Abstract:
A system for ligating a uterine artery in a patient generally includes a suture transfer tool, suture transfer darts, and one or more sutures. The suture transfer tool includes an upper jaw that is pivotally joined to a lower jaw. The lower jaw of the tool includes a number of suture capturing pins. The suture transfer darts are configured to be tissue piercing and are positionable within the suture capturing pins. Each end of the suture is connected to a suture transfer dart. When operating the tool, the suture transfer darts pierce through the tissue to either side of a patient&#39;s cardinal ligament, which contains the uterine artery, and simultaneously present an end of the suture to either side of the cardinal ligament. As such, the suture is in an open loop configuration about the cardinal ligament and can be tied tight to the ligament to occlude the uterine artery.

Description:
CLAIM TO PRIORITY  
       [0001]     The present application claims priority to U.S. provisional patent application Ser. No. 60/687,734, filed Jun. 6, 2005 and entitled “Devices and Methods for Treating Uterine Fibroids.” 
     
    
     FIELD OF THE INVENTION  
       [0002]     The present invention pertains to surgical procedures, tools, and kits particularly suited to effect uterine artery ligation in a minimally invasive manner to treat uterine fibroids or other conditions of the uterus.  
       BACKGROUND OF THE INVENTION  
       [0003]     Each year, many women undergo a surgical removal of the uterus (hysterectomy) due to the growth of muscular tumors of the uterus (leiomyoma or uterine fibroids) or for uterine cancer, adenomyosis, menorrhagia, uterine prolapse, and dysfunctional uterine bleeding (abnormal menstrual bleeding that has no discrete anatomic explanation such as a tumor or growth). The uterus has a pear-shaped, uterine body extending between a fundus extending right and left to junctions with the right and left Fallopian tubes and a uterine neck (cervix) that extends to the vagina. The uterus has a smooth muscle uterine wall (myometrium) with an interior uterine mucosa (endometrium) that lines a uterine cavity extending between the right and left Fallopian tubes and a cervical opening of the cervix to the interior of the vagina. The uterine body is supported within the pelvis by right and left ligamentous structures such that the uterine body (fundus) is bent (anteflexed) and tilted (anteverted) anteriorly over the bladder and separated from the sacrum by the bowel. The uterine cervix extends into a tissue cul-de-sec of the vagina such that a flexible, annular trough (fornix) of the vagina surrounds and is integrally connected with the cervix.  
         [0004]     The ligamentous structures each include a broad ligament (part of the peritoneum), a round ligament, an ovarian ligament, a uterosacral ligament, a cardinal ligament, and other tissue structures. The broad ligament is a broad fold of peritoneum extending over the uterus and from the lateral margins of the uterus to the wall of the pelvis; it is divided into the mesometrium, mesosalpinx, and mesovarium that extend on each lateral side of the uterus to the wall of the pelvis. The mesometrium is the portion of the broad ligament below the mesovarium, composed of the layers of peritoneum that separate to enclose the uterus. The mesovarium is a portion of the broad ligament of the uterus between the mesometrium and mesosalpinx, which is drawn out to enclose and hold the ovary in place. The uterosacral ligaments are parts of the thickening of the visceral pelvic fascia beside the cervix and vagina, passing posteriorly in the rectouterine fold to attach to the front of the sacrum. The cardinal ligaments are fibrous bands attached to the uterine cervix and to the vault of the lateral fornix of the vagina and are contiguous with the mesometrium sheathing the pelvic vessels including the right and left uterine arteries.  
         [0005]     Oxygenated blood is provided to the normal uterine cells and the cells of uterine fibroids by a redundant arterial blood supply denoted in the bilateral left and right uterine arteries and the bilateral left and right ovarian arteries. The right and left uterine arteries branch from the internal iliac artery and cross over the ureter at the level of the internal ostium (os) of the cervix and each divides into ascending and descending limbs. The ascending limb runs tortuously upward, between the leaves of the broad ligament, and supplies horizontal anterior and posterior branches to the cervix and the corpus. The descending branch of the uterine artery turns inferiorly and supplies the vagina from the lateral aspect. The ascending and descending branches of the uterine arteries extend through and are enclosed within the cardinal ligaments.  
         [0006]     Uterine leiomyomas, commonly known as fibroids or myomas, are well circumscribed, solid, benign tumors arising from the smooth muscle of the myometrium, and are composed of smooth muscle cells and extracellular matrix. Fibroids may occur in several locations within the uterine wall and are named subserosal, submucosal, or intramural depending on their location. Subserosal leiomyomas are located just under the uterine serosa and may be attached to the corpus by a narrow or a broad base. Intramural leiomyomas are found predominantly within the thick myometrium and may distort the uterine cavity or cause an irregular external uterine contour. Submucous leiomyomas are located within the myometrium proximate to the endometrium. Uterine leiomyomas or fibroids are clinically apparent in 20% to 25% of women during the reproductive years and cause symptoms necessitating treatment, typically surgical removal of the uterus.  
         [0007]     The surgical removal of the uterus requires exposing it sufficiently, ligating and severing the arteries and Fallopian tubes, severing the broad ligament and other ligaments from the uterine body, and severing the cervix from the fornix. Thus, in addition to the loss of reproductive capability, a hysterectomy requires major invasive surgery that can involve excessive blood loss, prolonged convalescence, attendant pain and discomfort, and economic costs. Newer treatment methods have been developed or proposed for at least some of these diseases and conditions. Nevertheless, hysterectomy remains the treatment of choice to treat the conditions and diseases listed above while less drastic treatments continue to be explored.  
         [0008]     In the case of uterine fibroids, intraluminal occlusion of the right and left uterine arteries has been demonstrated as efficacious in starving and killing fibroid cells in situ while leaving normal uterine cells intact. For example, uterine artery occlusion or embolization was demonstrated as effective in eliminating or lessening uterine fibroids in Ravina et al., “Arterial Embolization to Treat Uterine Myomata”,  Lancet,  1995; Vol. 344; pp. 671-692. In this technique, uterine arteries are accessed via a trans-vascular route from a common femoral artery disposing a delivery catheter within the left and right uterine arteries, and embolic coils are dispensed from the catheter into the uterine arteries to promote clotting and thereby occlude the arterial passageways. When the uterine arteries are occluded in this fashion (or in any other fashion), the normal uterine cells and the fibroid cells of fibroids within the fundus are deprived of one blood supply. However, as demonstrated by Ravina et al., the effect on the fibroid cells is greater than the effect on normal uterine cells. In most instances, the relatively faster growing fibroid cells require a higher volume of blood oxygen and die when starved of oxygen, leading to fibroid shrinkage and cessation or diminution of clinical symptoms. Various methods of intraluminal occlusion of the right and left uterine arteries near the upper and lower branches thereof are also set forth in U.S. Pat. No. 6,602,251 and in U.S. Patent Application Publication No. 2004/0202694, for example.  
         [0009]     Such catheter-based uterine artery embolization must be performed with fluoroscopic or other visualization equipment by an interventional radiologist trained in catheterization and embolization delivery techniques. Thus, other invasive or non-invasive or minimally invasive techniques have been proposed and clinically explored to access the bilateral uterine arteries trans-vaginally or in a laparoscopic approach from a skin incision to temporarily or permanently apply compressive force around and thereby close the uterine arteries.  
         [0010]     For example, trans-vaginal uterine artery occlusion with sutures tied around the right and left uterine ligaments exposed via a cervical incision is described by Harmanli, M D et al., in “Trans-vaginal Uterine Artery Ligation in a Woman with Uterine Leiomyomas”,  Journal of Reproductive Medicine,  May 2003, Vol. 48; pp. 384-386. In this minimally invasive approach through the vagina, the uterosacral and cardinal ligaments are exposed by an annular incision around of the cervix, and the sutures are tied around the right and left uterine arteries and the supporting ligaments to occlude the arteries. Preferably, sutures are tied around the right and left uterosacral ligaments supporting descending branches of the uterine arteries and at least a proximal portion of the right and left cardinal ligaments supporting ascending branches of the uterine arteries. Thus, it is necessary to surgically expose both ligaments in a trans-vaginal procedure that is customarily followed in the initial steps of performing a hysterectomy. Typically in a hysterectomy, the uterine arteries are first clamped, ligated, or cauterized to halt blood flow to the uterus before the supporting ligaments are severed along the uterine wall.  
         [0011]     A wide variety of further uterine artery occlusion techniques have been proposed in U.S. Pat. Nos. 6,254,601 and 6,546,933, for example, and in Burbank, et al., “Uterine Artery Occlusion by Embolization or Surgery for the Treatment of Fibroids: A Unifying Hypothesis-Transient Uterine Ischemia,”  The Journal of the American Association of Gynecologic Laparoscopists , November 2000, Vol. 7, No. 4 Supplement, pp. S3-S49. In particular, various methods and apparatus have been suggested to determine the location of the uterine arteries, effect either permanent of temporary cessation of blood flow through the uterine arteries to the uterus to starve uterine fibroids of sufficient oxygenated blood, and to verify the blood flow cessation.  
         [0012]     Various additional tools and minimally invasive techniques are presented for applying permanent or resorbable sutures or occlusion devices including snares, clips, and clamps, about at least a portion of each cardinal ligament and uterine artery are disclosed in U.S. Pat. Nos. 6,506,156, 6,550,482, 6,602,251, 6,635,065, and 6,638,286 and in U.S. Patent Application Publication Nos. 2002/0124853 and 2003/0120286. Typically, access to the uterine arteries and cardinal ligaments is obtained by instruments introduced trans-vaginally to make one or more incision through the fornix and to advance and affix the suture or occlusion device about a portion of each cardinal ligament and uterine artery tightly enough to diminish or halt oxygenated blood flow.  
         [0013]     Furthermore, tools adapted to be trans-vaginally applied temporarily to occlude the right and left uterine arteries are disclosed in U.S. Patent Application Publication Nos. 2002/0124853, 2002/0165579, 2002/0183771, 2003/0120306, 2003/0191391, 2004/0097961, 2004/0092979, 2004/0097962, 2004/0153105, 2004/0158262, and 2005/0113852. In one approach, the distal end of the tool that is advanced into the vagina is advanced into the fornix alongside the cervix to stretch the fornix and compress the right and/or left uterine artery against itself or against the cervix. The tool distal end is not advanced through the wall of the fornix, and the approach is therefore characterized as non-invasive. The tool may include a blood flow sensor to assist in disposing the tool distal end against a uterine artery and to verify that blood flow is reduced or halted when the uterine artery is compressed. The tool is applied to the uterine artery or arteries for a sufficiently long time period to effect starvation and death of uterine fibroids and is then withdrawn, allowing oxygenated blood flow to be restored unless occlusion has taken place.  
         [0014]     Despite these approaches, it would be desirable to provide improved surgical instruments, tools and/or occluding devices and procedures that can be safely, simply, and readily employed to effect temporary or permanent occlusion of the uterine arteries, particularly through a non-invasive or minimally invasive trans-vaginal approach. Since their gynecologist diagnoses the majority of the patients suffering from fibroids, there is an advantage to the patient to be treated with a procedure that can be performed by their gynecologists. Because of the perceived risk of patient loss to referral, many patients will go untreated or are recommended a hysterectomy to treat their symptoms. If a trans-vaginal approach that follows many of the steps of a hysterectomy, which most gynecologist can perform, were available for the treatment of fibroids, many more patients would benefit from the relief of their symptoms with a minimally invasive surgery that could be performed by their gynecologist.  
       SUMMARY  
       [0015]     The preferred embodiments of the present invention incorporate a number of inventive features that address the above-described needs. The surgical procedures, tools and kits of the present invention are not necessarily limited to but are particularly suited to effect uterine artery ligation in a minimally invasive manner to treat uterine fibroids or other conditions of the uterus by diminishing or blocking arterial blood flow to treat uterine diseases or disorders.  
         [0016]     The surgical procedures, tools and kits of the preferred embodiments of the present invention may be employed to restrict or block uterine arterial blood flow to treat uterine fibroids or other conditions through a minimally invasive trans-vaginal approach placing one or more sutures around the uterine arteries and at least a portion of the ligaments surrounding the uterine arteries.  
         [0017]     As such, the present invention comprises a system for ligating a uterine artery in a patient. The system generally includes a suture transfer tool, suture transfer darts, and one or more sutures. The suture transfer tool includes an upper jaw that is pivotally joined to a lower jaw. The lower jaw of the tool includes a number of suture capturing pins. The suture transfer darts are configured to be tissue piercing and are positionable within the suture capturing pins. Each end of the suture is connected to a suture transfer dart. When operating the tool, i.e., pivoting and compressing the upper jaw towards the lower jaw, the suture transfer darts pierce through the tissue to either side of a patient&#39;s cardinal ligament, which contains the uterine artery, and simultaneously present an end of the suture to either side of the cardinal ligament. As such, the suture is in an open loop configuration about the cardinal ligament and can be tied tight to the ligament to occlude the uterine artery.  
         [0018]     The upper jaw of the tool preferably includes a transfer hole opposite each suture capturing pin to receive and maintain the suture transfer darts upon activation of the tool. The transfer darts are preferably cut from the suture to enable tying of the loop. The system may further include a second suture that is secured to one of the same transfer darts as the first suture. Upon pivoting an compressing the upper jaw to the lower jaw, the piercing of the tissue presents the end of the second suture in a position intermediate the cardinal ligament and the uterosacral ligament allowing a loop to be created about the uterosacral ligament with the second suture that allows the uterosacral ligament to be tied off as well. If two sutures are used, they are preferably color-coded for easy identification. Each of the suture capturing pins preferably includes a slot that aligns the suture when the suture transfer dart is placed within the suture capturing pins.  
         [0019]     A method of the present invention for ligating a uterine artery includes the following steps: (1) simultaneously piercing the tissue to either side of a cardinal ligament, which contains the uterine artery; (2) while piercing, simultaneously delivering the ends of a suture through the tissue piercings so as to present one end of the suture to one side of the cardinal ligament and the other end of the suture to the opposite side of the ligament to thus present the suture in an open loop about the cardinal ligament; (3) pulling the suture tight to the cardinal ligament; (4) tying the ends of the suture tight about the cardinal ligament to occlude the uterine artery within.  
         [0020]     The method may further include the steps of simultaneously delivering an end of a second suture through one of the tissue piercings such that the end of the second suture is intermediate the cardinal ligament and the uterosacral ligament allowing an open loop to be formed about the uterosacral ligament with the second suture; then pulling the second suture tight about the uterosacral ligament; and tying the ends of the second suture tight about the uterosacral ligament to occlude the arteries contained therein.  
         [0021]     A system for ligating a uterine artery in a patient of the present invention may also comprise a means for piercing the tissue to either side of a cardinal ligament, wherein the cardinal ligament contains the uterine artery and a means for delivering the ends of a suture through the tissue piercings. Upon delivery the suture is presented with one end to a first side of the cardinal ligament and a second end to the opposite side of the cardinal ligament. The means for delivering operates simultaneously with the means for piercing. A resultant open loop about the cardinal ligament is closed with a means for tying to occlude the uterine artery therein. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0022]     These and other advantages and features of the present invention will be more readily understood from the following detailed description of the preferred embodiments thereof, when considered in conjunction with the drawings, in which like reference numerals indicate identical structures throughout the several views, and wherein:  
         [0023]      FIG. 1  is a drawing of a healthy uterus.  
         [0024]      FIG. 2  is a drawing of a uterus having leiomyomas.  
         [0025]      FIG. 3  is a perspective view of the tool of the present invention.  
         [0026]      FIG. 4  is a detailed perspective view of the upper and lower jaws of the tool of the present invention.  
         [0027]      FIG. 5  depicts a suture transfer dart of the present invention.  
         [0028]      FIG. 6  provides a detailed view of the preferred embodiment of the suture transfer dart.  
         [0029]      FIG. 7  is a surgical view of a uterus.  
         [0030]      FIG. 8  is a surgical view of a uterus.  
         [0031]      FIG. 9  is a surgical view of a uterus.  
         [0032]      FIG. 10  is a surgical view of a uterus.  
         [0033]      FIG. 11  is a drawing of a uterus indicating occlusion sites.  
         [0034]      FIG. 12  is a drawing of a frontal view of a uterus indicating occlusion sites.  
         [0035]      FIG. 13  depicts the tool of the present invention loaded with suture transfer darts.  
         [0036]      FIG. 14  depicts the tool of the present invention having placed suture loops about the cardinal and uterosacral ligaments  
         [0037]      FIG. 15  depicts the sutures, delivered by the tool of the present invention, tied off and occluding the cardinal and uterosacral ligaments. 
     
    
     DETAILED DESCRIPTION  
       [0038]     In the following detailed description, references are made to illustrative embodiments of methods and apparatus for carrying out the invention. It is understood that other embodiments can be utilized without departing from the scope of the invention. The surgical procedures, tools and kits of the present invention are not necessarily limited to but are particularly suited to effect uterine artery ligation in a minimally invasive manner to treat uterine fibroids or other conditions of the uterus. Thus, preferred methods and apparatus are described for controlling uterine arterial blood flow by diminishing or blocking arterial blood flow to the uterus to treat diseases and disorders, e.g., uterine fibroids and uterine bleeding. However, it should be noted that the surgical procedures, tools and kits of the present invention may be additionally useful in a hysterectomy procedure.  
         [0039]     Reference is now made to  FIG. 1 , which illustrates the uterus  20  of a healthy female. The uterus  20  has a lower portion, which is known as the cervix  22 , and an upper portion, known as the corpus  24 . Among other structures, the uterus  20  includes uterine walls  26  and a uterine cavity  28 . The uterus  20  accesses blood  32  by a number of means.  
         [0000]     The most direct means is through the uterine arteries  30 . Typically, a female has two uterine arteries  30 ; one artery generally on the left side  30   a  of the uterus  20  and one artery generally on the right side  30   b  of the uterus  20 .  
         [0040]     The uterus  20  is supported by means that include two cardinal ligaments  34 , one on the left side  34   a  of the uterus  20  and one on the right side  34   b  of the uterus  20 . In addition, the uterus  20  is supported by two uterosacral ligaments  36 , one on the left side  36   a  of the uterus  20  and one on the right side  36   b  of uterus  20 . Typically, the uterine artery  30  is surrounded by the cardinal ligament  34  when the artery enters the uterus  20 . Generally, the uterosacral ligaments  36  do not contain arteries. However some branches of a uterine artery may be in the vicinity of a uterosacral ligament  36 . It is also possible for the uterosacral ligament  36  and the cardinal ligament  34  to merge into a uterosacral cardinal complex which can attach to the uterus  20  in a merged manner. In addition, a uterosacral ligament  36  could include collateral source of blood  32  that could flow to the uterus.  
         [0041]      FIG. 2  illustrates a uterus  20  with leiomyomas  38 . Leiomyomas  38  are well known in the gynecological arts, and are generally described as benign smooth-muscle tumors. Leiomyomas  38  are also commonly known as fibroids. A leiomyoma  38  can attach to any portion of the uterus  
         [0042]     FIG. 3  depicts a preferred embodiment of the tool  40  of the present invention. The tool  40  operates as a transvaginal uterine artery ligation (TVUAL) suture transfer instrument. The tool  40  is presented in a plier configuration having a pair of pivoted jaws. Specifically, the tool  40  includes an upper jaw  42  extending back to a first handle  44  and a lower jaw  46  extending back to a second handle  48 . The jaws  42  and  46  are joined at pivot point  50 . A spring  52  is provide intermediate the first handle  44  and the second handle  48  proximate the pivot point  50  to prevent over extension of the handles  44  and  48 . A plurality of suture capturing pins  54  are provided on the lower jaw  46  of the tool  40 .  
         [0043]      FIG. 4  provides a detailed view of the upper and lower jaws,  42  and  46 , respectively. As shown, each of the plurality of suture capturing pins  54  is provided with a hollowed center sized to accommodate a suture transfer dart (described further below). Additionally, each of the plurality of suture capturing pins  54  includes at least one slot  56  to accommodate an extending suture, i.e., a suture relief (described further below). Opposite the capturing pins  54  of the lower jaw  46  are a plurality of transfer holes  58  extending through the depth of the upper jaw  42 . Each of transfer holes  58  is sized to accommodate reception of a suture transfer dart.  
         [0044]      FIGS. 5 and 6  depict the preferred embodiment of the suture transfer darts  60  and  61 , first suture  62  and second suture  64 . As shown in  FIG. 6 . each of suture transfer darts  60  and  61  has an upper portion  66  having a conical presentation, but may be any configuration suitable for penetrating tissue, and a lower portion  68  joined to the upper portion  66  via a chamfer  70 . The lower portion  68  of each of the suture transfer darts  60  and  61  is pierced partially through in a manner perpendicular to its central axis to present an opening for reception of the suture(s),  62  and  64 . In the preferred embodiment, suture  62  is secured between suture transfer dart  60  and suture transfer dart  61 , while suture  64  is connected only at a first end to suture transfer dart  61  with its second end remaining free. The sutures  62  and  64  are preferably secured within the piercing of the suture transfer darts  60  and  61  with a drop of adhesive. In the preferred embodiment, suture  62  may be designated the cardinal ligament suture while suture  64  may be designated the uterosacral ligament suture; sutures  62  and  64  are preferably color-coded for easy differentiation between the two.  
         [0045]     The tool  40  described above is preferably implemented through performance of the following procedure. With reference to  FIGS. 7-9 . General anesthesia is administered, the vaginal area  44  is prepared and draped, the patient is placed in a dorsal lithotomy position and the patient&#39;s bladder is drained. Then, the cervix can be exposed by a weighted speculum and vaginal retractors, and the cervix  22  is grasped with two tenacula  80 . Without intending to be limiting, a Lahey tenacula may be used, as well as others known in the art or to be discovered. Thereafter, a circumferential cervical incision  82  is made outside the transformation zone of the uterus  20 .  FIG. 7  illustrates an incision  82  of the posterior portion of the cervix  22  and  FIG. 8  illustrates an incision  82  of the anterior portion of the cervix  22 . While the foregoing steps are described to create a circumferential incision  82  in the uterus  20 , it is to be understood that these steps of the invention are not intended to be limiting. Other methods currently know in the art or to be discovered to prepare a patient and/or to enable vaginal access to the uterus  20  whereby a circumferential incision in the uterus are intended to within the scope and intention of the current invention. If only the cardinal ligament is to be ligated, the circumferential incision may be replaced with two smaller incisions, a superior and an inferior incision to the cervix, which allow both jaws  42  and  46  of the tool  40  to enter to the wound thereby enabling the final closure of the wound to be performed with less effort.  
         [0046]     During the initial steps, it is also preferable to retract the bladder  42  away from the uterus  20 . This will cause the ureters to be pulled away from the uterus  20  where they will be less likely to be impacted and/or damaged by the procedure.  
         [0047]     Next, the cul-de-sac  84  and avascular vesicouterine space  86  are entered. The cul-de-sac  84  is illustrated in  FIG. 9  and the avascular vesicouterine space  86  is illustrated in  FIG. 10 . The order in which the cul-de-sac  84  and avascular vesicouterine space  86  are entered is discretionary with the physician. As known in the art, entering the cul-de-sac  84  and avascular vesicouterine space  86  can include separating the uterus  20  from the abdomen by incising or cutting through the vaginal mucosa, connective tissue and/or peritoneal layer. Excellent results have been achieved by sharply entering the cul-de-sac  84  and avascular vesicouterine space  86  by Mayo scissors. However, it is to be understood that other means currently known or to be discovered for entering the cul-de-sac  84  and avascular vesicouterine space  86  are intended to be within the scope of this invention.  
         [0048]     Optionally, the weighted speculum can then be replaced with a longer, less obtrusive speculum to enable complete visualization of the cardinal and uterosacral ligaments.  
         [0049]     Next, blood sources flowing through at least one uterine artery and/or one uterosacral ligament  36  to the uterus are occluded by ligation with sutures  62  and/or  64  delivered by tool  40 . Generally, a uterine artery  30  can be occluded while located in the cardinal ligament  34  or after the artery is dissected away from the ligament. However, occluding the uterine artery  39  while it is located in the cardinal ligament  34  is preferable. Generally, the blood sources flowing through the uterosacral ligament  36  are collateral sources that might include a branch of the uterine artery. Occlusion of the blood sources through the uterosacral ligament  36  generally will occur while the blood source is located in the ligament.  
         [0050]     It is to be noted that occlusion of the at least one uterosacral ligament  36  generally is optional because the ligament is not a main source of blood to the uterus  20 . However, excellent results have been achieved by occluding the blood flowing through both the uterosacral ligaments  36  along with occluding the blood flowing through both uterine arteries  30 . It is discretionary with the physician whether to occlude at least one uterosacral ligament  36 . By way of example, and not intending to be limiting, a uterosacral ligament  36  might be occluded because it can be a collateral source of blood to the uterus  20 . In addition, in some instances distinguishing between the uterosacral ligament  36  and the cardinal ligament  34  might be difficult due to the specific anatomy of the patient. Also, in some instances, the uterosacral ligament  36  and the cardinal ligament  34  merge near their insertion site with the uterus  20  at a uterosacral cardinal complex.  
         [0051]     In addition, while occluding both uterine arteries  30  is recommended, there may be any number of reasons why occluding only one of the uterine arteries  30  could occur, while still obtaining desirable benefits. Similarly, there may be any number of reasons why occluding only one of the uterosacral ligaments  36  could occur, while still obtaining desirable benefits. By way of example and not intending to be limiting, a female patient could in rare cases possess only one uterosacral ligament  36  and/or only one cardinal ligament  34  due to genetic reasons or prior injury. In addition, there could be any number of reasons that the physician might decide to occlude only one of the uterosacral ligaments  36  and/or uterine arteries  30 , which could include, but would not be limited to, injury, expediency and the like.  
         [0052]     The order in which the at least one uterine artery  30  and optionally the blood sources in the uterosacral ligament  36  are occluded is discretionary with the physician. By way of example and not intending to be limiting, if all the uterine arteries  30  and the uterosacral ligaments  36  are going to be occluded, the physician might occlude the at least one uterosacral ligament  36  first because it is closer to the cervical incision  82  than the uterine artery  30 . Alternatively, the physician might want to occlude the at least one uterine artery  30  first because the uterine arteries  30  are a main source of blood to the uterus  20 . Thereafter, the physician might take a measurement of the blood flow to the uterus  20  before deciding whether to also occlude the at least one uterosacral ligament  36 . Any number of factors could influence the physician&#39;s choice relating to the order of occlusion. Also, in the preferred case where both of the uterine arteries  30  are occluded the order of occlusion in relation to left and right arteries is discretionary. Similarly, where both uterosacral ligaments  36  are occluded, the order of occlusion in relation to left and right ligaments is discretionary.  
         [0053]     Reference is now made to  FIGS. 11 and 12 , which indicate preferred occlusion points. The occlusion points are the general locations of the part of the ligament and/or artery that is manipulated to create the occlusion of the blood flow. The manipulation is performed by tool  40  and the sutures  62  and  64  presented thereby. In the preferred embodiment, as illustrated in these figures, the occlusion points are located on the ligament and/or artery immediately lateral to the isthmic  88  portion of the uterus  20 . The occlusion points could also be referred to as being immediately lateral to the insertion site of the ligament to the uterus  20 . Now specifically referring to the Figures, occlusion point  90  is on the left cardinal ligament  34 , occlusion point  92  is on the right cardinal ligament  34 , occlusion point  94  is on the left uterosacral ligament  36  and occlusion point  96  is on the right uterosacral ligament  36 . However, if necessary and/or desired the occlusion point can be located at other places along the at least one cardinal ligament  34  without departing from the intent and scope of the current invention. When the occlusion point in not located immediately lateral to the isthmic  88  portion it is important to avoid impacting or damaging the ureter, which is located in the vicinity.  
         [0054]     The occlusion points identified above are preferably located within a patient via palpation, however, a light source attached to the tool  40  or a retractor and/or a Doppler device could also be used to locate the occlusion points. Now referring to  FIGS. 13 and 14 , tool  40  is prepared for use. Suture transfer darts  60  and  61 , provided with sutures  62  and  64  already attached, are loaded into suture capturing pins  54 , one dart per pin, with the sutures  62  and  64  extending through slot  56 . The remaining length of the sutures  62  and  64  is drawn back proximate the handles  44  and  48 . The handles are then actuated by the physician to press upper jaw  42  and lower jaw  46  of tool  40  towards each other with the pressure being exerted upon the jaws  42  and  46  causing the suture transfer darts  60  and  61  to penetrate the tissue  100 , enter into the transfer holes  58  and be retained therein enabling the sutures  62  and  64  to be drawn upwards upon release of the jaws  42  and  46 . As can be noted in  FIG. 12 , the suture capturing pins  54  are spaced to present suture transfer dart  60  proximate the cardinal ligament  34  and the suture transfer dart  61  intermediate the cardinal ligament  34  and the uterosacral ligament  36 . As such, suture  62  is presented in a loop about the cardinal ligament  34  and suture  64  is positioned to create a loop about the uterosacral ligament  36 .  
         [0055]     Tool  40  is then withdrawn from the occlusion location drawing the sutures  62  and  64  about the cardinal ligament  34  and uterosacral ligaments. Sutures  62  and  64  may then be cut from the suture transfer darts  60  and  61 , which remain in the upper jaw  42  of the tool  40 , with a scissors. The sutures  62  and  64  are then pulled tight and tied off to occlude the cardinal ligament and the uterosacral ligament, see  FIG. 15 . The sutures  62  and  64  may provide for permanent occlusion or may be of a bioresorbable material enabling temporary closure of the uterine artery  30 . The result of occluding the ligaments is that blood flow to the uterus is reduced and fibroid ischemia occurs thereby reducing and/or eliminating the fibroid within the uterus. In an alternative embodiment only one of the sutures  62  or  64  is presented and delivered by tool  40  as desired.  
         [0056]     The final step of the procedure is to approximate the cervical incision  82  by any appropriate technique known or to be discovered in the art.  
         [0057]     All patents and publications referenced herein are hereby incorporated by reference in their entireties.  
         [0058]     It will be understood that certain of the above-described structures, functions and operations of the above-described preferred embodiments are not necessary to practice the present invention and are included in the description simply for completeness of an exemplary embodiment or embodiments. It will also be understood that there may be other structures, functions and operations ancillary to the typical surgical procedures that are not disclosed and are not necessary to the practice of the present invention.  
         [0059]     In addition, it will be understood that specifically described structures, functions and operations set forth in the above-referenced patents can be practiced in conjunction with the present invention, but they are not essential to its practice.  
         [0060]     It is therefore to be understood, that within the scope of the appended claims, the invention may be practiced otherwise than as specifically described without actually departing from the spirit and scope of the present invention.