Abstract:
A method for suturing a perforation comprises the steps of: observing an area around the perforation from an inside of a hollow organ by an observation device inserted from a natural opening of a living body; observing the area around the perforation from a body cavity side of the hollow organ by an observation device inserted from the natural opening of the living body; thrusting a needle of a suture unit inserted from the natural opening of the living body into a tissue around the perforation of the hollow organ to make a suture thread puncture the tissue via the needle; and closing the perforation by tightening up the suture thread puncturing the tissue.

Description:
BACKGROUND OF THE INVENTION  
       [0001]     1. Field of the Invention  
         [0002]     The present invention relates to a method for suturing by inserting a suture instrument via the mouth or the anus. For example, the present invention relates to a method of suturing a perforation formed in a wall of a hollow organ.  
         [0003]     2. Description of Related Art  
         [0004]     In the case of performing treatment in a body of a patient, the treatment can be performed by incising the body of the patient by surgical operation, or by oral endoscopic treatment or transanal endoscopic treatment. A method for suturing a perforation formed in an abdominal area by surgical operation is disclosed in FIGS. 6a to 6c of U.S. Pat. No. 6,066,146. According to this suturing method, a needle is thrust into the tissue around the perforation, and an anchor equipped with a suture thread is then extruded from the needle. After the needle is drawn out from the tissue, two suture threads across the perforation are knotted together to close the perforation.  
         [0005]     The treatment using an endoscope is carried out by passing a forceps, high-frequency treatment instrument, incision instrument, suture instrument or the like through a channel of the endoscope. When the medical treatment is carried out by using an endoscope inserted into a lumen through a natural opening of a living body such as the mouth, anus, or the like, for example, a hole is formed by removing the tissue from the abdominal cavity or incising the tissue in the abdominal cavity, and the medical treatment is then carried out by approaching the abdominal cavity through this hole from the inside of the lumen. After performing the medical treatment, the formed hole is sutured by a suture instrument.  
         [0006]     A method for suturing in a hollow organ is disclosed in FIGS. 6 to 9 of Japanese Laid-Open Patent Application No. 2004-601, for example. According to this suturing method, the tissue is drawn into an overtube, and a needle is then thrust through this tissue from the proximal side to the distal side thereof. From the inside of the needle, an anchor equipped with a suture thread is pushed out to the distal side of the tissue. After that, the needle is pulled out, and thereby the suture thread penetrates through the tissue and tightens up the tissue. There is also a method disclosed in FIG. 1, FIG. 4, FIGS. 5A to 5C of U.S. Pat. No. 5,297,536. According to this method, a flexible endoscope is inserted into the vicinity of a perforation via the mouth or the anus. The tissue around the perforation is aspirated by a tube of the flexible endoscope. When an O-ring provided at the outside of the tube is pushed out from the tip of the tube, the aspirated tissue is clamped by the O-ring.  
       SUMMARY OF THE INVENTION  
       [0007]     A method for suturing a perforation of the present invention comprises the steps of: observing an area around the perforation from an inside of a hollow organ by an observation device inserted from a natural opening of a living body; observing the area around the perforation from a body cavity side of the hollow organ by an observation device inserted from the natural opening of the living body; thrusting a needle of a suture unit inserted from the natural opening of the living body into a tissue around the perforation of the hollow organ to make a suture thread puncture the tissue via the needle; and closing the perforation by tightening up the suture thread puncturing the tissue. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0008]      FIG. 1  is a view showing a schematic constitution of an endoscope and a suture unit.  
         [0009]      FIG. 2  is a cross-sectional view of a suture unit and an end portion of an endoscope.  
         [0010]      FIG. 3  is a perspective view of a suture unit and an end portion of an endoscope.  
         [0011]      FIG. 4  is a view showing a constitution of a suture instrument.  
         [0012]      FIG. 5  is a schematic view showing a step of inserting an endoscope into the stomach of a patient to observe a perforation from the inside of the stomach.  
         [0013]      FIG. 6  is a schematic view showing a step of observing the outside of the stomach.  
         [0014]      FIG. 7  is a schematic view showing a step of puncturing the tissue with a needle of a suture unit.  
         [0015]      FIG. 8  is a schematic view showing a step of putting an anchor out from a needle to the outside of the stomach.  
         [0016]      FIG. 9  is a schematic view in which two anchors are placed outside the stomach.  
         [0017]      FIG. 10  is a schematic view showing a step of tightening up a perforation by a suture instrument.  
         [0018]      FIG. 11  is a schematic view showing manipulation for grasping a suture instrument gripped by a forceps.  
         [0019]      FIG. 12  is a view in which a perforation is sutured by a forceps and a suture instrument.  
         [0020]      FIG. 13  is a schematic view showing a rod which is an example of a retracting instrument.  
         [0021]      FIG. 14  is a schematic view showing a balloon catheter which is an example of a retracting instrument.  
         [0022]      FIG. 15  is a schematic view showing a balloon catheter in which a balloon is inflated.  
         [0023]      FIG. 16  is a schematic view showing a forceps which is an example of a retracting instrument.  
         [0024]      FIG. 17  is a schematic view showing one example of combination of an endoscope with a suture unit.  
         [0025]      FIG. 18  is a schematic view showing one example of combination of an endoscope with a suture unit.  
         [0026]      FIG. 19  is a schematic view showing one example of combination of an endoscope using an overtube with a suture unit.  
         [0027]      FIG. 20  is a schematic view showing one example of combination of an endoscope with an observation device.  
         [0028]      FIG. 21  is a schematic view showing one example of combination of an endoscope with a suture unit.  
         [0029]      FIG. 22  is a schematic view showing one example of combination of an endoscope using an overtube with a suture unit.  
         [0030]      FIG. 23  is a schematic view showing a step of observing the outside of the stomach.  
         [0031]      FIG. 24  is a schematic view showing a step of puncturing the tissue from the outside of the stomach with a needle of a suture unit.  
         [0032]      FIG. 25  is a schematic view showing a step of pushing out an anchor from a needle to the inside of the stomach.  
         [0033]      FIG. 26  is a schematic view in which two anchors are placed on the outside of the stomach.  
         [0034]      FIG. 27  is a schematic view showing a step of tightening up a perforation with a suture instrument.  
         [0035]      FIG. 28  is a schematic view showing manipulation for grasping a suture instrument by a forceps.  
         [0036]      FIG. 29  is a view in which a perforation is sutured by a forceps and a suture instrument.  
         [0037]      FIG. 30  is a schematic view showing a step of observing the outside of the stomach.  
         [0038]      FIG. 31  is a schematic view showing a step of puncturing the tissue with a needle of a suture unit.  
         [0039]      FIG. 32  is a schematic view showing a step of pushing out an anchor from a needle to the inside of the stomach.  
         [0040]      FIG. 33  is a schematic view in which two anchors are placed on the outside of the stomach.  
         [0041]      FIG. 34  is a schematic view showing a step of tightening up a perforation with a suture instrument.  
         [0042]      FIG. 35  is a schematic view showing a step of thrusting a needle from the inside of the stomach after observing the inside and the outside of the stomach by an endoscope.  
         [0043]      FIG. 36  is a schematic view showing one example of combination of an endoscope with a suture unit.  
         [0044]      FIG. 37  is a view showing the order for tightening up plural suture instruments. 
     
    
     DETAILED DESCRIPTION OF THE INVENTION  
     First Embodiment  
       [0045]     In  FIG. 1 , an endoscope and a suture unit used in this embodiment are shown. An endoscope  1  (flexible endoscope) has an endoscope operation unit  2  which is operated by an operator. The endoscope operation unit  2  is connected to a control device via a universal cable  3  and equipped with various switches  4  and angle knobs  5 . At the tip of the endoscope operation unit  2 , an endoscope insertion part  6  that is flexible and long is extendedly formed. At the tip of the endoscope insertion part  6 , an observation device (first observation device, hereinafter, merely referred to as observation device)  7  for an endoscope which obtains an image of the internal body, a lighting unit  8 , and a tip opening of a channel  9  are provided. As the observation device  7 , an imaging device having a CCD (Charge Coupled Device) or an optical fiber can be used. The lighting unit  8  has an optical fiber that conducts light from a light source. The channel  9  opens at a lateral part  2   a  of the endoscope operation unit  2  through the endoscope insertion part  6 . At an opening of the lateral part  2   a , a cap  10  is provided. In the cap  10 , an insertion hole is formed, and a treatment tool such as a suture unit  11  or the observation device is inserted into the channel  9  through this insertion hole.  
         [0046]     As shown in FIGS.  1  to  3 , in the suture unit  11 , a flexible inner sheath  13  is passed through the inside of a flexible outer sheath  12  so as to be able to freely move forward or backward. To the tip of the inner sheath  13 , a needle  14  is fixed. The needle  14  has a slit  15  formed in a longitudinal direction from the tip thereof. A suture instrument  16  is contained inside of the needle  14 . Each of the lengths of the outer sheath  12  and the inner sheath  13  is longer than that of the channel  9  of the endoscope  1 . At a proximal end of the inner sheath  13 , an operation unit  17  is provided. The operation unit  17  has a handle  19  which can freely slide with respect to a main body  18  of the operation unit. To the handle  19 , a proximal end of a pusher  20  is fixed. The pusher  20  extends through the inside of the inner sheath  13  to the inside of the needle  14 . A distal end portion  21  of the pusher  20  is pressed against the suture instrument  16 .  
         [0047]     As shown in  FIG. 4 , the suture instrument  16  has a suture thread  25 . The suture thread  25  is folded approximately in two and a knot  31  is formed in the vicinity of its turn-around point. Moreover, the suture thread  25  is bundled at both end portions thereof and passed through a stopper  26  that is substantially triangular. To each end portion of the suture thread  25 , an anchor  27  is fixed. The anchor  27  has a cylindrical shape and the suture thread  25  is fixed at an approximately center portion in a longitudinal direction of the anchor  27 . The stopper  26  includes a long, thin plate member in which a hole  28  is formed at the center portion in a longitudinal direction thereof, through which the suture thread  25  is passed. Both end portions  29  in a longitudinal direction of the stopper  26  are diagonally folded back to hold the suture thread  25  therebetween. Both end portions  29  in a longitudinal direction of the stopper  26  are cut to form triangular sections  30 . Both end portions  29  of the stopper  26  are diagonally folded back so that the sections  30  intersect with each other to hold the suture thread  25  therebetween. As a result, the suture thread  25  is prevented from passing through a space formed between end portions  29 . When the knot  31  of the suture thread  25  is pulled in a direction away from the stopper  26 , both end portions  29  of the stopper  26  are slightly opened. Accordingly, the stopper  26  allows the suture thread  25  to move in the same direction. On the other hand, when end portions of the suture thread  25  at the side of the anchors  27  are pulled, the suture thread  25  is ready to move in a direction shown by an arrow in  FIG. 4 . However, both end portions  29  of the stopper  26  close and secure the suture thread  25  at this time, and thereby the suture thread  25  does not move.  
         [0048]     As shown in  FIG. 3 , the suture instrument  16  sequentially holds two anchors  27  in an inner hole of the needle  14 . The suture thread  25  is drawn out from the slit  15  of the needle  14 . As shown in  FIG. 2 , the stopper  26  is held at a more distal end portion than the needle  14  in the outer sheath  12 . The number of the anchors  27  and the shape of the stopper  26  are not limited to the embodiment shown in the figures.  
         [0049]     Next, a suturing method of this embodiment will be explained mainly with reference to FIGS.  5  to  12 . FIGS.  5  to  12  are pattern diagrams illustrating manipulation and show the stomach as an example of a hollow organ.  
         [0050]     As shown in  FIG. 5 , the endoscope insertion part  6  is inserted from the mouth (a natural opening of a living body, such as the anus, nose, or ear) of a patient  41  prepared with a mouthpiece  40 . When the tip of the endoscope insertion part  6  is bent by the angle knob  5 , a perforation  42  can be checked by the observation device  7  from the inside of the stomach  43  (the inside of the hollow organ). As shown in  FIG. 6 , an observation device (second observation device)  50  is passed through the channel  9  of the endoscope  1 . The observation device  50  is, for example, a catheter having a camera at the tip thereof. The observation device  50  may be a long and narrow fiberscope.  
         [0051]     The tip of the observation device  50  is inserted from the perforation  42  into the abdominal cavity  44 , and the tip of the observation device  50  is then bent back by a wire or the like, which is not shown in the figures. By using the observation device  50 , an area around the perforation  42  to be punctured with the needle  14  (referred also to as a puncture position or a position through which the needle  14  passes) is observed from an abdominal cavity  44  side (which is also the side at which the anchor  27  is placed), that is, from the outside of the stomach  43  (referred also as a body cavity side of the hollow organ or the abdominal cavity side) to check that other tissues such as the small intestine, the liver, or the like do not exist at the position through which the needle  14  is passed in order to prevent these tissues from being punctured or sutured together.  
         [0052]     As shown in  FIG. 7 , the suture unit  11  is projected to puncture the tissue around the perforation  42  with the needle  14  while observing the stomach  43  from the abdominal cavity  44  side by the observation device  50 . When the tissue is punctured, the needle  14  is projected from the outer sheath  12  as shown in  FIG. 3 . The stopper  26  which is contained at the more distal end portion than the needle  14  is extruded from the outer sheath  12  into the stomach  43  when projecting the needle  14 . When the needle  14  is moved forward with the outer sheath  12  fixed, the needle  14  punctures the tissue. When the handle  19  provided at an operator-side as shown in  FIG. 1  is pushed in, the pusher  20  moves forward, and the first anchor  27  is pushed out from the tip of the needle  14  into the abdominal cavity  44 , as shown in  FIG. 8 . When the first anchor  27  is pushed out, the pusher  20  is stopped, and the needle  14  is drawn out from the tissue. The first anchor  27  remains on the abdominal cavity  44  side. The suture thread  25  penetrates through the tissue. The stopper  26  is then in the stomach  43 .  
         [0053]     Moreover, the needle  14  is thrust again at an approximately symmetrical position with respect to the position at which the needle  14  is previously thrust centered about the perforation. In the same manner as when using the first anchor  27 , when the needle  14  penetrates through the tissue, the pusher  20  is moved forward. The second anchor  27  is pushed out into the abdominal cavity  44 . As shown in  FIG. 9 , when the needle  14  is drawn back, the second anchor  27  remains on the abdominal cavity  44  side, the suture thread  25  penetrates through the tissue, and two anchors  27  are placed on the abdominal cavity  44  side to sandwich the perforation  42  therebetween.  
         [0054]     Next, as shown in  FIG. 10 , after the observation device  50  is drawn back to the inside of the stomach  43 , the suture thread  25  is pulled so that the anchor  27  and the stopper  26  tighten up the tissue, and thereby the perforation  42  is sutured. When the suture thread  25  is pulled, a forceps  60  shown in  FIG. 11 , for example, is used. The forceps  60  is passed through the channel  9  in the place of the observation device  50 . The forceps  60  has an outer sheath  61  having an external diameter larger than the anchor  27  and an inner sheath  62  passed through the outer sheath  61  so as to freely move forward or backward. At the tip of the inner sheath  62 , a supporting member  63  is provided, and a pair of grip segments  64  are supported on the supporting member  63  so as to freely open or close.  
         [0055]     After the knot  31  of the suture thread  25  of the suture instrument  16  is gripped by the grip segments  64 , the outer sheath  61  is moved forward to press the tip of the outer sheath  61  against the stopper  26 . As shown in  FIG. 12 , when the outer sheath  61  moves further forward, the stopper  26  is pushed into the wall of the stomach  43 . Since the stopper  26  is constructed to be able to move in this direction, the stopper  26  moves toward the wall. Since the position of the pair of the grip segments  64  does not change, the stopper  26  moves relatively forward with respect to the suture thread  25 . As a result, the distance between the stopper  26  and the anchor  27  decreases. This pulls together the tissue around the perforation  42 , and the perforation  42  is sutured by the suture thread  25 . After suturing the perforation  42  by the suture instrument  16 , the outer sheath  61  is moved backward, and the grip segments  64  are then opened to release the suture thread  25 . Although the tip of the stopper  26  can move in a direction in which the tissue is tightened up by the suture thread  25 , it acts to tighten up the suture thread  25  in a direction for loosening the suture thread  25 . As a result, the suture thread  25  is not loosened, even if the suture instrument  16  is placed inside of the stomach  43 .  
         [0056]     When a hollow organ such as the small intestine or the colon or another organ such as the spleen or the liver (hereinafter, merely referred to as tissue) exists in the area around the perforation  42  (the position through which the needle  14  is passed), the other tissue is pulled away from the stomach  43  by inserting a retracting instrument. The retracting instrument used in this case is exemplified in FIGS.  13  to  16 . A retracting instrument shown in  FIG. 13  is a rod  70  of which a tip portion can be bent. When the rod  70  is bent, the other hollow organ is pushed off to form a space through which the needle  14  is passed. A retracting instrument shown in  FIGS. 14 and 15  is a balloon catheter  71 . When a balloon  73  provided at the tip portion of a catheter  72  is inflated by supplying a fluid from the operator-side to push off the other hollow organ, the space through which the needle  14  is passed is formed. A retracting instrument shown in  FIG. 16  is a forceps  74 . When the other hollow organ is grasped by the forceps  74  to draw it away from the stomach  43 , the space through which the needle  14  is passed is formed. At the tip portions of these retracting instruments, an optical fiber or an observation device having a CCD may be provided. When the observation device is provided, it becomes possible to retract other tissues while observing the state of the abdominal cavity  44 .  
         [0057]     In this embodiment, the perforation  42  is observed from the inside of the stomach  43  by the observation device  7  of the endoscope  1  at first, and the perforation  42  is then observed from the abdominal cavity  44  side by the observation device  50 . After that, the suture unit  11  is made to penetrate through the tissue around the perforation  42  to mount the suture instrument  16 , and the perforation  42  is sutured by using this suture instrument  16 . Accordingly, it is possible to suture the perforation  42  after respectively checking from the inside (the side from which the needle  14  is thrust) and the outside (the side through which the needle  14  penetrates or at which the anchor  27  is placed) of the stomach  43  that another tissue does not exist around the perforation  42 . According to a suturing method using an endoscope of the prior art, it is impossible to check the opposite side. According to the endoscopic suturing method in this embodiment, it is possible to easily and certainly check for the existence of other tissues, as a result of which manipulation can be carried out with rapidity.  
         [0058]     Modified examples of this embodiment are shown in FIGS.  17  to  22 .  
         [0059]     As shown in  FIG. 17 , two external sheaths  80  are provided at the periphery of the endoscope insertion part  6 . A suture unit  11  is passed through each external sheath  80  so as to freely move forward or backward. The anchors  27  are individually contained in the respective needles  14 . It is possible to thrust two needles  14  into the tissue at the same time or in an arbitrary order. As another example, one external sheath  80  may be used, and two anchors  27  may be contained in one needle  14 . Moreover,  FIG. 18  shows an example in which the suture units  11  are individually passed through two channels  9  of the endoscope insertion part  6 .  
         [0060]     As shown in  FIG. 19 , the endoscope insertion part  6  is inserted into an overtube  81 . At the inner periphery of the overtube  81 , a lumen  82  is provided, and the suture unit  11  is passed through the lumen  82 . At the inner periphery of the overtube  81 , two lumens  82  may be provided, and the suture units  11  may be individually passed through each of the lumens  82 .  
         [0061]     As shown in  FIG. 20 , a channel  84  may be provided at the periphery of the endoscope insertion part  6 , and the observation device  50  may be passed through this channel  84 . Moreover, the observation device  50  may be directly provided at the periphery of the endoscope insertion part  6  without using the channel  84 .  
         [0062]     As shown in  FIG. 21 , an external channel  85  may be provided parallel to the endoscope insertion part  6 , and the suture unit  11  may be passed through the channel  85 . The tip portion of this channel  85  can be bent. When observing the perforation  42  from the abdominal cavity  44  side as shown in  FIG. 6 , the endoscope insertion part  6  is passed through the perforation  42  and moved into the abdominal cavity  44 , and the tip portion of the endoscope insertion part  6  is then bent to observe by the observation device  7  provided at the tip portion thereof.  
         [0063]     As shown in  FIG. 22 , the suture unit  11  may be passed through the lumen  82  formed inside of the overtube  81 . In this case, the area around the perforation  42  is observed from the abdominal cavity  44  side by using the observation device  7  of the endoscope insertion part  6 .  
       Second Embodiment  
       [0064]     In this embodiment, the same endoscope  1  and suture unit  11  as in the first embodiment are used. Descriptions that overlap with the first embodiment will be omitted.  
         [0065]     A suturing method of this embodiment will be explained. As shown in  FIG. 5 , the endoscope insertion part  6  is inserted into the vicinity of the perforation  42  to observe the perforation  42  from the inside of the stomach  43 . Next, as shown in FIG.  23 , the endoscope insertion part  6  is moved from the perforation  42  into the abdominal cavity  44 , and an area around the perforation  42  is then observed from the abdominal cavity  44  side by the observation device (first observation device)  7  of the endoscope insertion part  6 . After confirming that other hollow organs do not exist in the area around the perforation  42 , the needle  14  of the suture unit  11  is projected from the endoscope insertion part  6  as shown in  FIG. 24 , and the needle  14  is thrust from the abdominal cavity  44  side into the stomach  43 . Since the safety of the inside of the stomach  43  is confirmed first, the inside of the stomach  43  may not be checked when thrusting the needle  14 . The inside of the stomach  43 , however, may be punctured while observing the inside of the stomach  43  (the side at which the anchor  27  is placed) by using another observation device. In this case, it is possible to puncture at the puncture position while observing both the inside and the abdominal cavity  44  side of the stomach  43 .  
         [0066]     As shown in  FIG. 25 , the first anchor  27  is extruded into the stomach  43  from the tip of the needle  14 . As shown in  FIG. 26 , after placing two anchors  27  so as to sandwich the perforation  42  therebetween, the suture unit  11  is contained inside of the channel  9 . After that, the endoscope  1  is drawn back to the inside of the stomach  43 .  
         [0067]     As shown in  FIGS. 27 and 28 , the forceps  60  is passed through the channel  9  of the endoscope  1  drawn back to the inside of the stomach  43 . The forceps  60  grasps the knot  31  of the suture thread  25  existing in the abdominal cavity  44  side, and draws the suture thread  25  and the stopper  26  into the stomach  43  through the perforation  42 . As shown in  FIG. 29 , when the stopper  26  is pressed against the tissue by the outer sheath  61 , the suture instrument  16  tightens up the tissue, and thereby the perforation  42  is sutured.  
         [0068]     In this embodiment, after observation of the inside of the stomach  43  by using the endoscope  1 , the endoscope  1  is moved to the outside of the stomach  43  to check from the abdominal cavity  44  side that other tissues do not exist in the area around the perforation  42 . After that, the needle  14  is thrust into the tissue from the outside to mount the suture instrument  16  and suture the perforation  42  while passing the endoscope  1  through the perforation  42 . Accordingly, other tissues can be easily prevented from being sutured together when suturing by using the endoscope  1 .  
       Third Embodiment  
       [0069]     In this embodiment, the same endoscope  1  and suture unit  11  as in the first embodiment are used. Descriptions that overlap with the first embodiment will be omitted.  
         [0070]     A suturing method of this embodiment will be explained. As shown in  FIG. 5 , the endoscope insertion part  6  is inserted in the vicinity of the perforation  42  to observe the perforation  42  from the inside of the stomach  43 . Next, as shown in  FIG. 23 , the endoscope insertion part  6  is moved from the perforation  42  into the abdominal cavity  44 , and an area around the perforation  42  is then observed from the abdominal cavity  44  side by the observation device (first observation device)  7  of the endoscope insertion part  6 . After checking that other tissues do not exist in the area around the perforation  42  (the position through which the needle  14  is passed, the puncture position, or the position at which the anchor  27  is placed), the endoscope insertion part  6  is drawn back to the inside of the stomach  43 . Next, the suture unit  11  which is passed through the channel  9  is projected. As shown in  FIG. 30 , the tip portion of the suture unit  11  is moved from the perforation  42  to the abdominal cavity  44 . The tip portion of the suture unit  11  is then bent to face the outside of the stomach  43  and an area around the perforation  42  in the abdominal cavity  44 .  
         [0071]     As shown in  FIG. 31 , the suture unit  11  projects the needle  14  from the outer sheath  12 , and the needle  14  penetrates the tissue around the perforation  42  from the abdominal cavity  44  side into the stomach  43 . It is preferable that the stopper  26  be made to enter the stomach  43  when the needle  14  is projected from the outer sheath  12 . As shown in  FIG. 32 , after the needle  14  penetrates the tissue, the first anchor  27  is pushed out and placed inside of the stomach  43 . As shown in  FIG. 33 , after placement of two anchors  27  inside the stomach  43  so as to sandwich the perforation  42  therebetween, the suture unit  11  is drawn back to the inside of the stomach  43 , and contained in the channel  9 . As shown in  FIG. 34 , the forceps  60  is then passed through the channel  9 , and the tissue is tightened up by the suture instrument  16  using the forceps  60  to suture the perforation  42 . The suturing method is the same as in the second embodiment.  
         [0072]     In this embodiment, after the inside and the outside of the stomach  43  are sequentially observed by the observation device  7  of the endoscope  1  to check that other tissues do not exist in an area around the perforation  42 , the endoscope  1  is drawn back to the inside of the stomach  43 , and the tissue is punctured with the needle  14  from the outside of the stomach  43 . Accordingly, other tissues can be easily prevented from being sutured together when suturing by using the endoscope  1 .  
         [0073]     Next, modified examples of this embodiment will be explained. As shown in  FIG. 23 , after observing the outside of the stomach  43  by using the observation device  7  of the endoscope insertion part  6 , the endoscope insertion part  6  is drawn back to the inside of the stomach  43 . After that, the suture unit  11  is projected from the endoscope insertion part  6  present in the stomach  43 , and the needle  14  is thrust from the inside into the outside of the stomach  43 , as shown in  FIG. 35 . After placement of the anchor  27  at the outside of the stomach  43 , the suture instrument  16  is tightened up to suture the perforation  42 , as shown in  FIGS. 11 and 12 . In this case, other tissues can be easily prevented from being sutured together when suturing by using the endoscope  1 .  
         [0074]     As shown in  FIG. 36 , a channel  91  may be provided at the periphery of the endoscope insertion part  6 , and the suture unit  11  may be passed through this channel  91 . Moreover, the suture unit  11  may be provided parallel to the periphery of the endoscope insertion part  6 . The tip portion of the suture unit  11  is constructed so as to be able to be independently bent.  
         [0075]     This invention can be widely applied without being limited to the above-mentioned embodiments.  
         [0076]     For example, the endoscope  1  may be inserted from the anus into the colon which is an example of a hollow organ. In this case, a perforation formed in the colon is sutured. Although the perforation  42  is described as being already formed, the manipulation of the above-mentioned embodiment may be carried out after forming the perforation  42  by using the endoscope  1 . In this case, the endoscope  1  is inserted from a natural opening into the inside of the stomach  43 , and a determined incision portion is checked by the observation device  7  provided at the tip of the endoscope insertion part  6 . After that, the determined incision portion is incised after passing a high-frequency knife or the like through the channel  9  of the endoscope  1  to form the perforation  42 .  
         [0077]     When the stomach  43  is widely incised and the perforation  42  is sutured by using at least three suture instruments  16 , suture instruments  16  plurally lined up are preferably sequentially tightened up from one end thereof. In an example shown in  FIG. 35 , a suture instrument  16   a , a suture instrument  16   b , a suture instrument  16   c , a suture instrument  16   d , and a suture instrument  16   e  are tightened up in this order, for example. Since the perforation  42  is sutured from one end thereof, and the size of the perforation  42  can be gradually diminished, suturing can be easily carried out. Alternatively, the suture instrument  16  at the center of the suture instruments  16  lined up may be tightened up first, followed by tightening the suture instruments  16  at the center positions between the suture instrument  16  tightened up at the center position and the suture instruments  16  at the ends thereof. In the example shown in  FIG. 37 , the suture instrument  16   c  is tightened up first, the suture instrument  16   b  and the suture instrument  16   d  are then tightened up, and the suture instrument  16   a  and the suture instrument  16   e  are finally tightened up. Since the center position of the opening is always sutured, the degree of slippage of suture positions can be diminished.