Abstract:
A surgical implantation device comprising: a flexible conduit having a proximal end and a distal end; a means for securing the flexible conduit to an operator&#39;s hand over a surgical glove such that the position of the conduit may be adjusted by the movement of one of the operator&#39;s fingers; a tissue anchor configured to enter the opening in the proximal end, be advanced through the conduit, and exit the opening in the distal end where it can be deployed beyond the surface of a target tissue layer; a suture element connected to the tissue anchor, the suture element configured to extend from the tissue anchor through the conduit; and a flexible rod having a proximal end and a distal end, the distal end of the rod configured to advance the tissue anchor through the conduit and deploy the tissue anchor beyond the surface of the target tissue layer.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS  
       [0001]     This application claims priority to U.S. Provisional Patent Application Ser. No. 60/809,877, filed Jun. 1, 2006, and to U.S. Provisional Patent Application Ser. No. 60/789,845, filed Apr. 5, 2006, both of which are hereby incorporated by reference as if set forth herein. 
     
    
     BACKGROUND  
       [0002]     1. Field of the Disclosure  
         [0003]     The present invention relates to a surgical introducer apparatus and method for inserting material to be retained within a living body.  
         [0004]     2. Background  
         [0005]     Securing materials such as graft material and suture material into the body is often used in the context of therapeutic surgical procedures. One area in which such procedures are often performed is vaginal reconstructive surgery. In this field, graft material is used to repair pelvic support defects such as cystoceles, rectoceles, and vaginal vault prolapse. The accurate placement of graft material or suture material at various positions via small incisions is desirable and has been an area of great progress in recent years. The “open access” Capio® (Boston Scientific, Natick, Mass.) device is commonly used to place suture material through the fibromuscular layers of the pelvic floor in the context of vaginal reconstructive surgery. This instrument passes a bullet-tipped suture through the layers of the pelvic floor and transfers the bullet-tipped suture to a receiving end, effectively placing a single stitch without the necessity of visualization. Limitations of this device include the following.  
         [0006]     First, the exit point of the suture is about 1 cm from the entrance point, effectively displacing the point of fixation of the graft material more distally than desired. In addition, because a loop of suture is created using the Capio® device, the possibility of inadvertently incorporating a portion of the bladder wall and/or the ureter exists. If this occurs, the bladder wall and/or the ureter may be constricted, obstructed, or otherwise injured as the suture is tied down.  
         [0007]     Second, use of this device in the repair of vaginal prolapse requires the operator to insert the device and his own finger into the paravaginal dissection. This insertion requires a dissection large enough to accommodate these two separate structures. Furthermore, feeling where the tip of the Capio® is located can be challenging because it is a thick and rigid instrument.  
         [0008]     Third, the Capio® has a limited depth of penetration (estimated 3 mm). Especially when placed against a flat surface such as the pelvic floor musculature. Depth of penetration is a critical factor in obtaining a secure purchase of tissue. A secure purchase of tissue is essential in creating an adequate and durable repair.  
         [0009]     A substantial improvement to the present state of the art would be afforded by an instrument that allows these same points of attachment to be obtained without the above-described deficiencies.  
         [0010]     Several other devices have been introduced recently to facilitate placement of graft material at various positions within the pelvis for the purpose of vaginal reconstructive surgery. The IVS Tunneler™ (Tyco Corp., Princeton, N.J.) was FDA approved as a method of obtaining a secure fixation point in the pelvic floor musculature in the context of vaginal vault suspension. This device involves the insertion of an introducer via a peri-anal incision through the ishiorectal fossa to the posterior surface of the coccygeus muscle. The introducer is then passed through the coccygeus muscle at which point a graft is loaded onto the tip of the introducer. The introducer is then withdrawn and the graft is pulled through the vaginal incision and out through the perianal incision. This procedure is then repeated on the contralateral side. The midline of the graft is sutured to the vaginal vault. Since the introduction of this instrument, several companies have introduced similar technologies that provide a method of creating secure points of attachment for either vaginal fibromuscularis or graft material. Some examples of these so-called trochar systems include: Avaulta™ (CR Bard, Inc., Murray Hill, N.J.), Apogee/Perigee™ (American Medical Systems, Minnetonka, Mich.). Deficiencies with these products include the following.  
         [0011]     These products involve the blind passage of introducers for relatively long distances along the posterior surface of the pelvic floor, where important nerves and vascular structures may be injured.  
         [0012]     The use of these products involves the necessity to leave long tags of permanent synthetic graft material between the posterior surface of the pelvic floor and the groin or perianal incision sites. A greater amount of foreign body may confer a greater risk of infection and or erosion.  
         [0013]     The technical difficulty in passing the introducers of these products to the desired position along the pelvic floor translates into greater surgical risk, especially for new adopters of the technology.  
         [0014]     These products result in the need for additional surgical incisions outside the vagina.  
         [0015]     A substantial improvement to the present state of the art would be afforded by an instrument that allows these same points of attachment to be obtained without the above-described deficiencies.  
         [0016]     Levy et al., in U.S. Pat. Nos. 6,332,888 and 6,475,135, describe a finger-guided surgical instrument with applications in the treatment of female urinary incontinence and vaginal prolapse. The instrument is a “thimble-like element” that fits over the operators finger in such a way that the tactile sensory function of the finger is relatively preserved. The design contains a mechanism to pass a surgical needle through and stitch tissue that the operator&#39;s finger abuts. Levy et al. describe an instrument in which there are channels within the housing of the “thimble-like element” to allow for passage of a surgical needle, an anchor guide and anchor, a capillary tube, or other instrument into tissue in close juxtaposition to the operator&#39;s finger tip. Deficiencies with this instrument include: (1) Relatively bulky design that is mechanically complex; (2) Position of the guide for the anchor element is lateral to the operator&#39;s finger tip and, therefore, not at the exact anatomic site palpated by the operators finger tip; (3) Relatively cumbersome in terms of reloading the instrument after placement of a suture or tissue anchor; (4) Relatively expensive to produce; and (5) In the embodiment that describes wearing the device over the ventral surface of the operator&#39;s finger, the insertion instruments extend from the distal tip of the instrument rather than immediately under the ventral pad of the operators finger. The rigid and bulky nature of this instrument would interfere with the operator&#39;s ability to discriminate landmarks as the device is deployed.  
         [0017]     A substantial improvement to the present state of the art would be afforded by an instrument that allows for the tactile-guided placement of a tissue anchor without the above described deficiencies.  
         [0018]     Various devices and techniques have been described to place tissue anchors within the soft tissues of the human body. The vast majority of these devices describe anchors that are intended to be placed within the substance of a muscle or tendon. These types of anchors often utilize barbs, spines, or other designs, such as a screw or helix shape, that are intended to grab the surrounding tissues so as to prevent the anchor from being dislodged. These types of anchors are most suitable for bulky, thick, target tissues, as the pull out force will be proportionate to the strength of the host tissue between the anchor and the point of insertion. These types of anchors are referred to as “partial thickness” anchors.  
         [0019]     For very thin muscles, partial thickness anchors are suboptimal because only a narrow band of tissue will remain between the insertion site and the anchor. When working with very thin muscles, such as the pelvic floor muscles, it would be ideal to utilize the strength of the full thickness of the target tissue. This utilization could be accomplished by placing the anchor through the target tissue such that it comes to rest against the deep surface of the target tissue. Various bar-shaped or T-shaped anchors have been described that could be used in this fashion. In the context of vaginal reconstructive surgery, it would be suboptimal to have any portion of the anchor impinging on the vaginal lumen. If a T-shaped anchor were used for this purpose, the vertical member of the T could cause male dysparunia or erosion through the vaginal epithelium. Because the pelvic floor muscles are very thin, even a bar-type anchor may be palpable through the vaginal epithelium.  
         [0020]     Furthermore, the solid bar-type anchors have several drawbacks. This anchor-type involves placement of a relatively large foreign body, which requires a relatively large insertion tract, and may be associated with greater risk of erosion into surrounding tissues and infection.  
         [0021]     A substantial improvement to the present state of the art would be afforded by an instrument that allows full thickness anchor placement without the above-described deficiencies.  
       SUMMARY  
       [0022]     The present invention provides a new, useful and non-obvious finger-directed implant system, device and method for precisely deploying a tissue anchor within the soft tissues of a living body via a minimally invasive technique. The system comprises four basic elements: (1) a conduit or conduit-glove assembly; (2) an insertion rod; (3) a suture element; and (4) a tissue anchor.  
         [0023]     According to one aspect of the present invention, there is provided a glove-like garment that contains a conduit along the ventral surface of the index finger that admits a flexible rod having a distal tip designed to penetrate the target tissue. The distal end of the rod is fashioned to carry the tissue anchor element into the target tissue and deposit the anchor element within the target tissue as the rod is withdrawn. The channeled glove contains a window over the tip of the guiding finger, centrally aligned with the tip of the conduit, allowing the operator to palpate the position of anatomical landmarks before the implantable element is deployed. Once the tip of the operator&#39;s finger is in position over the desired fixation point, the implantable element can be deployed by advancing the rod through the channel in the glove (i.e., the conduit). As the rod is advanced, it penetrates the host tissue at a point immediately beneath, and centrally aligned with, the ventral surface of the distal phalanx of the operator&#39;s finger. As the rod is advanced further, the implantable element is moved into the host tissue. The rod is advanced until the implantable element has moved through the host tissue layer. Once deposited beyond the deep surface of the target tissue layer, the rod is withdrawn from the channel, leaving the implantable element and attached sutures in place.  
         [0024]     As an alternative to the glove-conduit assembly, a conduit may be produced as a separate device, along with a means of attaching it to a standard surgical glove. For example, a conduit with an adhesive backing along one side could be used to attach it to any surgical glove. This configuration would solve the problem of trying to produce a single glove garment that would satisfactorily fit all operators. This solo conduit may be positioned along any finger the operator chooses to use as the guiding finger. The solo conduit would likely be easier to affix to the operator&#39;s hand than a separate glove device. In addition, a solo conduit could be produced less expensively and without the issue of right-left laterality that would exist with a glove-conduit assembly.  
         [0025]     In one embodiment, the implantable tissue anchor is a compressible ring-like element with memory of its natural annular, or semi-annular, shape. Covering the central area of the ring is a biocompatible fabric. The fabric contains a window at its distal end that allows the ring to be mounted onto the tip of the insertion rod. Suture material is attached to the tissue anchor such that it can be used, after the ring is deployed, for surgical purposes including, but not limited to, the fixation of graft material to the site where the anchor is deployed.  
         [0026]     In one version, the suture material is attached to the central region of the fabric that covers the central area of the ring. In a preferred embodiment, the frame of the tissue anchor includes a barb on the convex surface of the proximal edge designed to snare the host tissue and dislodge the implant from the insertion rod as the rod is withdrawn. The thickness of the frame is such that it is compatible with a recessed portion of the introduction rod. As the insertion rod and implantable element are introduced into the glove conduit the frame becomes compressed and elongated. The rim of the tissue anchor fits into the lateral and dorsal recesses of the insertion rod. The biocompatible fabric that covers the central portion of the frame drapes over the dorsal aspect of the insertion rod. The suture material attached to the central portion of the fabric passes along the side of the insertion rod as it is inserted into the conduit.  
         [0027]     In a preferred embodiment, the surgical implantation device comprises a flexible conduit having a proximal end and a distal end opposite the proximal end. The flexible conduit comprises an opening at the proximal end in communication with an opening at the distal end. The device also comprises a means for securing the flexible conduit to an operator&#39;s hand over a surgical glove such that the position of the conduit may be adjusted by the movement of one of the operator&#39;s fingers. The device further comprises a tissue anchor configured to enter the opening in the proximal end, be advanced through the conduit, and exit the opening in the distal end, where it can be deployed beyond the surface of a target tissue layer. The device also comprises a suture element connected to the tissue anchor. The suture element is configured to extend from the tissue anchor through the conduit, from the distal end to the proximal end. A flexible rod is also included, having a proximal end and a distal end opposite the proximal end. The distal end of the rod is configured to advance the tissue anchor through the conduit from the opening in the proximal end of the conduit to the opening in the distal end of the conduit and deploy the tissue anchor beyond the surface of the target tissue layer. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0028]      FIG. 1  is a ventral view of an exemplary conduit-glove assembly with a conduit extending across the palm region, along the ventral surface of the operator&#39;s index finger, to the distal phalanx of the index finger in accordance with the present invention;  
         [0029]      FIG. 2  is lateral view of an exemplary insertion rod in accordance with the present invention;  
         [0030]      FIG. 3  is a plan view of an exemplary insertion rod in accordance with the present invention;  
         [0031]      FIG. 4  is a plan view of an exemplary tissue anchor in accordance with the present invention;  
         [0032]      FIG. 5  is a lateral view of an exemplary embodiment of the insertion rod/tissue anchor assembly in accordance with the present invention;  
         [0033]      FIG. 6  is a ventral view of an exemplary embodiment of the tissue anchor-insertion rod assembly being advanced along the glove conduit in accordance with the present invention;  
         [0034]      FIG. 7  is a ventral view of an exemplary embodiment of the tissue anchor-insertion rod assembly emerging from the distal end of the glove conduit in accordance with the present invention;  
         [0035]      FIG. 8A  is a ventral view of an exemplary embodiment of the distal end of the glove conduit abutting the target tissue and the tissue anchor-insertion rod assembly advancing through the target tissue layer in accordance with the present invention;  
         [0036]      FIG. 8B  is an enlarged view of the anchor-insertion rod assembly, target tissue layer, and finger tip shown in  FIG. 8A ;  
         [0037]      FIG. 9A  is a ventral view of an exemplary embodiment of the rod being withdrawn from the target tissue, leaving the anchor on the deep side of the target tissue layer, in accordance with the present invention;  
         [0038]      FIG. 9B  is an enlarged view of the anchor, target tissue layer, and finger tip shown in  FIG. 9A ; and  
         [0039]      FIG. 10  illustrates an exemplary embodiment of the tissue anchor deposited within the target tissue in accordance with the present invention. 
     
    
     DETAILED DESCRIPTION  
       [0040]     Persons of ordinary skill in the art will realize that the following description is illustrative only and not in any way limiting. Other modifications and improvements will readily suggest themselves to such skilled persons having the benefit of this disclosure. In the following description, like reference numerals refer to like elements throughout.  
         [0041]     The present invention provides a tactile-guided system  2  for the precise, and minimally invasive introduction of an instrument into a body. The system  2  can be applied to surgical procedures involving placement of tissue anchors, incision and drainage of cystic structures, radiological localization of an anatomic structure, and injection of materials into the tissues of a body. The functionality of this instrument will be described with reference to  FIGS. 1-10 .  
         [0042]      FIG. 1  illustrates a glove garment  4  with an attached conduit  6  extending from the palm region  12  of the ventral surface of the operators hand, along the ventral surface of the operator&#39;s index finger  14 , to the operator&#39;s distal phalanx  16 . A window  12  may be disposed in the glove fabric over the ventral surface of the operator&#39;s distal phalanx  16  such that it exposes a portion of the operator&#39;s underglove (standard surgical glove)  56 . This window  18  allows the operator optimal tactile discrimination of anatomic landmarks relevant to the surgical procedure being performed.  
         [0043]     The conduit  6  contains a first opening at its proximal end  8  and second opening at its distal end  10  in order to allow passage of an insertion rod, such as insertion rod  20  shown in  FIGS. 2-3 , and a tissue anchor, such as tissue anchor  50  shown in  FIG. 4 , through the conduit  6 , as seen in  FIGS. 6-7 . In a preferred embodiment, proximal end  8  is substantially blunt, while distal end  10  is substantially tapered, preferably forming a sharp edge. However, it is contemplated that proximal end  8  and distal end  10  may be formed in a variety of different shapes.  
         [0044]      FIGS. 1 and 6 - 9 B show glove garment  4  covering a majority of palm region and completely envelopes the index finger, with the exception of window  18  on the ventral surface of the distal phalanx  16 , while leaving the underglove  56  exposed on a majority of the thumb, the ring finger and the little finger. In another embodiment, glove garment  4  may covers the operator&#39;s thumb in addition to the palm region and the index finger. It is contemplated that different finger configurations of glove garment  4  are well within the scope of the present invention. Preferably, glove garment  4  is configured to be worn over the operator&#39;s hand such that it covers at least a portion of the operator&#39;s palm and wraps around the back of the operator&#39;s hand to securely hold itself in position on the operator&#39;s hand. Additionally, glove garment  4  is preferably configured to extend over a substantial portion of at least one of the index finger and the middle finger.  
         [0045]     Glove garment  4  provides a secure, yet easily removable, surface for holding conduit  6  in position on the operator&#39;s hand during use. The conduit element  6  may extend along the ventral surface of the operator&#39;s index finger  14  to a window region  18  in the glove element  4  over the ventral surface of the distal phalanx  16  of the operator&#39;s index finger. In a preferred embodiment, conduit  6  is configured to extend all the way from the operator&#39;s palm region  12  to the distal phalanx  16  of the operator&#39;s index finger.  
         [0046]     It has been appreciated that the conduit element  6  may be provided separate from any glove garment. In this alternative embodiment, conduit  6  is provided along with a means of securing it to a standard surgical glove. One method of securing such a solo conduit would be to cover one surface of the conduit  6  with an adhesive tape having a removable backing such that when the backing is removed, the tape extends on either side of the conduit  6 , thereby allowing the conduit  6  to be secured to a standard surgical glove at a position desired by the operator. Other securing means may be used in addition, or as an alternative, to an adhesive. This simplification of the present invention eliminates the need for multiple sizes of glove garments to accommodate operators with different sized hands. In addition, the solo conduit would be less expensive to produce, package, and ship, than a glove-conduit assembly. Production of a solo conduit eliminates the issue of right-left laterality inherent to the glove-conduit assembly.  
         [0047]     In a preferred embodiment, conduit element  6  is made of a flexible material such that it will conform to the contour of the ventral surface of the operator&#39;s palm and finger as the operator&#39;s finger is flexed to the degree necessary to palpate the site desired for anchor placement.  
         [0048]     In a preferred embodiment, insertion rod  20  is an elongated, flexible instrument having a proximal end  22  and a distal end  24  opposite proximal end  22 . Insertion rod  20  is configured to fit within the conduit element  6 . The proximal end  22  is preferably blunt, so as to avoid any accidental incisions, and may comprise a slit  26  that is configured to receive the suture elements  44  of the tissue anchor  50 , shown in  FIG. 4 , in such a way that the suture elements  44  are held securely in place within slit  26 , as seen in  FIG. 6 , while the rod  20  is inserted through the conduit  6  and into host tissue. By securing the suture elements  44  to the proximal end  22  of the insertion rod  20  in this way, and under a reasonable amount of tension, the anchor  50  will be held in a stable position on the distal end  24  of the insertion rod  20 . This secure positioning will be useful when inserting the insertion rod/anchor assembly into the proximal end  8  of the conduit  6 , and will help prevent premature deployment of the anchor  50 .  
         [0049]     A depth marker  58  may be provided along the shaft of the insertion rod  20  to indicate to the operator when the distal tip of the insertion rod  20  has been advanced to a desired depth, as seen in  FIGS. 6-7 . The depth marker  58  may comprise any means suitable for indicating the depth of the insertion rod, such as printed markings or notches, and is preferably disposed closer to proximal end  22  than to distal end  24 . The depth marker  58  will arrive at the proximal end  8  of the conduit  6  when the desired depth of penetration has been reached, as seen in  FIGS. 7-8A .  
         [0050]     As seen in  FIGS. 2-3  and  5 , the distal end  24  of the insertion rod  20  is fashioned to translocate the tissue anchor  50  through the conduit  6 , and through a thickness of host tissue. Distal end  24  comprises a penetrating tip  32  that is configured to penetrate the target tissue. In this fashion, distal end  24  may be formed in the shape of a needle tip. The insertion rod  20  is designed to translocate the tissue anchor  50  in only one direction as it is advanced forward through the conduit  6  and host tissues. The insertion rod  20  is also designed to separate from the tissue anchor  50  as the insertion rod  20  is withdrawn from the host tissue, leaving the tissue anchor  50  within the host tissue.  
         [0051]     The distal end  24  of the insertion rod  20  may contain lateral grooves  28  of a depth and width adequate to accept the frame  36  of the anchor element  50 . These lateral grooves  28  are preferably in continuity with a distal groove  30  within the penetrating tip  32  of the distal end  24  of the insertion rod  20 . The groove  30  in the penetrating surface of the insertion rod  20  is of a depth and width adequate to accept the leading end  38  of the anchor frame  36 . In FIG.  3 , line  31  illustrates one example of how deep groove  30 . It is contemplated that different groove depths are within the scope of the present invention.  
         [0052]     In a preferred embodiment, there is a recess  54  in the material of the insertion rod  20  that is disposed proximal to the lateral grooves  28 . This recess  54  accommodates the lagging end  40  of the anchor frame  36 . Recess  54  and the grooves  28  and  30  described above serve to reduce the thickness of the insertion rod/anchor assembly. In addition, the proximal recess  54  allows the lagging end  40  of the anchor element  50  to be dislodged from the insertion rod  20  by the surrounding host tissues as the rod  20  is withdrawn from the host tissues.  
         [0053]     In a preferred embodiment shown in  FIG. 4 , the tissue anchor element  50  comprises a frame  36 , a biocompatible fabric  42 , and suture elements  44 . The frame  36  is preferably composed of a strong flexible material that possesses the property of memory. Possible materials include, but are not limited to, heat treated stainless steal (memory wire), various metallic alloys, resins, plastics, silicon, synthetic rubbers, various bio-absorbable materials such as polyglycolic acid (vicryl), or some combination of these or any other suitable materials. The physical properties of the frame material allow the frame  36  to be compressed into an elongated shape as it is loaded onto the insertion rod  20  and advanced through the conduit and host tissues. The physical property of memory will cause the anchor frame  36  to expand once it is advanced completely through conduit and into sufficiently compliant tissue, such as adipose tissue.  
         [0054]     In a preferred embodiment, such as shown in  FIG. 4 , the leading end  38  of frame  36  is substantially angled, while the lagging end  40  is substantially rounded. However, it is contemplated that a variety of different frame shapes are within the scope of the present invention.  
         [0055]     The biocompatible fabric element  42  of the anchor  50  preferably extends across a majority of the interior of anchor frame  36 . A window  48  may be disposed in the fabric  42  at the leading end  38  of the anchor element  50 . This window  48  is configured to receive the penetrating tip  32  of the insertion rod  20  as the anchor  50  is loaded onto the distal end  24  of the insertion rod  20 , as seen in  FIG. 5 .  
         [0056]     The biocompatible fabric  42  may comprise any material compatible with the human body. For example, fabric  42  may be composed of a permanent synthetic material, such a woven, knitted, or molded polypropylene. The fabric  42  may also be a biological allograft or xenograft. The fabric material may also include a bio-absorbable material, such as polyglycolic acid. The fabric  42  may be composed of any other biocompatible material having the softness, strength, and flexibility suitable for insertion, deployment, and retention within a body.  
         [0057]     The fabric  42  can be attached to the anchor frame  36  by a variety of techniques including, but not limited to, adhesive or heat bonding. If the frame  36  and the fabric  42  are composed of the same material, they may be manufactured as a single piece, thereby circumventing the need to attach two separate elements. The fabric  42  may also have the property of memory, such that it will contribute to the expansive force of the frame  36  as it resumes it&#39;s original shape once it is deployed.  
         [0058]     In a preferred embodiment, the suture element  44  is attached to the central region  46 , or a location proximate the central region  46 , of the biocompatible fabric  42 . In another embodiment, a single strand of suture is looped through the biocompatible fabric in such a way that it can slide through the fabric if traction is applied to one arm of the suture. This later embodiment would allow the suture to be used as a pulley apparatus to elevate a tissue graft secured to the second arm of the looped suture strand.  
         [0059]     The device of the present invention can be used for a variety of procedures requiring fixation of suture material at precise locations within a body. Among these procedures are vaginal reconstructive procedures including, but not limited to, vaginal vault suspension, uterine suspension, rectocele repair, cystocele repair, and urethral sling procedures. This apparatus can be used in the context of graft augmented procedures, or procedures in which the sutures are attached to the patient&#39;s own tissues.  
         [0060]     The following describes the application of the present invention in the context of graft augmented vaginal vault suspension and rectocele repair. With adequate anesthesia established, and with the patient prepped and draped in a lithotomy position, the posterior vaginal wall is incised along the midline for a distance of approximately 5 cm. The posterior vaginal wall epithelium is dissected off the underlying rectum laterally to the pelvic floor musculature, and cephalad up to the ishial spines. The dissection is continued cephalad until the undersurface of the vaginal vault tibromuscularis is adequately exposed.  
         [0061]     With the conduit  6  (either secured as a solo conduit directly on underglove  56  or grouped with conduit glove  4 ) being secured on and positioned by the index finger of the operator&#39;s left hand, the patient&#39;s left ishial spine is palpated with the ventral surface of the distal phalanx of the operators first finger. While the operator holds the tip of his first finger against this boney landmark, the tissue anchor/insertion rod assembly is inserted into the proximal end  8  of the conduit  6  and advanced through the conduit  6  until the tip  32  of the insertion rod  20  emerges from the distal end  10  of the conduit  14 . The insertion rod is then advanced further pushing the tip of the insertion rod through the pelvic floor musculature just anterior to the ishial spine, as seen in  FIGS. 8A-8B . The insertion rod is advanced until the depth marker  58  aligns with the proximal end  8  of the conduit  6 , indicating that the lagging end  40  of the tissue anchor  50  is beyond the deep surface of the target tissue layer  52 . The suture elements  44  are then dislodged from the holding slit  26  in the proximal end  22  of the insertion rod  20 . The insertion rod  20  is then withdrawn from the conduit  6 , leaving the tissue anchor  50  deployed within the host tissue  50 , as seen in  FIGS. 9A-10 . The operator&#39;s hand is then removed, as the sutures  44  attached to the anchor  50  slide through the conduit  6 .  
         [0062]     Additional anchors can be placed at more distal locations along the left side of the pelvic floor. This procedure is repeated on the patient&#39;s opposite side using the operator&#39;s opposite hand in order to place anchors at corresponding symmetric positions along the pelvic floor. The sutures attached to the various anchors are then used to secure an approximately trapezoidal shaped piece of biological or synthetic graft material into position over the rectum and beneath the fibromuscularis of the vaginal vault. Excess suture is trimmed. A tacking suture is placed between the graft and the undersurface of the fibromuscularis of the vagina vault and the midline of the upper edge of the graft. The posterior vaginal wall epithelium is closed in the usual fashion.  
         [0063]     It should be appreciated that the material used to fabricate the insertion rod is sufficiently flexible to allow the tip of the insertion rod to be deflected off of a boney structure as the insertion rod and anchor are advanced through tissues that are closely applied to bone. Additionally, the penetrating tip of the insertion rod may be slightly blunt so as to prevent the tip from imbedding into the periostium of a boney structure it may contact in the course of anchor insertion.  
         [0064]     A similar technique can be used to perform a graft augmented cystocele repair.  
         [0065]     The apparatus can be used to place tissue anchors through the pelvic floor musculature at the location appropriate for fixation of a mid-urethral sling. With anchors placed symmetrically in such a position, a small strip of graft material can be secured at the level of the midurethra to treat urinary incontinence. The flexible properties of the conduit and the insertion rod will allow the tip of the rod to be directed in a desired, relatively lateral, direction as the host tissue is penetrated by the tip of the insertion rod.  
         [0066]     The apparatus can be used to perform a so-called “male sling” procedure by obtaining fixation points along the pelvic floor musculature at a suitable location for placement of a graft over the proximal urethra.  
         [0067]     The tissue anchor-insertion rod assembly can also be used for laparoscopic procedures requiring fixation of suture material at precise locations within the host tissues. Examples of such procedures include laparoscopic uterine suspension or vagina vault suspension.  
         [0068]     While embodiments and applications of this disclosure have been shown and described, it would be apparent to those skilled in the art that many more modifications and improvements than mentioned above are possible without departing from the inventive concepts herein. The disclosure, therefore, is not to be restricted except in the spirit of the appended claims.