CA2042596A1

CA2042596A1 - Surgical suture instrument with remotely controllable suture material advancement

Info

Publication number: CA2042596A1
Application number: CA002042596A
Authority: CA
Inventors: Inbae Yoon
Original assignee: Individual
Current assignee: Individual
Priority date: 1989-08-21
Filing date: 1990-08-20
Publication date: 1991-02-22
Also published as: WO1991002490A1; US4935027A

Abstract

The invention relates to surgical instruments (10) and methods for effecting suturing of tissue that can be controlled from a position (16) remote from the suture site. The invention provides for the continuous feed of suture material (30) through opposed forcep jaw members (24) between which the tissue segments are interposed to expedite the suturing process and enable suturing to be accomplished at remote internal sites of the body incident to various endoscopic procedures.

Description

WO91/02490 ' ~ PCT/US90/04603 ~R~C~ 8~R~ 'r~XB~ ~T~ R~ Y

BAC~GROUND OF THE DISCLOSURE

The invention relates generally to ~urgical in~truments, and particularly to surgic21 instru~ents for suturing ti~sue at a ~urgioal ~ite. More parti~ularly, the invention relate~ to ~urgical 6uturing instruments that are controllable from a position remote fro~ the surgical site to effect tissue suturing at the surgi~al site.
Suturing of bodily tissue is a time consuming a~pect of most surgical procedures, including both open surgery and endoscopic or closed surgery. The term "open" surgery as used herein relates to surgical procedures in which the surgeon gains access to the surgical site by way of a relatively large incision formed in an exterior portion og ~he pa~ient's body.
The terms "~ndoscopic" or ~'closedH surgery as used herein relate to urgery in which the surgeon gains access to a surgical site positioned beneath the surface of the pat~t~ body by way of one or more portals through which one or ~ore endoscopic devic~s can be introduced to Yiew the surgical sit~ ~ variety of in~t ~ ents such as forceps, cutters, applicatoxs and the like can be introduced through the portals to the surgical ~ite. Endoscopic surgery has gained popularity ln recent y~ars due to the relatlvely reduc2d degree o~
2S trau~a and incapacitati~n associated wi~h ~uch procedures ~nd the co~parativ21y ~aster rat~s o~ pati~nt reco~ery there~rom. Co~mon~y per~ormed endoscop~c surgical proeedures include arthroscopy, laparoscopy ~ (p~l~$s~opy~, gastroentroscopy, and ~ laryngobron :; 30 choscopy.
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WO91/02490 ~ 9 ~ PCI/US90/04603 Prior to the developmerlt o~ the ~j ect suture deYice, suturing had b~l3n accomplished through the use of a sharp, curved metal suture needle hav irlg attached to a back end of the needle a length of suture material.
5 - The surgeon or a surgical attendant wc~uld extend the surgical needle and trailing ~uture ma~erial through the tissue to be j oined by th~ suture, a:fter which the suture mzlterial would be ti E3d inlto a knot and manipulated such that the knot could be advanced to he tissue site and adjusted for tension in order to accommodate the particular type of ~issue b~ing E;utured and to permit control of approximation, occlusiorl and attachmPnt of . th~ tissue. However, the proc~ess o tissue penetration and knotting of th~ suture ~aterial can be time consuming and tedious worX, particularly when per~ormed in connection with microsurgery and endoscopic surgery, and c:an unduly prolong th~e duration of surgery, and there~ore the period in whi ::h the patient i~ under anesthesia. ACcordingly, there exislts a need for surgical instruments and pro ::edures which greatly simplify ~he suturing proc~ss, render more expedient sllturing, and lzss~n the period duriny which th~ patie~t is under anesthesia.

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The inventiorl provides an apparatus and method whlch greatly si~pli~ie~3 surgical suturing and thereby expedite~ surgical procedure~3O The invention provide3 an laasily manipulable surg:ical instn~ent and ~ethod in which oppo3ed Sorcep ; aws can ~ displ~ d relative to one another fro2~ a re~otely-cc~ntrolled position so as to - p~n~trate tis~ue s~nts inl:erposed be1:ween the ~orcep ~ws. Suture . ~at2rial cart b~3 advan::ed fro~ one jaw to arlother 5;0 as to form a connec:ting loop o~ ~;utur~
~atarial that extend~s bet~e~n the l:i3sue ~eg~nt~ to b~

:. ::: : ; :: ~.:: . : . . . ~ . . ~. .: . . : , J~ 6 WO91/024gO P~T/U~90/0~603 ~oin~d. The suture material 1~ adv~nced in a cont~nuou~
manner through the opposed forcep jaw~ 80 aB to extend outwardly at or near the proxi~al end o~ th~ instrument.
Following release of the forcep iaws, a knot can ~e ti~d in the suture material so as to join the outwardly-extending end thereof with the inlet supply of suture material, and the knot can be advanc~d toward th~ ue segments so as to join together the ti~sue ~e~ments under the appropriate ten~lon. T~8 ~uture ~aterial ean be any of a variety of rigid, s~mi-rigid, bioabsorbable ...
or non-bioabsorbable suture material. .
In an alternative aspect o~ the invention, the forcep jaws can be fixedly positioned relative to one another but arranged so as to provide a pathway through which suture material can be advanced ~o as to extend from one forcep jaw lnto and through the opposed forcep jaw and any one or ~ore tissue segment,~ int~rposed therebetween. Following continuous advAncement of sutur~ material through the opposed ~orcep jaw~ a knot . , is.tied in the suture ~aterial and advanced toward the tissue s~gments to be joined and appropriately tensioned to provide a ~uture.
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BRIEF DES ~ I ~ THE ~RA~WING~
'' ' "' ' Further details of the ~ubj~ct invention will beco~e apparent from a reading o~ the following detailed `~
d~scription when read in con~unction with the accompanying drawings, in which: .
Fig. 1 i~ a lonc3itudinal side view o~ a surgical . .
~uturing device in arcordance with the invention;
: 3 0 Figs . lA~lF il}u~trate detail~ o~ alt~ati~e arrange~ents ~or use in the apparat:us dep~ ct~d in FigO

: Fig~. 2A and 2~ axe view~ of alternatiYe arrange~ent o~ th~ for~ep ~se~bly o~ ~ig. ~; i -~ "", ..

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WO91/02490 ~ ,)'.i 9 ~ -4- PCT/US90/04603 Fig. 3 is an enlarged viaw of the forcep a~e~bly o~ Flg. 1;
Fig6. 4 and 5 are cross ~ectional views o~ a forcep arm;
Figs. 6-10 are alternative forcep configuration~;
Figs. 11 is a partial sectio,nal view of a portion of the instrument of Fig. l;
Figs. 12A and 12B are cross-~ectional ~iews of variouB portionB of the instrument of Fig. 1;
Fig. 13 is a detailed sid2 view of a portion of ~he instru~ent of Fig. l;
Figs. 14A-14D are ~chematic ~iews illustrating operation of the invention; -Fig. 15 is a side view of a suture knot ~civancing 15. device that can be ~sed various configurations of t~e instrument depicted in F~g. l; and Figs. 16 and 17 are cross sectional views of an altarnatiYe aspect of a portion o~ the instrum~nt dep~cted in Fig. 1.
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ETAIL$D D~_CRIP~ION OF THE P~EFERR$~_EM~IMENT~ ~
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Wi~h re~erence to the ~rawings, wherein like re~erence characters designate like co~ponents throughout the variou~ Yiews, and with particular r~r~nce to Fig. 1, there is depicted a suturing instrument 10 for suturing tissue at a surgical site.
The suture instrument 10 co~prise~ a tubular me~ber 12 having a distal end 14 and a proximal end 16, a forcep a~se~bly 18 positioned at the distal end 14 of the tube, a handle as~e~bly 20 position~d adj~ce~t to the proximal Qnd o~ th~ tub~,.and sutur~ advanciny ~ean~ 2~ coupled ~ ~ to the proxi~al end o~ ~he instru~ent. A~ use~
throughout thl~ disclo~ure, th~ di~tal ~nd gen~r~lly : ~ re~r~ to the le~t-ha~d sid~ of a d~awing, whereas the .
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~ , ' WO91/0249~ ~3i~ 3 6 PCT/~90/04603 proxlmal end general.ly refar~ to the right-hand ~ide o~
ths drawing, unl~ss otharwi~e sp~cifi~d.
The forcep assembly 18 is comprised of a palr of opposed forcep arms 24a and 24b, each terminating at its S respective distal end at a tip 26a and 26b. Ona or both of the forcep arms 24a, 24b can b~ arranged so as to be displaceable relative to the d~.~tal end 14 of the tubular member 12 to move the di~t~l tip~ 26a, 26b between an open position, as illustrated in Fig. 1, and a closed position, as illustratecl ~n Fi~ 2A, or the opposed forcep arms can be fixed in po~ition with a separation space therebetween o~ prescribed di~ensisns, as illustrated in Fig. 2B. The arms 24a and 24b of th~
forcep assembly can have a variety of con~gura~ions, such as the outwardly, distally curv~d conf~s~uration illustrated in Fig.. 1, the generally planar con~iguration illustra~ed in Fig. 2B, or a variety o~
other configuration as may be desirable in ~ccoxdance with the tissue type to be sutured, the location oP the surgical ~ite, and other consideration~.
The ~orcep arms 24a and 24b each define a forcep lumen 28a, 28b through whioh suture ~aterial 30 is extensible in a ma~ner de~cribed in greater detail below. Th~ forcep arms 24a and 24b can be provided with a closed cylindrical con~iguration, as indicated in Fig.
3, or they can b~ provided ~ith a generally "C"-~haped or "U~-shaped cros~-seotional con~iqura~ion, as illustrated in conneot~on w~th forcep arm 2~a in ~igs.
4 and 5, so as to provide~an open cha~nel 32 extending the length of each o~ the respectiv~ ~orcep ar~ 24a and 24b~ The chann~l ope~ing~ 32 acilit~tQ fluid drainage from ~he forcep ~ss~mbly 18 and allow for advancement in a ~ nner descri~ed below ~hrough the ~orcep as~embly ~8 o~ a ~utur~ knot (not depict~d) fon~d in the ~uture material 30.

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wO 9l/02490 ~ .` `?~ ~3 ~ PCr/US90/04603 t~o upper forcep a~ 24a, i~ de~lred. In either arr~ngQ~ent of forcep aralls, th~ d.i~tal tip8 26a ~nd 26b extend distally downwardlyO This arrans~ement ~inimize~
the occurrence of suture sn gging or tearing upor removal of the forceps from the 6utur~ ~ite incident to knot ~ormation in the manner described below. The distal tips ~6a, 2~b o~ the forc~p arm~; o~ any o~ the variou~ forcep configuration~ a~ illu~trated in Figs. 6-10 can be provided with a tip ::on~iguration as lllustrated in Fig. 10, in which the dis$al 2dg~ oi~ the forcep tip is provided with ~a cun7ed ~lot 33 that extends inwardly toward th forc~ep arm lumen 28a, 28b.
This arrangement can be provided to furtller ~nini~ize the occurrence of suture material snagging and t~eari.ng fro~
engagement with sharp edges o~ the distal ltip that could otherwise occur in th~ absence o~ suc:h slots. 33.
A further altexnative ~orcep arrangeDIent i~
illustrated in Figs. lD and lE. In this zllternative ~orcep con~iguration, onQ o~ the rorc~p arms ~ ~uch as the lower forcep arm 2~a, i~ conr~gure~ a~ in gener~lly hook-shaped con~iguration co~prisiny a generally distally ext0nding leg 25a, a cu ~ed ~ed~ally-extending leg 25b, and a proximally-axtending leg 25c. The curved leg 25b is arrang2d such ~hat i~ extends ~ro~ one side of the longitudinal axis L o~ the ~ubular member 12 to th~ other side thereo~ so as to enable tissue s~ent piercing and jo~ning by the ~ingle ~orcep arm ~4b. In thi~ manner, sutur~ ~aterial can b~ advanced wi~hin lu~en 28b o~ the ~nrcep ar~ 24~ ~o ~ to ~xtend t~rough all tissue se~ent~ to be ~o~ned be~ore ~erging ther~fro~. T~e suture ~terial exitin~ ~he proximal leg 25c o~ the ~orcep arm ~4b can be received by upper forcep arm 24a, wh~ ca~ b~ con~igured ~ a fixed or di~place~bl~ ar~ hav~ lu~n 28a in th~ ~ann¢r de~cr~ed abo~ (Fig. 1~, or a~ ~ tubular rod 200 carry~ng a plur~lity og radi~lly ~xtzn~ible ~or6ep ;

WO9l/02490 ~ L~ ,.J ~ ~9 6 Pcr/~sso/o46o3 tongue~ 198 (Fig. lE) that are selectiYely ~xten~ible and retractable upon manipulation o~ handle 202 ~ounted at th~ proximal end thereo~. Th~ rod 200 i~ arranged a~
an extensible tubular member recei~d within tubular S member 12 and include~ a selective:Ly extensible and retractable inner rod 204 having mourlted at its distal end the array of forcep tongu~. 5'he handle 202 is provided with a generally im~erted U-shaped configuration that includes a distal ar~ 206 coupled to proximal arm 208 by spring arm 210. The free end 212 o~
handle arm 206 is coupl~d to th~ exterlor o~ rod 200, whereas the free end 214 of handle arm 208 is coupled to rod 200 such that, upon urging of handle arms 206, 208 toward one another, rod 200 extends d~stally and ~orcep tongues extend radially outwardly so as to define an opening for grasping the diætal end of suture material emerging fro~ the opposed forcep arm 24b. Upon release of handle te~ion, t;ie inner rod 204 is retracted wi~hin outer th~ rod and the flange tongues 198 grasp ~$rm1y against the suture mat~rial to s~cure ~h~ suture material therebetweenO Once the suture ~aterial has been grasped by the ~orc~p tongues l9R, the rod 200 can be withdrawn from tubular member 12 so as to circulate suture material through forcep arm 24b and advance ~he grasped free end o~ the suture ~at~rial proximally ~o per~it ~uture knot tying~ Once a sutur~ knot has be~n ti~d, tha kno~ ~an be advanced to the tissue ~eg~ents ~oined thereby ln the manner describ~d above, a~ by u~e of the ~ored~scribed d~vic~ 70 fFig. 15)~
Fig. 11 illustxate~ detail3 o~ the tubular memb~r 12 of the instrument 1~ The tubular member 12 i5 pr~vide~. wlth a pair o~ inner tubular ~e~bers 34a and 34b whi~n ex~end ~ro~ the proxi~al ent 16 to ~he di~tal ~nd 14 o~ ~he outer tubul~r ~ber 12. The i~ner 3S tubular ~e~ber~ 34a and 3~b c~n b~ in the ~og~ o~
t~ular chann~l3 borr2d in a tubular me~ber 12 that i~
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WO91/0~490 ~ PCT/US90/04603 solid in cross-section, as indicated by rePerence numeral 35, or they can be in the form o~ discrete tubular members position~d within a cavity 35a ~ormed ln the outer tubular member 12, as shown in Fig. 12A. The inner tubular members 34a and 34;b are pr~ferably arra~ged in axial alignment with fo:rcep arms 24a and 24b, respectively, and are in ~luid communication with the respective lu~ens 28a, 28~ thereo~ ~o as to provide for the advancement of suture materia:l 30 therethrough.
In particular, it is desirable to advance suture material 30 from the proximal end 16 of the outer tubular member 12 through one of the inner tubular me~bers, such as inner tubular member 34a, through ~he lumen 28a of the correspo~ding forc~p a~m 2.4a so a~ to extend in a continuous manner into the lumen 28b of the opposed forcep arm 24b for return passage through the other of the inn~r tubular members 34b proxi~ally in this dQscribed configurat~on. However, i~ i~ to be apprecia~ed that the resp~ctive direct~onal ori~ntat~ons of suture material advancement can be reversed fro~ that described above such that suture ~ater1al advances fro~
the proxi~al end 16 o~ the tubular member 12 through inner tubular me~ber 34b so as to be eonveyed through lower forcep arm 24b, through upper forcep arm 24a, and back through inner tubular member 34a for knot tying in the suture material.
In a further preferred arrangement for the outer tubular memb~r l~, inner ~ubular ~embers 34a and 34b are ~ecured in a conventional manner to the inner w~ll oi a middle tubular me~b2r 36 concentrically recelved within outer tubular ~ember 12. A pair of tubular chann~l ~emb~r~ 38 can be position~d adjacent the inner tubulax members 34a, 34b 80 as to extend longitudinally through ~iddl~ tubular ~e~ber 36. Th~ tubular ~h~nn~l ~e~bQr 38, which can be con~igured as ~1O~Qd-Sided tubular channFlæ, or as generally ~cn-~haped or op~n-~ided ~ :

91/02490 'J ~ I} ') ~ r~ ~ PCT/US90/04603 chann~ hown, provide ~or thQ circulation og fluid to and fro~ the suryical ~ite, as well a~ for the in3ertion therethrough af one or more ~l~iliary surgical instrument~ such as fiber optic and other imaging, treatment or diagnostic apparatus/ and can be permanently or detachably mounted to the middle tubular member 36. Detachable mounting of the channel member~
38 can b~ advantageous whe~ preparlng ~he surgical in~tru~ent 10 for st¢rilization following use on a patient or when the channel memb~rs are arranged to b~
disposabl~ and replaceable by replacemen~ channel members formed from a suitable material, such a~
plastic. In this and su~sequent drawing~, extension of the suture material 30 through he respective inner tubular members 34a and 34b is directionally ori~nted such that advancement of the suture material tow~rd the forcsp assembly 18 is designated 30i (inlet), whereas return of the suture material therefrom is designat~d as 30O (outlet~. As noted previously, th2 respQctiv~
direct~onal orientation~ o~ advancemen~ of th~ sukure material through inner tubular ~e~bers 34a and 34b can be reversed fro~ that described herein, if desired.
With reference again to Fig. 1, the handle assembly 20 inGludes a distal arm 40 joined to a proximal axm 42 through a spring member 44. Handling rings 46 and 48 are provided such that ring 46 i5 ~o~nted to distal arm 40 and ring 48 is mounted to proxi~al arm 42. The handling r~ng~ ~6, ~8 are dimensioned ~o as to rec~i~e one or ~ore f inqers of a user so as to facili~ate r~lative displacement of the handle ar~ 40, 42 inwardly or outwardly, as indicated by th~ arrow ~, and can be provid2d with a variety o~ different configurations, ~uch a~ half-ctrcular (Fig. 1) or annular (Fig. lA~.
The shoulder 50 (Fig. 1) o~ distal arm 40 ¢xtends through ~lot 51 forme~ in th~ outer tubular ~e~ber 12 to engage the inn~r tubular ~mb rs 3~a and 34b either -., . ~ ., , ~ . .. .. . . . .
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WO91/02490 ~ u ~ PCr/US90/04603 dix~ctly~ or by way of enqagement with middle tubular member 36 (Fig~ 12A). The shoulder 52 of proximal handle arm 42 is coupled to the outer l:ubular ~ember 12 such that ~ovement of the handle arms 40 and 42 toward one another results in proximal di.splacement of forcep arms 24a and 24b so as to close the respective tip portion~ 26a and 26b toward one another as the ~orcep .:
ar~C are retracted within dista.lly e~tending outer tubular member 12. Slot~ 53a, 53b can be formed along the interior surface of the distal portio2l 14 of the outer tubular member 12, as shown in Fig. 1213, to provide a guiding structure along which the proximallyo displaced port:ions o~ the forcep arsos 24a, 24b can slide incid~nt to closure or approxim?tion to facil~tate ~5 re~raction (alld extension) of the gorcep a~se~bly relative to the outer tubular member during Porcep arm manipulation through the handle as~embly 2 O .
Displacement o~ the handle arms 4 O and 4 2 away ~rom one another, a~ would . occur upon the release o~ the ~ ;
compressive force stored in the spring :Member ~4 generated by the move~ent o~ the handle arans 4LO and ~a2 toward 0~12 another, results in proximal moveD~ent of the outer tubular me~nber and simultaneous distalL ~ovemen~ of ~-inner tubular ~emb~r~ 34a and 34b (and any surrounding ;:
~5 middle tubular member 3~ that may be pres~nt~ so as to r~le~ and extend the ~orcep ar~s 24a and 24b to the open po-~ition illustrated in Fig. 1. :
Th~ relative position of handle arms 40 and 42 can be ~ixed by ~electiv~ ~ngagement o~ locking ~echanis~
150 so as tQ correspondi.ngly fix th~ relative poaition~
oP the opposed ~orcep arm~i 24a a~d 24b. The locking ~echani~ 150 includes n ar~ or bar 152 pivota~ly ~ount~d to one of the handl~ ar~s su~h as ar~ 42, by ~ :
p1vot ~ean~ uch as pivo~ pin 154, ~hat e~tendsi through j.
a ~lot 156 ormed in the other handle ar~ 40. The lock , : arm 152 can b~ con~igured a~ a gear ra~k ~aving a .
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wogl/02490 ~ J.~ ~9 ~ PCT/US90/04603 plur~llty of angled or ratchet-like protrusions 158 formed along a portion of the exte.rior ~ur~ace o~ the arm that are selectively engageable with coxresponding, complementary-angl~d or ratchet-liXe protrusions 160 S formed along one of the sides o the 810t 156 upon rota~able manipulation of the lock arm 152 by handle 162 80 a8 to bri~g the respective ar~ 2md ~lot prot~usions 158, 160 into juxtaposition. Lncking o~ the handle ar~s can be advantageous so a~ to ~reQ ~h~ u~er'~ hands to io operate further components of the instrument, such a~
the suture material advancing means 22 desorib@d below, or to operate other equipment related to the surgical procedure to be used in co~junction with, or independently o~, the instrument 10.
In an alternative arrangeme~t,-the handle 20 c~n be configured as a scissor-like handle, as ~llustrated in Fig. lB, in which the distal and proximal arm~ ~0' and 42' are pivotably coupled to one another ~t pivot 47 and ar~ re~ ntly biased by spring ~eans ~9 i~ a po~itlon so a~ to orient ~h~ forc~p arms 24a, 24~ coupled thereto i~ any of the ~anners described above in a pred~termined ..
position. For ~xample, coupling of distal scis~or ar~
40' to outer tubular ~emher 12 and proximal sci~sor arm 42' to inner tubular ~eE~er 34a, 34b either direc~ly or : 25 through ~iddle tubular member 3~, as shown, predisposes the ~orcep ar~ to maintain in an open ~separated) po3ition until the handle arms 40', 42' ~re urged toward one ~nother against the force exerted by spring ~eans 49~ Th~ handl~ ar~s 40', 42' can ba lock~d toge~h~r in a ~elect~d po~itlon ~hrsugh engagement o~ ~utually engageable locking -.~m3 ~52a, 152b and thQir reQp~ctlve, correspondingly-con~i~uired engagement ~ur~ace~ 158~, 160' as described aboYe in connection wi~h the arr~nge~ent depi~ted in F~g. 1.
~lth re~er~nce to Figs. 1 and 13, the suture ~at~rial ad~ancing as~embly 22 position~d ~t th~
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WO~1/0~490 PCT/US90/04603 pro~imal end 16 o~ the outer ~ubular member 12 comprise~
a p~ir of inlet guid~ roll~r~ 54a, 54b pivotably mounted by pins 56 to support ar~s 58a a.nd 58b, respectively.
Positioned opposite the inlet guide rollers 54a and 54b is a pair of outlet guide rollers 60a a~d 60b ~ounted by pins 56 to support arms 58a and 58b, respecti~ely. The support arms 58a and 58b are, in turn, are mou~ted to a support rod 6~ which is coupled at it~ di~tal end to the outer tu~ular member 12 at shoulder 52. The ~upport rod 62 can be disengageably mounted with respect to the outer tubular me~ber 12 to permit its r~moval therefrom incident to replacement, eleansing and sterilization of the instrument, as well as to per~it for the insextion of various ~uppleme~tal instruments through the cav$ty 35 of the outer tubular member~ A supply 64 of ~uture material 30 mounted within reel assembly 65 is coupled thereby to rod 62 through opposed fl~nges 6S (Fig. lC) and pin 56. Manually or automatical}y-operable provisions for advancing suture material ~rom the supply reel 65 can be provided. In the rrangement depicted in Fig. 1, a hand-operated crank 67 coupled to the supply reel 65 through a conventional spring release ~ssembly, designated generally by reference numeral G8, can be provided to control the advancement of suture material between inle~ rollers 54a and 54b. The spring relea~e as~bly 68 can be Or the type which provides a spring re~istance to rotation of the reel 65 unless the reel 65 i8 displacPd laterally with respect to 1ang~s 66 to prevent inadvertent release o~ suture ~aterial fxom the r~el 65, or can be coupled to an automatically operable devic~ such ~g a spr~ny motor (not shown) that i~ wound upon rotation of the handle winding de~ic~ 67 in 2 predeter~ined direction. Alternatively, the winding handl~ 67 and any related winding apparatus can b~
:: 35 arranged ~o as to b~ opera~le wi~h respect to o~e or : both o~ ineake rollers 54a, 54b (Fiq. ~ 3) in ord~r to .~ . ' ~ ,.: ' . - , - . . ~ ., : ., . ........................ . ... - . . .. .

', .. : ' ' , ' . ."' WO91/02490 PCT/U~90/04~03 o provide for automatic or manual advancement o suture mater~al into an appropriate one of the inner tubular members 34a, 34b. It i~ to be appreciated that advancement of suture ~aterial :in any o~ the above~
described manners advance~ suture ~aterial through one of the inner inlet tubular members, ~uch as 34b, through corresponding forcep arm 24b ~o ~ to extend into and through oppo~ed forcep arm 24a 21nd return proximally through inner tu~ular ~e~ber 34a to e~erge betwe~n oppose~ outlet rollers 60a and 60b for further manipulation, such as future knot: tying. Alte~native roller arrangements to that dep.icted in Fig. 1 can be provided Por the advancement o~ suture materi2l1. For example, single inlet and outlet rollers 54a, SOa ~Fig.
lF) can be provided in lieu of the mult.ipl~ roll~r arrangement of Fig. 1. The spring release and crank assembly can b~ mounted to the inle~ roller 54a as shown, or to the reel 65 in th~ manner described above to control the supply of sutur~ ma~erial ~o the forcep assembly 18 in the manner described above.
Alternative con~iguratio~s and modes of opera~ion for the suture ~aterial advancing means 22 can be substituted for the handle and crank asse~bly described above. For ! example, suitable DC-powered or spring-2~ powered motor assemblie~ can be provided to advance the sutur~ ~aterial distally throu~h the ~orcep arms 24a and ~4b in a continuous ~anner until disengagement of ~otor actuation in the case o~ the DC~motor or uncoupling o~
the spring motor from the suture 5upply reel. Such nau~oma~Qd" ~utur~ advancing sy~ems may be particularly adYantageou~ in configurations oP the suture ins~rum~nt ~0 in which the out~r tub~ 12 th~r~o~ i~ pro~ided with a length of on t~e order of 30 cm or longer ~o a~ ~o : ~ ~inimize operat~r fatigue and exp~di~e th~ i~uturing process. Alterna~ively, ~he su~ure ~ri 1 c~n be ~anually advanced in~o the out~r tubular ~ember 12 by .

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WO9l/02490 ~ PCT/US90/0~603 configuring the supply reel 65 a~ a thu~b-roller in fr~tional engagement with the inlet roller 54b and the outlet roller 60b such that rotation of the reel roller 65 directs relative movement of the respective inlet rollers 54a, 54~ so as to clraw suture matexial therebetwee~ from the r~el 65 to advance the ~uture material distally, through the ~orcep~ 24a, 24b, and outwardly therefrom to exit the instru~ent 10 betwe~n outlet rollers 60a, 60b. Advancem~ent of ~utuxe material is terminated upon the USeE ~ S cesC;ation o~ operation o~
the thumb roller 65, thereby providing the us2:r with a high degree of control as to the amount and rate of suture material advancement through the instrument.
~igs. 14A-14D illustrate in ~che~atic form formation of a suture wi~h the in~trument. Two or mor2 tissue or organ segments to be sutured, designated T1 and T2 throughout the drawin~s, are positionad betweQn, the open forcep arms 24a and 24b and are pierced thereby upon closure of the forc~p arms, aæ illustrated in Fig.
ZO 14A in the manner described above. Suture ~ateri~l 3 ol is adYanced dis ally toward the ~issu~ Tl, T2 through one o~ the forcep arms (orcep arm 24b in the drawings), through the opposed forcep a~ t24a), and returns proxi~ally, as illustrated in Fig. 14~, preferably ~hrough the corresponding inner tubular member 34a (Fig8. 11 and 12A). Followin.g extension of the suture ~aterial through the tissue segments T1 and T2, the gorcep arm5 are separa~ed ~rom one a~other and removed fro~ the tis~ue, leaving a loop 30L o~ sutur~ material . 30 extending betwQen the tissue segments ~1 and T2. As the forcep a ~ ~ 24a, 24b are wi~hdrawn fro~ ~h~ tissu~
~: seg~en~s, suture mat~rial can b~ advanced by way o~ any one o~ th~ foregoing uture advancing arrangement~
th~ough the instru~ent and tissue ~gm~nt~ in the direction o~ the arrows (Fig. 14C). Once the instxument ha~ b~en rema~ed fro~ t~e suture s$te~ ~ surgical knot ' ` ` '`:

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31 (Fig. 14D) can be tied in the ~uture material, advanced to the tissu~ seqments, and appropriately tensioned to join the tissue seg~ent~3 together.
A device 70 that is helpful in a~3vancing the suture Xnot 31 to the tissue segments Tl ancl T2 is illustrated schematically in ~ig. 15. The knot ad~ancing device comprises an elongated tubular st1~ctur~ 72 having formed therein a longitudinal slot 74 wh~.ch ex~end~ fro~
tbe distal end 76 to the proximal ~nd 78 o~ the de~ice.
A knob 79 detach~bly mount~d a~ the proximal end of the device includes means such as an angularly extending slot 81 for receiving the suture material from the groove. A recess 80 fo~med at the dist~l end of th~
device 70 is provided for receiving the knot 31 therein.
The device rece~s 80 is advanced distally against the knot 31, and the outwardly-extending length ~f suture material 30O is pulled along groove 74 and along slot 74 as the knob 79 is advanced proximally, as indicated in phantom, to advance the sutur~ knot into a desired tensioned engagement with tissue segments T1 and T2 joined by the suture loop 30L.
In an altern3tive con~iguration of the instrum~nt u 10, as illustrated in Figs~ 16 and 17, the inner tubular members 34a and 34b are each provided with a generally "C"-shaped or "~"-shaped cross-sectional con~iguration (Fig. 16), ox an open-sided crescent-shaped configura~ion (Fig. 17) so as to provide a lo ~itudinally-extending channel lO0 ext0nding into the ca~_ty 35 of the outer tubular ~e~ber. The channels 100 are dimensioned so as to permit pa~sage therethrough o~
~uture ~aterial 30O and 301. The cha~nel~ lO0 can be ,.
~lofied off ~ suitable obstructing ~ean~ such a~ a plate ~e~ber 102 (~ig. 16) or a rotatable rod 104 having a generally ~CY or ~U~-shaped cross-~ection so as to de~ine a lumen 106 ~or r~ceiving suture material s~rands 30i and 30O. R~mo~al o~ plat~ 102 or rotation og rod .

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W~91/02490 PCT/US90/046Q3 J ~ 3 ~ -16-104 such that the rod lumen opening faces the channel~
100 p8rmit~ for displacem~nt of the suture material from the inner tubular members 34a, 34b into the cavity 35 of the outer tubular member, thereby permitting insertion of device 70 into the cavity 35 following sutura knot formation so as ~o advanc~ the suture ~ot 31 toward the tissue segm~nts Tl and T2 (Figs. 14A-14D) through the instrument cavity 35.
The foregoing detailed d~scription i~ illu6tr.Lous 10 o~ various e~bodiments of the suture tying instrument of the subject invention. It will be appreciated from the foregoing description that variations and changes that can be made to the invention as set forth hereinabove and in the accompanying drawings expressly intended to 15 be encompassed by this description and the accompanying claims.
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Claims

WHAT IS CLAIMED IS:

1. A surgical suture device, comprising:
a cylindrical tubular member defining a cavity extending from a distal end of the tubular member toward a proximal end of the tubular member;
a forcep assembly comprising at least two opposed jaw members, at least one of said jaw members being selectively displaceable with respect to said tubular member, each of said jaw members defining a lumen in fluid communication with said tubular member cavity;
means for selectively displacing said at least one displaceable jaw member; and means for advancing suture material through said opposed jaw members so as to extend proximally within said tubular member cavity following passage through said jaw members.

2. The device according to claim 1, wherein said tubular member is configured as an outer tubular member defining at least one inner tubular member extending between one of said jaw members and the proximal end of the outer tubular member.

3. The device according to claim 1, wherein said tubular member is configured as an outer tubular member defining at least two inner tubular members, one of said inner tubular members extending between each of said jaw members and the proximal end of the outer tubular member.

4. The device according to claim 3, wherein each of said inner tubular members is provided with a longitudinally-extending channel open toward said outer tubular member cavity.

5. The device according to claim 4, wherein said inner tubular member channels are oriented so as to face one another.

6. The device according to claim 5, further comprising means for closing off at least one of said inner tubular member channels.

7. The device according to claim 6, wherein said inner tubular channel closing off means is selectively removable from the tubular member cavity.

8. The device according to claim 7, further comprising means insertable between said inner tubular member channels for advancing a suture material knot toward said forcep assembly.

9. The device according to claim 4, wherein said suture knot advancing means comprises an elongated member having a recess formed at one end thereof for receiving the suture material knot.

10. The device according to claim 4, wherein said inner tubular member channels are selectively alignable with one another.

11. The device according to claim 4, wherein each of said inner tubular members is provided with a generally crescent-shaped cross-sectional configuration.

12. The device according to claim 4, wherein each of said inner tubular members is provided with a generally circular cross section.

13. The device according to claim 1, wherein each of the opposed jaw members is selectively displaceable relative to said tubular member.

14. The device according to claim 1, wherein each of said jaw members is provided with a sharp-edged distal tip and the opposed jaw members are displaceable relative to one another between an open and a closed position.

15. The device according to claim 14, wherein said opposed distal tips are positionable adjacent one another in close proximity when said jaw members are oriented in the closed position.

16. The device according to claim 15, wherein said jaw member distal tips are angled relative to one another in partially overlapping relationship so as to facilitate tissue piercing upon closing of the jaw members.

17. The device according to claim 16, wherein said opposed jaw member distal tips are angled in opposite directions relative to one another.

18. The device according to claim 16, wherein said opposed jaw member distal tips are angled in substantially similar directions.

19. The device according to claim 14, wherein one of said opposed jaw member distal tips is insertable in the lumen of the distal tip of its opposed jaw member.

20. The device according to claim 19, wherein said suture advancing means includes means for advancing suture material distally through said tubular member cavity to said jaw member distal tip insertable into said opposed jaw member lumen.

21. The device according to claim 1, wherein said jaw member displacing means comprises a handle assembly operable by a user to selectively extend and retract said at least one displaceable jaw member relative to its opposed jaw member.

22. The device according to claim 21, wherein said handle comprises a proximal handle member and a distal handle member, said at least one displaceable jaw member being coupled to one of said handle and the tubular member being coupled to the outer of said handle members.

23. The device according to claim 22, wherein said at least one displaceable jaw member includes means extending through said tubular member cavity for coupling with said respective handle member to effect displacement of the displaceable jaw member.

24. The device according to claim 23, wherein said means extending through said tubular member cavity comprises an inner tubular member through which suture material is advanceable to said lumen of said at least one displaceable jaw member.

25. The device according to claim 24, wherein said proximal handle member is coupled to said inner tubular member and said distal handle member is coupled to said outer tubular member.

26. The device according to claim 24, wherein said inner tubular member is telescopically extensible within said outer tubular member.

27. The device according to claim 24, further comprising a second inner tubular member extending between the lumen of the other of said opposed jaw members through which suture material is advanceable.

28. The device according to claim 23, wherein both of said jaw members are selectively displaceable, said inner tubular members being coupled to its respective handle member to effect jaw member displacement upon manipulation of said handle members relative to one another.

29. The device according to claim 1, wherein said suture material advancing means is detachably mounted to the proximal end of the tubular member.

30. The device according to claim 1, wherein said suture material advancing means comprises means for advancing suture material through the tubular member cavity to one of said forcep jaw members.

31. The device according to claim 30, wherein said suture material advancing means comprises a reel assembly through which suture material can be passed that is selectively operable to advance suture material into said tubular member cavity.

32. The device according to claim 31, further comprising self-powered means for operating said reel assembly.

33. A method for suturing tissue at a surgical site, comprising the steps of:
positioning a suturing instrument adjacent the tissue to be sutured, the suturing instrument having at least two opposed forcep jaw members, at least one of the jaw members being displaceable relative to an instrument body and being selectively operable to move between a forcep open position and a forcep closed position, each of the opposed jaw members defining a lumen extending therethrough;
interposing the tissue to be sutured between the opposed jaw members and urging the displaceable jaw member toward its opposed jaw member to the closed position such that at least one of the jaw members penetrates the tissue to be sutured;
advancing suture material through the opposed jaw members so as to extend through the tissue to be sutured;
urging opposed jaw members of said forceps to said open position;
tying a knot in the suture material; and advancing the suture knot toward the tissue to be sutured.

34. The method according to claim 33, further comprising the step of advancing the suture knot through the instrument body to the tissue to be sutured.

35. The method according to claim 33, further comprising the step of inserting a distal tip of one of the jaw members into the lumen of the other of the opposed jaw members.

36. The method according to claim 35, further comprising the step of advancing the suture material through the lumen of the inserted jaw member and into the lumen of the opposed jaw member.

37. The method according to claim 33, further comprising the step of actuating suture self-advancing means to advance suture material through the opposed jaw members.

38. The device according to claim 1, wherein at least one of the opposed jaw memers is provided with a longitudinally extending slot that extends into said lumen.

39. The device according to claim 1, wherein at least one of said opposed jaw members is provided with an umbricated, concave recess formed at the distal end of the respeetive jaw member.

40. The device according to claim 1, wherein the device is configured as a single use disposable instrument .

41. The device according to claim 1, wherein the device is configured as a reusable instrument that is disassembleable to facilitate instrument cleaning and sterilization.

42. The device according to claim 3, wherein said inner tubular members are detachably mounted within said outer tubular member.

43. The device according to claim 22, wherein said proximal and distal handle members are coupled to one another by a spring arm.

44. The device according to claim 43, further comprising means for selectively fixing the relative position of said proximal and distal handle members.

45. The device according to claim 22, wherein said proximal and distal handle members are configured as scissor handle members that are pivotably connected to one another.

46. The device according to claim 45, further comprising biasing means for urging said scissor handle members toward a predetermined orientation.

47. The device according to claim 45, further comprising means for selectively fixing the relative position of said scissor handle members.

48. The device according to claim 1, wherein said forcep assembly is selectively retractable within said tubular member.

49. The device according to claim 31, wherein said reel assembly comprises a suture material supply reel and at least one pair of opposed roller wheels cooperable with said supply reel to advance suture material through the suture device.

50. The device according to claim 9, wherein said knot advancing means further comprises a slot that extends medially from an outer surface of the member for receiving suture material extending from said suture knot.

51. The device according to claim 50, wherein the elongated member is generally symmetrical along its longitudinal axis.

52, The method according to claim 38, wherein the suturing instrument is removed from the tissue to be sutured prior to tying of the suture knot.

53. The method according to claim 33, wherein the suture knot is tied prior to removal of the suturing instrument.

54. A device for advancing a knot formed in suture material toward tissue to be sutured, the device comprising an elongated member having a knot-receiving recess formed at one end thereof and a longitudinally-extending slot which extends medially from an outer surface of the elongated member.

55. The device according to claim 54, further comprising a detachable end cap having means for receiving suture material.

56. The device according to claim 54, wherein said slot extends from said knot-receiving recess.--

57. The device according to claim 56, wherein the device is generally symmetrical about its longitudinal axis .