Patent Application
20130023904
1. Field of the Invention
The present invention relates to a suturing method, and more particularly, to a suturing method using a suturing apparatus that sutures a perforation OT the like formed in the tissue of hollow organs, such as the stomach and intestines, using a suturing unit in which anchors are attached to the ends of a suture thread.
2. Background Art
In the related art, a suturing instrument using a suture thread that has anchors attached to both ends thereof in order to suture a perforation, a laceration, or the like that is formed in the tissue of hollow organs, such as the stomach and intestines, is known (for example, refer to International Publication No. 2007-37326). In this suturing instrument, suturing is performed by locking the anchors attached to both ends of the suture thread around a perforation in the tissue or outside of the tissue, and pulling and tightening the suture thread to draw the tissue having the anchors locked thereon.
Moreover, International Publication No. 2007-37335 describes that the suturing instrument of the same system includes a base having flexibility, an anchor holder that is arranged at a distal end of the base, is capable of accommodating a plurality of anchors therein, and has a distal end directed to a proximal end of the base, and a distal end position changing mechanism that moves the anchor holder in a direction that crosses an axis of the base in a length direction thereof. In this suturing instrument, if an attraction jig is brought close to the anchor, the anchor is released by magnetism from the anchor holder.
The present invention provides a suturing method of tissue using a suture apparatus including a suturing instrument that has a hollow anchor holder at a distal part thereof, the hollow anchor holder having a sharp distal end and having a plurality of anchors accommodated in an inner cavity thereof, and that performs suturing of tissue using a suture unit in which the plurality of anchors is attached to ends of a suture thread; an endoscope including an insertion part having a channel that allows the suturing instrument to be inserted thereinto; and a pressing part capable of being mounted on a distal end of the endoscope. The suturing method includes inserting the endoscope having the pressing part attached to the distal end thereof into a body cavity, and moving the endoscope to a near side of the tissue; inserting the suturing instrument having the suture unit mounted thereon into the channel, and projecting the distal part from the distal end of the endoscope; moving the anchor holder having the plurality of anchors accommodated therein to a back side opposite to the near side of the tissue; and inserting the distal end of the anchor holder into the tissue from the back side opposite to the near side while the tissue is pressed by the pressing part from the near side, and ejecting at least one of the plurality of anchors from the anchor holder.
A suturing method of a first embodiment of the invention will be described with reference to
The needle 11 is a hollow member formed of metal or the like, and is obliquely cut so that a distal end 11A forms an acute angle with an axis. An anchor of a suturing unit 103 is accommodated in an inner cavity of the needle 11 from a sharp distal end 11A thereof.
The stopper 105 is bent such that right and left ends 105A and 105B of a plate-shaped member made of metal, resin, such as biodegradable resin, or the like face each other, and is formed such that the ends 105A and 105B are engaged with each other.
A hole 105C is provided near the center of the stopper 105 in a right-and-left direction thereof, and the suture thread 104 that is bent at a middle point 104A is arranged so as to be inserted through the hole 105C from a surface opposite to the ends 105A and 105B and pass between the ends 105A and 105B that engage each other.
The first anchor 106A and the second anchor 106B are substantially round-bar-shaped members, and have the suture thread 104 connected to positions near the longitudinal centers thereof. Each of the anchors 106A and 106B is cut so as to form an acute angle with respect to each axis.
As shown in the partially cross-sectional view of
The base 12 is a member that is made of resin, a metal, or the like, and is formed in a substantially tubular shape. A turning shaft 15 that forms a right angle with an axis X1 of the tubular base 12 is attached to a distal portion of the base 12, and a proximal side of the base is connected to a sheath part 30 that connects the distal part 10 and the operating part 40. The sheath part 30, as shown in
The part of an outer peripheral surface of the base 12 that is located in the same phase as the turning shaft 15 is cut out over a predetermined range in a longitudinal direction so as not to interfere with the rotation of the needle 11. Additionally, although the outer peripheral surface of the base in a phase that faces the turning shaft 15 across the axis X1 is also cut out over a predetermined range from the distal side, the outer peripheral surface in the phase is left behind to such a degree that the distal end 11A of the needle 11 can be supported.
As shown in
The needle 11 is pivoted by the base 12 as the turning shaft 15 is inserted through the pivot portion 16, with the distal end 11A directed to the proximal side of the base 12. Thereby, the posture of the needle 11 can be switched to a first state and a second state by operating to advance or retreat the pulling wire 18 in the axis direction of the base 12. The first state is a state where the portion that is substantially parallel to the base 12 and closer to the distal end 11A side than the pivot portion 16 is accommodated in the inner cavity of the base 12, and the second state is a state where the axis of the needle 11 forms an angle with the axis X1, and the distal end 11A is directed to the direction away from axis X1.
The pusher part 13 includes a first pusher 19 for ejecting the first anchor 106A, and a second pusher 20 for ejecting the second anchor 106B.
The first pusher 19 is a round-bar-shaped member, and one end (a second end) thereof is formed with a connecting portion 19A that protrudes radially outward. A first wire (pusher wire) 21 for operating the first pusher 19 is locked to the connecting portion 19A. The second pusher 20 is a tubular member that has an inner cavity into which the first pusher 19 can be inserted, and has a connecting portion 20A that protrudes radially outward at one end thereof. A second wire (pusher wire) 22 for operating the second pusher 20 is locked to the connecting portion 20A.
In the needle 11, a groove 23 is formed in the outer peripheral surface of almost the same phase as the pulling portion 17 from the proximal end 11B side of the needle 11. The groove 23 has a first region 23A near the proximal end 11B, and a second region 23B that has a width narrower than the first region 23A and is continuous with the first region 23A. Both the lengths of the first region 23A and the second region 23B are almost equal to the longitudinal length of each of the anchors 106A and 106B of the suturing unit 103.
In the first pusher 19 and the second pusher 20, with the end of the first pusher where the connecting portion 19A is not provided being inserted into the end (the second end) of the second pusher 20 where the connecting portion 20A is provided, the end (the first end) of the second pusher where the connecting portion 20A is not provided is inserted into the proximal end 11B of the needle 11. The respective connecting portions 19A and 20A are arranged such that the phases thereof in a circumferential direction are matched with the groove 23, and as the connecting portions 19A and 20A move in the groove 23, the pusher part 13 can advance or retreat in the axis direction with respect to the needle 11. In the groove 23, the dimensions of the groove 23 and the respective connecting portions 19A and 20A are set so that, as for the width of the first region 23A, both of the connecting portions 19A and 20A can advance into the first region, and as for the width of the second region 23B, only the connecting portion 20A can advance into the second region.
The wires 21 and 22 connected to the pulling wire 18 and the pusher part 13, as shown in
The main body 41 is formed of resin or the like, and has therein a space along which the above-described three wires pass. Although the proximal end of the coil sheath 31 is connected to a distal portion of the main body 41, the proximal end of the resin sheath 32 can advance or retreat with respect to the main body 41 without being connected to the main body 41. An annular finger hooking portion 43 is provided at a proximal end of the main body 41.
The sliding portion 42 has slider 44, a second slider 45, and a third slider 46 that are slidably attached to the main body 41, respectively. An end of the first wire 21 is fixed to the first slider 44. An end of the second wire (not shown) is fixed to the second slider 45. An end of the pulling wire 18 is fixed to the third slider 46. Accordingly, as the respective sliders advance or retreat in the axis direction of the main body 41 with respect to the main body 41, the corresponding wires are advanced or retreated with respect to the base 12 of the main body 41 and the distal part 10, the pusher part 13 and the needle 11 can be operated.
The flow of the suturing method of the invention using the suturing instrument I configured as described above will be described with reference to
First, as shown in
Next, the distal part 10 of the suturing instrument 1 is inserted into a forceps opening 101 of an endoscope 100, and a distal end of the resin sheath 32 is projected from a working channel of the endoscope 100. Here, as shown in
As shown in
While the suturing instrument 1 is held, the operator retreats the resin sheath 32, and exposes the distal part 10 of the suturing instrument 1. In this state, if the operator pulls the third slider 46 of the operating part 40, the needle 11 is turned around the turning shaft 15, and as shown in
Next, the operator retreats the suturing instrument 1 with respect to the endoscope 100 while advancing the endoscope 100 to press the near side of the target tissue St around the perforation Pf using the cap 110, and as shown in
In the place where the needle 11 is passed through, the operator pulls the first slider 44 to the proximal side while holding a state in which the third slider 46 is pulled. Then, the second pusher 20 and the first pusher 19 are integrated, and move toward the distal end 11A in the needle 11. Since the connecting portion 19A of the first pusher 19 cannot advance into the second region 23B of the groove 23, the first pusher 19 stops in a place where the connecting portion 19A has moved to a connection part between the first region 23A and the second region 23B, and the operator cannot pull the first slider 44 anymore. At this time, since the second pusher 20 pushed by the first pusher 19 moves only by an amount corresponding to one anchor in the needle 11, as shown in
After the ejection of the first anchor 106A, the operator advances the whole suturing instrument 1, and extracts the needle 11 from the target tissue St. Then, the third slider 46 is advanced to bring the needle 11 into the first state, and then, as shown in
In addition, although the rotational operation of the suturing instrument 1 described above may be performed while the needle 11 is in the second state, the rotational operation of the suturing instrument while the needle is in the first state is safer because, for example, a situation in which the distal end of the needle 11 touches the target tissue St unintentionally does not easily occur.
Subsequently, the operator operates the third slider 46 to bring the needle 11 into the second state again as shown in
In the place where the needle 11 has penetrated the target tissue St, the operator pulls the second slider 45 to the proximal side. Then, the second pusher 20 pulled by the second wire 22 moves further toward the distal end 11A side in the needle 11 as the connecting portion 20A moves in the second region 23B of the groove 23. As the connecting portion 20A moves up to a terminal point of the groove 23 located in the vicinity of the pulling portion 17, the second pusher 20 moves in the needle 11 by approximately a length equivalent to one anchor. Thereby, as shown in
The operator removes the suturing instrument 1 from the endoscope 100, inserts a treatment tool for completing suturing into the forceps opening 101, and as shown in
The operator advances the forceps sheath 114 with respect to the forceps 112, with the vicinity of the middle point 104A of the suture thread 104 being gripped by the forceps 112. Then, while the stopper 105 and the forceps sheath 114 abut each other, only the suture thread 104 is accommodated in the forceps sheath 114, and the distance between the stopper 105 and each of the anchors 106A and 106B becomes short.
Since the anchors 106A and 106B are locked to the target tissue St, respectively, as shown in
In the suturing method of the present embodiment, by operating the third slider 46 of the suturing instrument 1, the posture of the needle 11 can be switched to the second state as shown in
Additionally, since the pusher part 13 is provided at the distal part 10, the anchors can be more reliably ejected by the pusher part 13 by operating the operating part 40 to pull the first wire 21 and the second wire 22.
Generally, in order to eject two anchors using a pusher, a stroke (travel distance) equivalent to the length of two anchors is needed. Accordingly, a suturing instrument with such a structure, the range (hard length) where a high-rigidity member is arranged in the distal part becomes the sum of the length of the needle 11 and the stroke of the pusher, and the length becomes the sum of the length of the needle 11 and a length equivalent to two anchors at the minimum.
However, in the suturing instrument 1 of the present embodiment, the needle 11 is provided with the groove 23 where the respective pushers 19 and 20 are movable. Thus, even in a state where the respective pushers 19 and 20 are completely accommodated in the needle 11, the pushers can be moved toward the distal end 11A by pulling the first wire 21 or the second wire 22. Accordingly, in order to secure a stroke, the projecting length from the needle can be shortened. As a result, it is possible to provide a suturing instrument in which the hard length is kept from becoming long and the insertion property to the endoscope 100 is held appropriately.
Moreover, since the pusher part 13 has two pushers of the first pusher 19 and the second pusher 20, and the number of the anchors and the number of the pushers are the same, the two anchors can be reliably ejected one by one. Moreover, since the groove 23 has the first region 23A and the second region 23B, the respective anchor 106A and 106B can be reliably ejected one by one by an easy operation of pulling the first slider 44 to a limit and then pulling the second slider 45 to a limit.
Moreover, since the pivot portion 16 of the needle 11 is located on the outer peripheral surface of the same phase as the part of the slope of the distal end 11A closest to the proximal side, the sharp distal end 11A does not easily protrude from the base 12 in the first state. Accordingly, the distal end 11A does not easily interfere with the inner surface or the like of the working channel of the endoscope or the like, for example, when the suturing instrument 1 is removed. In addition, even in a case where the needle 11 is slightly turning from the first state, as the inner surface or the like of the channel and the slope contact each other at the time of removal, the needle 11 easily returns to the first state. As a result, it is possible to provide a suturing instrument that can perform removal or the like smoothly and that is easier to use.
Additionally, according to the suturing method of the invention, when the needle 11 is inserted toward the near side of the target tissue St from the back side thereof, the insertion is performed while pressing the target tissue St from the near side thereof, using the cylindrical cap 110 attached to the distal end of the endoscope 100.
Since many of hollow organs that are targets of the present suturing method are excellent in extensibility, even if the needle is pushed against a hollow organ from one direction, tissue merely stretches or moves and may not be easily punctured. However, in the present suturing method, the target tissue St is punctured while being pressed toward the needle 11 by the cap 110. Thus, the needle can be inserted in a state where the target tissue has stretched to some extent, thereby preventing the situation as described above to make it possible to perform puncturing appropriately.
In the suturing instrument 1 of the present embodiment, when the needle 11 is in the first state, the proximal end 11B of the needle 11 is located at the distal end of the suturing instrument 1. Therefore, as in a modification shown in
Next, a second embodiment of the invention will be described with reference to
The second pusher 66 is tubularly formed of materials, such as metal, and the second wire 67 is connected to a proximal end that protrudes from the needle 63 by welding or the like. A distal part of the second wire 67 connected to the second pusher 66 is folded back in the shape of a hairpin, and a part ahead of a folded-back point 67A and a part behind a folded-back point 67A become substantially parallel to each other.
The first wire 68, similarly to the second wire, is folded back in the shape of a hairpin, and a distal part 68A that is bent after being folded back is inserted through the second pusher 66, and advances into the needle 63. That is, the distal part 68A inserted into the needle 63 functions as the first pusher.
Although the usage of the suturing instrument 61 configured as described above is almost the same as that of the suturing instrument 1, if the third slider 46 is pulled to bring the needle 63 into the second state, as shown in
If the first wire 68 is advanced until the distal part 68A of the first wire 68 is mostly accommodated in the second pusher 66 when the anchors are ejected, the distal part 68A as the first pusher advances by one anchor, and the first anchor 106A is ejected first. Subsequently, if the second wire 67 is pulled, the second anchor 106B is ejected by the second pusher 66.
When the first wire 67 and the second wire 66 are drawn, since the advance direction of the pushers differs from the retreat direction of the wires, a force that mutually separates a distal end and a proximal end in each wire acts. However, since each wire is folded back in the shape of a hairpin, this folded-back part holds the shape of each wire against the force that mutually separates the distal end and the proximal end. As a result, the pushers can be appropriately advanced within the needle.
In the suturing method of the present embodiment, the suturing instrument 61 includes a pusher part 69 made up of the distal part 68A and the second pusher 66. Thus, the respective anchors 106A and 106B of the suturing unit 103 can be reliably ejected similarly to the suturing instrument 1.
In the present embodiment, the first wire 68 and the second wire 67 are bent in the shape of a hairpin, and the distal part 68A of the first wire 68 functions as the first pusher. Thus, it is preferable that single wires with relatively high rigidity be used as these wires.
Although the preferred embodiments of the invention have been described above, it should be understood that the invention is not limited to these embodiments. Additions, omissions, substitutions, and other modifications can be made without departing from the scope of the present invention.
For example, during the insertion of the needle, it is necessary that the third slider is held in a pulled state. Therefore, the third slider may be adapted to be capable of being temporarily fixed to the main body of the operating part by a screw, a ratchet mechanism, or the like.
Additionally, the number of the anchors in the suturing unit is not limited to two, and may be arbitrary as long as a plurality of anchors is provided. In this case, it is preferable that the same number of pushers as the number of the anchors being provided, since the anchors can be easily ejected one by one, this is preferable.
Moreover, for example, in a case where a target tissue has sufficient thickness or the like, an anchor may be ejected into the tissue, with the distal end of the needle being located in the tissue.
Additionally, as shown in
Additionally, the cap used for the suturing method of the invention does not necessarily have to be a cylinder. For example, as in a cap 110B shown in
As shown in
By operating the needle 11 so that the sharp distal end 11A of the needle 11 does not protrude to the outside of the cap 110B from the separating portion, and by puncturing the target tissue St located in the cavity of the cap 110B, it is possible to reliably puncture only the target tissue St without damaging surrounding organs with the needle.
Here, as shown in
Thus, as shown in
