suturing procedure. That is, the needle 10 and length of suture
material 18 can be supplied to the surgeon with the enlarged proximal end
26 already in place or the enlarged proximal end can be formed by the
surgeon as part of the suturing procedure. The needle 10 can have various
shapes preferred for performing specific procedures and suturing
particular tissue structures located at various positions within an
internal body cavity, such as curved, straight, hooked or the like.
An anchor 28 is used to engage or capture the length of suture material
once the tip 12 of the needle has passed through the tissue to be sutured.
The anchor can have various configurations allowing the anchor to engage
or to grip the suture material including conventional clips or staples,
such as those marketed by various companies, including Ethicon
Endo-Surgery, United States Surgical Company, and Linvatec Weck Endoscopy,
for use in endoscopic procedures to close or occlude tissue structures.
The anchor 28 is shown in FIG. 2 as a clip formed of a bent, U-shaped
member of any suitable, medical grade material to have a pair of spaced,
opposed legs 29 and 30 terminating at spaced distal ends 31 and 32,
respectively, defining an opening therebetween. Such clips are
conventionally applied to tissue with the use of a forceps-type instrument
having opposing jaws 34 cooperating with the legs 29 and 30 to laterally
compress or clamp the legs together; however, an instrument having a
stationary jaw and a distally movable jaw to longitudinally compress or
clamp the legs together, such as that shown in U.S. Pat. No. 5,171,250 to
Yoon, the disclosure of which is hereby incorporated herein by reference,
can also be used. While conventional clip applier instruments can be used
in accordance with the present invention, it is preferred to modify such
instruments such that one of the jaws is longer than and curves toward the
other jaw to taper to a tip 35 that can be used to hook or hold the loop
of suture material as will be appreciated from the following.
An anchor applier instrument 44, as shown in FIG. 2, includes an elongate
barrel 49 extending from an open distal end adjacent jaws 34 to a proximal
end received by a handle 50. A plurality of anchors 28 are housed in
barrel 49 in end-to-end arrangement and are biased distally by a piston 51
and a compression spring 53 such that the inwardly turned distal ends 31
and 32 of the end anchor are held by a pair of opposing gates 55 extending
radially inwardly from the distal end of a substantially cylindrical
cartridge 57 having a proximal end 59 connected with a proximal end 61 of
an actuator tube 63 via a U-shaped, spring handle 65. The actuator tube 63
has an open distal end 67 adjacent gates 55 such that squeezing spring
handle 65 causes the actuator tube distal end 67 to open gates 55 to
permit spring 53 and piston 51 to eject an anchor 28 from the barrel into
the anchor receiver formed by jaws 34. Handle 50 is formed of a grip
member 69 secured to a tubular, receiver support member 71 mounting jaws
34 at the distal end thereof, and grip member 69 passes through a slot 73
in an outer barrel member 75. A grip member 77 is pivotally mounted to
grip member 69 and has an end coupled with the proximal end of outer
barrel member 75 such that squeezing of grip members 69 and 77 moves outer
barrel member 75 distally over cams 79 carried by jaws 34 to close the
jaws and compress the anchor legs 29 and 30. Partial squeezing of the
handle grip members 69 and 77 will cause the anchor distal ends 31 and 32
to engage; and, thereafter, the legs can be completely compressed by
further squeezing of the handle grip members.
FIG. 3 illustrates suturing according to the present invention performed
during an endoscopic procedure wherein portal sleeves 36 and 38 are
introduced through an anatomical cavity wall 40 with the use of
penetrating members such as trocars, not shown. A suturing instrument 42
is introduced into the cavity through portal sleeve 36, and the anchor
applier instrument 44 is introduced into the cavity through portal sleeve
38. The suturing instrument 42 includes needle 10 with suture material 18
attached thereto and an elongate operating member 46 carrying movable jaws
47 at a distal end thereof for holding the proximal end of the needle 10.
The operating member has a length to extend through portal sleeve 36 to a
proximal end received by a handle 48. Numerous needle holders, sometimes
also referred to as needle drivers or needle graspers, are presently
available for use in endoscopic surgery and can be combined with suture
needle 10 and suture material 18 to form a suturing instrument 42
according to the present invention, such needle holders being operable at
proximal ends externally of the cavity by various handle mechanisms, the
handle 48 being formed by pivotal grips. As discussed above, the anchor
applier instrument 44 has an elongate barrel 49 housing a plurality of
anchors 28 with a distal end for ejecting anchors into an anchor receiver
formed by jaws 34, and the barrel has a length to extend through portal
sleeve 38 to a proximal end received by a handle 50. As previously noted,
numerous clip applier instruments for endoscopic procedures are available
on the market and can be used as an anchor applier instrument for suturing
in accordance with the present invention, preferably modified to have
tapered, inwardly curving tip 35.
To suture tissue portions T1 and T2, suturing instrument 44 is manipulated
to drive needle tip 12 through an entry point 52 in tissue portion T1 and
then through tissue portion T2 and out of an exit point 54 carrying the
suture material 18 through the tissue portions along with and adjacent the
needle body 14 as shown in FIG. 4. When tip 12 and attachment position 19
have passed through tissue portion T2, a portion 56 of the length of
suture material 18 is exposed and will bulge outwardly away from the
needle to form a loop spaced from the needle body when the needle is
backed out or moved proximally slightly. The anchor applier instrument is
now moved to insert tapered tip 35 in the looped portion 56 and place an
anchor 28 within the loop as shown in FIG. 5 to engage the suture
material. When the anchor is a clip, the distal ends 31 and 32 of the clip
can be clamped together while leaving the clip legs 29 and 30 spaced as
shown in FIG. 6 to allow the length of suture material to move through the
clip or the loop can be held by leaving the applier jaw 34 and clip within
the loop 56 such that the suture material can be moved therethrough.
After the anchor and/or applier jaw has been positioned in the loop 56, the
needle is backed out or withdrawn through the same opening or passage
through the tissue portions pulling the suture material with it until the
enlarged proximal end 26 of the suture material abuts the entry point 52
in the tissue as shown in FIG. 7. Once the enlarged end 26 of the length
of suture material has been drawn up against tissue portion T1 at entry
point 52, tension can be applied to the suture material by pulling the
suture material around the anchor 28 and/or applier jaw to adjustably
approximate tissue portions T1 and T2 as shown at 58 in FIG. 7; and,
thereafter, the anchor 28 can be compressed to clamp legs 29 and 30
together to grasp the loop 56 tightly and secure the suture material in
the tensioned position to complete the first stitch. If only a single
stitch is required, the suture material can be cut adjacent the entry
point. Of course, the stitch can also be completed by securing another
anchor 28 to the length of suture material at the entry point 52 while
leaving the anchor 28 at the exit point open to allow the length of suture
material to slidably engage the anchor. If desired, the stitch can be
completed by holding the loop with a hook and, after tensioning around the
hook, applying an anchor to the loop 56 of suture material.
Where more than one stitch is required, the needle tip 12 is inserted
through the tissue portions at a position spaced from the first stitch,
and an anchor 28 is placed in engagement with the loop 54 formed in the
second stitch in the same manner as described above with respect to the
first stitch. The needle is then backed out through the same opening, and
the length of suture material is tensioned to controllably approximate the
tissue portions as previously described. Once one or more stitches are
placed in the tissue, as required, the length of suture material is
severed from the needle, and a distal anchor 60 can be secured to the
distal end of the length of suture material to abut the tissue at the
entry point of the last stitch, if desired, after the appropriate tension
has been placed on the length of suture material to approximate the tissue
as shown in FIGS. 8 and 9. An entry point anchor can be compressed or
clamped to the length of suture material either after each stitch or after
all stitches are completed. The entry point anchors, such as anchor 60,
can have the same configuration as anchors 28 or can merely have an
enlarged shape to prevent pulling of the length of suture material through
the entry points.
The arrangement of the length of suture material and anchors where a
plurality of stitches are made with a continuous length of suture
material, as shown in FIGS. 8 and 9, is illustrated in FIG. 10 wherein the
first stitch A is formed from a run 62A of the suture material extending
between enlarged proximal end 26 at entry point 52A and a portion 56A
engaged by and looped around anchor 28A at exit point 54A and a run 64A of
the suture material extending between portion 56A and the entry point 52A
adjacent run 62A. From run 64A, the length of suture material extends to
the second stitch B via a connecting run 66B, and stitch B is formed from
run 62B, portion 56B engaged by anchor 28B and run 64B between entry point
52B, exit point 54B and back to entry point 52B. The third stitch C and
the fourth or end stitch D are similarly formed and parts thereof are
given the same reference numbers with C and D added thereto, respectively.
Once the suture material has been tensioned after the end stitch D, distal
anchor 60 can be affixed to the end of run 64D at entry point 52D to
secure the loose end of the suture material in the tensioned position, and
any remaining suture material is severed and removed from the cavity. Of
course, the suture material can also be severed just beyond anchor 28D
eliminating run 64D depending upon whether anchor 28D is clamped to the
suture material.
While any anchor of a size to resist passing through the tissue and capable
of engaging the length of suture material can be used with the present
invention, conventional ligating clips are advantageous since multiple
clip applier instruments for endoscopic use are presently available from
various companies, including Ethicon Endo-Surgery, Weck Linvatec Endoscopy
and United States Surgical Company, as noted above. Other anchor
configurations for use with the present invention are shown in U.S. Pat.
No. 5,100,418 to Yoon et al, the disclosure of which is incorporated
herein by reference, and previously mentioned U.S. Pat. No. 5,171,250 to
Yoon, and are also shown in FIGS. 11, 12, 13 and 14.
In the embodiment of FIG. 11, an anchor 68 has a link or "dog bone"
configuration with a smaller transverse dimension central portion 70
terminating at opposite ends at round, protruding larger transverse
dimension lobes 71 and 72 such that the loop 56 of the length of suture
material can be engaged by the central portion 70 with the lobes
preventing the loop from slipping off of the anchor 68. The flat sides of
the anchor 68 allow the anchor to be flush with tissue to be sutured; and,
when an aperture 74 is formed in lobe 72, the length of suture material
can be passed therethrough to secure either end thereof. By forming lobe
71 with a button 75 protruding therefrom of a size and configuration to be
snapped into or frictionally held in aperture 74 in lobe 72, anchor 68 can
be bent or folded on itself along a transverse axis 71 of central portion
70 to force button 75 into aperture 74 to lock suture material loop 56
therein as shown in FIG. 12. Anchor 68 can be made of any medical grade
metal or plastic material allowing the anchor to be folded upon itself. In
the embodiment of FIG. 13, an anchor 76 is made of a member having a
circular cross-section formed in a "FIG. 8" configuration to have a
smaller transverse dimension central portion 78 held in place by a sleeve
81, the central portion terminating at larger transverse dimension lobes
80 at opposite ends such that, similar to anchor 68, the loop 56 of the
length of suture material will be engaged by the central portion 78 and
captured by lobes 80. In the embodiment of FIG. 14, an anchor 82 has a
barbell-like configuration with a central portion 84 and extending ends 86
to capture the loop 56 of the length of suture material in the same manner
as anchors 68 and 76. When non-clamping anchors, such as 68, 76 and 82,
are used to engage the loops 56 of the suture material at the exit points,
it will be appreciated that the distal end of the suture material after
the last stitch will be held with an anchor of the type that can be
clamped or otherwise secured to the end of the suture material, such as a
clip. Accordingly, the non-clamping anchors are used in the same manner as
anchors 28 along with a distal anchor 60 as described above.
In order to facilitate engagement of the loop 56 of suture material with
anchors 68, 76 or 82, the anchor applier instrument 44 can have an anchor
receiving cradle 88 formed at the distal end of barrel 49 to receive
anchors ejected from the barrel, the cradle terminating at a distal jaw
forming a curved hook or tapered tip 90 as shown in FIG. 15, such that the
tip can be inserted easily within the loop 56 to properly position an
anchor within the loop. In FIG. 15, a plurality of anchors 68 are shown in
end-to-end alignment in the applier; and, with an anchor 68 positioned in
the cradle 88, once the distal end of the applier has been inserted in the
loop, the anchor will be positioned such that the central portion 70
engages the loop 56 when the loop is tightened allowing the applier to
release the anchor while the anchor is held against the tissue. Whether
using lateral clamping, longitudinal clamping or cradle receivers for
anchors in the anchor applier instruments, it is desirable to allow
selective placement of an anchor in the receiver at the distal end of the
barrel to permit use of the tip and/or jaws for other functions with no
anchor in the receiver.
Another instrument 92 for suturing according to the present invention is
shown in FIGS. 16, 17 and 18, the suturing instrument 92 including a
needle body 94 having a sharp tip 96 at a distal end, a curved portion 98
and a shank 100 terminating at a proximal end 102, as best shown in FIG.
17. An elongate, tubular operating member 104 has a distal end 106 holding
the needle body proximal end 102, a proximal end 108 rotatably,
frictionally received in a bore 110 of handle 112 and a length to extend
through a portal in an anatomical cavity wall. The operating member
proximal end 108 carries a knurled collar 11 to facilitate rotation of the
operating member relative to the handle, a plastic end cap 116 sealing the
open end thereof and an electrical connector 118 extending radially
therefrom. The handle 112 includes a hand grip 120, a toothed rack 122
extending distally from the hand grip and a counterbore 124 receiving a
coiled spring 126 mounted in compression between a radial shoulder 128 and
a proximal end 130 of a hollow, cylindrical safety shield 132
longitudinally movable in the counterbore 124 of the handle. A trigger 134
depends from the safety shield proximal end 130 through a slot 136 in the
counterbore 124 and carries a pawl 138 cooperating with rack 122. Safety
shield 132 has a length such that, in a distally extended protective
position, a distal end 140 of the safety shield covers the needle body 94
as shown in FIG. 16 and, in a proximally retracted operative position, the
needle body 94 is exposed for suturing as shown in FIG. 18.
The length of suture material 18 is attached at its distal end to needle
body 94 adjacent distal tip 96 in the manner shown in FIG. 1, and enlarged
proximal end 26 is disposed in the lumen of operating member 104 during
insertion of the suturing instrument 92 through a portal. Needle body 94
can be formed integrally, nondetachably with the operating member 104 or
can be detachably held by the operating member distal end 106, for example
by forming a slot 142 in the needle body proximal end 102 to receive the
peripheral edge of operating member distal end 106. Preferably, the
opposing arms formed by slot 142 are received in corresponding recesses
144 in the operating member distal end to produce a smooth profile and to
assure that rotation of the operating member in the handle 112 causes
movement of the needle body.
In use, the suturing instrument 92 is inserted through a portal in an
anatomical cavity wall with the safety shield in the protective position
shown in FIG. 16 to cover the needle body 94 and prevent contact of the
sharp tip with components of the portal sleeve or tissue within the
cavity. Once the suturing instrument 92 has been introduced to the
surgical site in the cavity, trigger 134 is squeezed to move the safety
shield proximally against the bias of spring 126 to the operative position
shown in FIG. 18 with the safety shield locked in place by engagement of
pawl 138 with rack 122. Suturing is accomplished in the same manner as
described above, and rotation of operating member 104 positions needle
body 94 to facilitate manipulation for tissue penetration. If
cauterization is needed during the procedure, an electrical source can be
coupled to connector 118 to allow use of the needle as a unipolar cautery.
To this end, operating member 104 and needle body 94 are preferably made
of electrically conductive materials, such as metal; and, handle 112, end
cap 116 and safety shield 132 are preferably made of electrically
insulating materials, such as plastic. By removing cap 116, the lumen of
operating member 104 provides communication with the anatomical cavity
without removing the suturing instrument from the portal, for example to
permit introduction of other instruments to the surgical site.
A modification of the suturing instrument is shown in FIG. 19 wherein the
shank 100 of needle body 94 carries a ball 146 at the proximal end thereof
movably held in a socket 148 in the distal end of the operating member,
and the rotational position of the ball 146 in the socket 148 is
controlled by four, equally spaced, control members 150, such as strings
or wires, passing through the operating member to the handle such that
longitudinal movement of the control members positions the needle body for
proper suturing orientation. Each control member is connected to a wheel
152 mounted on the handle to allow positioning of the needle body by
rotating the wheels with a finger. Another modification of the suturing
instrument is shown in FIG. 20 wherein the shank 100 of the needle body 94
is received in a chuck 154 having four opposing jaws at the distal end of
the operating member such that the shank is aligned with the longitudinal
axis of the operating member for rotation therewith. The chuck is operated
by a trigger 156 adjacent a handle 158 at the proximal end of the
operating member. The modifications of FIGS. 19 and 20 are also preferably
provided with safety shields and electrical connectors as in suturing
instrument 92.
In view of the above, it will be appreciated that the present invention
permits fast and precise suturing in endoscopic procedures with adjustable
tension and tissue approximation. In particular, a single surgeon can
quickly suture tissue by himself by manipulating a suturing instrument in
one hand and an anchor applying instrument in the other hand.
Inasmuch as the present invention is subject to many variations,
modifications and changes in detail, it is intended that all subject
matter discussed above or shown in the accompanying drawings b | | |
