Knotting element for use in suturing anatomical tissue and methods therefor

A knotting element for use in surgical procedures to effect a knot in a length of filamentous material includes a body for being attached to a segment of the filamentous material and having opposed legs, an engaging member carried by one of the legs and a recess formed in the other of the legs corresponding to the engaging member. The body is movable from an open position wherein the engaging member is disposed externally of the recess to receive a second segment of the filamentous material to a closed position wherein the engaging member is disposed within the recess to immovably fixate the second segment of filamentous material to the knotting element to effect a knot. A method of effecting a knot in a length of filamentous material includes the steps of providing a knotting element attached to a first segment of a length of filamentous material, placing a second segment of the filamentous material between legs of the knotting element with the knotting element in an open position, positioning the second segment of filamentous material in engagement with an engaging member carried by one of the legs and moving the knotting element to a closed position wherein the engaging member is disposed in the other of the legs to fixedly secure the second segment of the filamentous material to the knotting element to effect a knot.

BACKGROUND OF THE INVENTION 
1. Field of the Invention 
The present invention pertains to suturing of bodily tissue and, more 
particularly, to methods and apparatus for suturing tissue during 
endoscopic and open surgical procedures. 
2. Discussion of the Prior Art 
Suturing of bodily tissue is a time consuming part of most surgical 
procedures including both open surgery and endoscopic or minimally 
invasive surgery. By open surgery is meant surgery wherein the surgeon 
gains access to the surgical site via a relatively large incision, and by 
endoscopic surgery is meant surgery wherein the surgeon gains access to 
the surgical site via one or more portals through which endoscopes are 
introduced to view the surgical site and through which various instruments 
are introduced to the surgical site. There are many common endoscopic 
surgical procedures, including arthroscopy, laparoscopy (pelviscopy), 
gastroentroscopy and laryngobronchoscopy, for example. In the past, 
suturing has been accomplished with the use of a sharp metal suture needle 
attached to the end of a length of suture material, the suture needle 
being caused to penetrate and pass through the tissue pulling the suture 
material through the tissue. Once the suture material has been pulled 
through the tissue, the surgeon ties a knot in the suture material, the 
knotting procedure allowing the surgeon to adjust the tension on the 
suture material to accommodate the particular tissue being sutured and 
control approximation, occlusion, attachment or other conditions of the 
tissue. The ability to control tension is extremely important to the 
surgeon regardless of the type of surgical procedure being performed; 
however, knotting of the suture material is time consuming and tedious 
work, particularly in microsurgery and endoscopic surgery. In 
microsurgery, suturing is necessarily time consuming due to the limited 
space at the suture site, the small size of the suture needle and the 
suture material and the concomitant difficult manipulation required to 
pass the suture needle through the tissue and to tie a knot in the suture 
material. With respect to endoscopic surgery, suturing and tying knots 
represents an even more time consuming procedure due to the difficult 
maneuvers required. Accordingly, while endoscopic surgery would be 
preferred for most procedures, the advantages can be outweighed by the 
disadvantages caused by the length of time required to complete the 
endoscopic surgical procedure, which time is greatly extended due to the 
time required for suturing. It is extremely important for knotting or 
tying of sutures to be consistently performed to provide a stitch with 
controlled, non-slipping tension; and, to this end, it is common for 
surgeons to tie double knots, that is, a first knot to control tension and 
a second knot to secure the first knot. Accordingly, it will be 
appreciated that there is a great need for improving the tying procedure 
involved in suturing to permit expedited knotting while also providing 
consistent, secure knots. 
There have been many attempts to provide devices to take the place of 
conventional suturing with a suture needle and a length of suture 
material; however, such devices have essentially been staples, clips or 
clamps not facilitating adjustment of tension by the surgeon. French 
Patent No. 2,651,113 to Alain and U.S. Pat. No. 3,123,077 to Alcamo, No. 
3,570,497 to Lemole, No. 4,548,202 to Duncan, No. 4,592,355 to Antebi, No. 
4,730,615 to Sutherland et al, No. 4,935,028 to Drews, No. 4,950,285 to 
Wilk, No. 4,955,913 to Robinson and No. 5,123,913 to Wilk are 
representative of devices for use during open surgery to adjustably hold 
tissue together similar to suturing and tying but fail to provide the same 
feel and tension control as tying or knotting a length of suture material. 
U.S. Pat. No. 3,910,281 to Kletschka et al is representative of suture 
anchors for facilitating tying. U.S. Pat. No. 2,075,508 to Davidson, No. 
2,199,025 to Conn and No. 3,664,345 to Dabbs et al are illustrative of 
suture buttons for retaining sutures. U.S. Pat. No. 3,976,079 to Samuels 
et al and 4,291,698 to Fuchs, deceased, et al, are representative of 
suture buttons having structure for clamping suture material. U.S. Pat. 
No. 4,750,492 to Jacobs discloses apparatus and method for suturing 
utilizing both an anchor and a clenching device. 
Endoscopic surgery is preferred over open surgery due to the greatly 
reduced trauma and wound healing time for the patient and due to 
concomitant cost savings associated with shorter hospital stays and 
performing surgery in non-hospital or out-patient surgery sites. 
Accordingly, there has been much effort spent to develop techniques for 
facilitating the suturing normally performed by use of a suture needle and 
a length of suture material. Alternative techniques proposed have included 
electrical coagulation, mechanical devices such as clips, clamps and 
staples, and lasers; however, no alternative technique has yet been well 
accepted by surgeons to produce the results obtained by suturing and 
tying. Thus, there is a great need for suturing techniques useful in 
endoscopic surgery to permit surgeons to suture with controlled tension 
and approximation of tissue similar to that obtained by conventional knot 
tying. 
U.S. Pat. No. 3,541,591 to Hoegerman, No. 3,753,438 to Wood et al, and No. 
3,775,825 to Wood et al disclose apparatus and methods for suturing 
wherein clips are secured on the free ends of a suture filament. U.S. Pat. 
No. 5,078,731 to Hayhurst, No. 5,160,339 to Chen et al, No. 5,171,251 to 
Bregen et al, No. 5,234,449 to Bruker et al, No. 5,282,832 to Toso et al 
and No. 5,330,442 to Green et al are representative of clips for clamping 
suture material to eliminate knotting during endoscopic procedures. 
European Patent Publication No. 0 477 020A to Chen et al and U.S. Pat. No. 
5,015,250 to Foster, No. 5,037,433 to Wilk et al, No. 5,059,201 to Asnis, 
No. 5,084,058 to Li, No. 5,087,263 to Li, No. 5,100,415 to Hayhurst, No. 
5,100,421 to Christoudias, No. 5,144,961 to Chen, No. 5,147,373 to Ferzli, 
No. 5,152,769 to Baber and No. 5,163,946 to Li are representative of 
needle holders and apparatus for suturing, knotting or ligating during 
endoscopic procedures. The above techniques and instruments have the 
disadvantages of requiring complex instruments, of requiring special 
suture devices, of being difficult to manipulate and/or of not 
sufficiently reducing the time required for suturing and tying or 
knotting. 
U.S. Pat. No. 4,932,962, No. 4,981,149, No. 5,074,874 and No. 5,100,418 to 
Yoon et al and U.S. Pat. No. 4,935,027, No. 5,053,047, No. 5,222,976, No. 
5,330,503 and No. 5,366,459 to Yoon disclose methods and apparatus 
particularly useful for suturing during endoscopic procedures to permit 
tissue approximation with controlled tension. 
SUMMARY OF THE INVENTION 
Accordingly, it is a primary object of the present invention to overcome 
the aforementioned disadvantages of the prior art. 
Another object of the present invention is to provide a knotting element 
attached to a length of filamentous material and having opposed legs and 
an engaging member on one of the legs for engaging a segment of the 
filamentous material when the legs are in an open position and for being 
disposed within the other of the legs when the legs are in a closed 
position to immovably fixate the segment of filamentous material. 
A further object of the present invention is to engage the segment of 
filamentous material with the engaging member while permitting adjustment 
of the knotting element relative to the filamentous material when the legs 
are in the open position. 
The present invention has as another object to provide a space between the 
engaging member and the one leg for positioning the segment of filamentous 
material between the engaging member and the one leg, with the space being 
disposed within the other leg when the legs are in the closed position to 
prevent disengagement of the segment of filamentous material from the 
engaging member. 
A still further object of the present invention is to provide a knotting 
element attached to a first segment of a length of filamentous material, 
to engage a second segment of the length of filamentous material with an 
engaging member of the knotting element when the knotting element is in an 
open position and to move the knotting element to a closed position 
wherein the engaging member is disposed within the knotting element to 
fixedly secure the second segment of filamentous material. 
An additional object of the present invention is to plastically deform the 
knotting element to cause the engaging member to enter the other leg. 
Some of the advantages of the present invention are that the knotting 
element can be utilized in many various procedures including suturing and 
ligation, one or more engaging members can be oriented in many various 
ways for optimal positioning in accordance with procedural use, the 
engaging members can be attached to one or more segments of the 
filamentous material either movably or fixedly when the knotting element 
is in the open position, the knotting elements take the place of 
conventional knot-tying and provide redundant protection similar to that 
obtained with the tying of multiple knots, the knotting elements can be 
locked in the closed position and/or movable to a further closed position, 
and the knotting elements do not present any exposed sharp edges. 
These and other objects, advantages and benefits are realized with the 
present invention as characterized in a knotting element attached to a 
first segment of a length of filamentous material and having a body 
defining opposed legs with inner surfaces. An engaging member protrudes 
from the inner surface of one of the legs, and a recess is formed in the 
other of the legs along the inner surface thereof for receiving the 
engaging member. The knotting element is movable from an open position 
wherein the inner surfaces are spaced from one another such that the 
engaging member is disposed externally of the recess to a closed position 
wherein the engaging member is disposed within the recess. A passage is 
defined between the engaging member and the associated inner surface for 
receiving a second segment of the length of filamentous material when the 
knotting element is in the open position, thereby attaching the second 
segment of filamentous material to the knotting element. When the knotting 
element is moved from the open position to the closed position, the 
engaging member enters the recess to immovably fixate the second segment 
of the length of filamentous material to the knotting element to effect a 
knot. A method of effecting a knot during surgical procedures according to 
the present invention includes the steps of providing a knotting element 
attached to a first segment of a length of filamentous material, placing a 
second segment of the length of filamentous material between legs of the 
knotting element with the knotting element in an open position, placing a 
second segment of the length of filamentous material in engagement with an 
engaging member disposed between the legs and moving the knotting element 
to a closed position wherein the engaging member enters a recess in the 
knotting element to fixedly secure the second segment of the filamentous 
material to the knotting element to effect a knot. 
Inasmuch as the present invention is subject to many variations, 
modifications and changes in detail, it is intended that all subject 
matter discussed above or shown in the accompanying drawings be 
interpreted as illustrative only and not be taken in a limiting sense.

DESCRIPTION OF THE PREFERRED EMBODIMENTS 
FIG. 1 illustrates a knotting element 12 according to the present invention 
for use in the various apparatus and methods for suturing and ligating 
tissue disclosed in applicant's co-pending prior U.S. applications Ser. 
No. 08/366,285 filed Dec. 29, 1994, Ser. No. 08/377,723 filed Jan. 25, 
1995, Ser. No. 08/401,002 filed Mar. 9, 1995 and Ser. No. 08/531,153 filed 
Sep. 15, 1995 incorporated herein by reference. Knotting element 12 is 
illustrated in FIG. 1 in a suture apparatus 10 comprising a suture supply 
and a needle 14 coupled with the suture supply. The suture supply includes 
one or more knotting elements 12 and a length of filamentous suture 
material 16 carrying knotting elements 12, the suture supply for suture 
apparatus 10 including a single knotting element 12. The suture material 
16, which is coupled to needle 14, can be of any conventional filamentous 
construction, such as a monofilament or multifilament strand or thread. 
The suture material can have a length dependent upon the type of stitch to 
be performed when a single knotting element is carried by the suture 
material; and, when a plurality of knotting elements are carried by the 
suture material, the length of the suture material can correspond to the 
number of stitches expected to be made or can be essentially indefinite by 
utilizing a package, such as a spool having the suture material wound 
therearound. The suture material can be solid or hollow; and, when the 
suture material is hollow, small holes can be formed in the wall of the 
suture material to communicate with the hollow interior thereof. Various 
substances, such as medicaments, can be supplied within the hollow 
interior of the suture material to leach out through the holes and enter 
tissue in which the suture material is placed. The suture material can be 
made of non-stretchable or stretchable, bioabsorbable or non-bioabsorbable 
materials, and the suture material can have various outer diameter or 
cross-sectional sizes in accordance with procedural use including sizes 
suitable for use in microsurgical procedures. 
The knotting element 12 includes a body formed of a medical grade, 
bioabsorbable or non-bioabsorbable, plastically deformable or malleable 
material. The body has a configuration defining angularly oriented, 
opposed legs or jaws 20 and 22 connected to one another by a curved base 
23. Legs 20 and 22 each have a partial oval contour or configuration with 
curved or rounded outer surfaces 24 and 26, respectively, merging with a 
curved or rounded outer surface 25 of base 23 and with opposed, inner 
surfaces 28 and 30, respectively, converging at base 23. A locking 
protrusion 32 at a distal end of one of the legs, i.e. leg 22 in FIG. 1, 
extends inwardly toward the other leg and is angled slightly proximally 
toward base 23. The other or opposite leg, i.e. leg 20 in FIG. 1, 
terminates distally at an outer angled end surface 34. A plurality of 
locking members 36, formed as teeth or protrusions, are formed on end 
surface 34, and a plurality of locking members 38, formed as corresponding 
teeth or protrusions, are formed on an inner surface of protrusion 32 for 
locking engagement with teeth 36 when the knotting element 12 is moved 
from an open position to a closed position as explained further below. 
Protrusion 32 has a curved or rounded outer surface such that the knotting 
element 12 forms a smooth profile in the closed position to avoid damage 
to surrounding anatomical tissue. 
A lug 40 protrudes from inner surface 30, and a recess 42 is formed in leg 
20 along inner surface 28 opposite lug 40. Lug 40 has a passage therein 
receiving a first segment 41 of the length of suture material 16 such that 
the suture material extends from lug 40 in a direction transverse to a 
longitudinal axis of knotting element 12. Accordingly, lug 40 defines an 
attachment site at which the knotting element 12 is carried by or attached 
to a first segment of the suture material either by immovable fixation or 
by a movable fixation or sliding engagement; and, in the case of suture 
apparatus 10, the knotting element 12 is immovably attached to the first 
segment of the length of suture material 16 at lug 40. The first segment 
of suture material can extend entirely through lug 40, partly through lug 
40 or can terminate at lug 40. In the case of knotting element 12, the 
suture material extends entirely through lug 40 to pass entirely through 
the knotting element in the transverse direction and terminates proximally 
at a rigid tail 43. 
A hook, retaining or engaging member 44 protrudes from inner surface 28, 
and a corresponding recess 46 is formed in leg 22 along inner surface 30 
opposite hook member 44. Hook member 44 defines a curved hook, finger or 
catch curving inwardly and distally from inner surface 28 in a concave 
manner. The hook includes a first end attached to inner surface 28, a 
second or distal end 47 spaced from inner surface 28 to define a space or 
opening 48 between the end 47 and the inner surface 28 and a curved 
segment between the first and second ends defining an innermost end. 
Opening 48, which faces distally in knotting element 12, communicates with 
a passage 50 defined between surface 28 and an inner surface of the curved 
segment of hook member 44. Passage 50 is of a size to receive or 
accommodate the cross-sectional size of the filamentous material, and 
passage 50 can be of a size to frictionally or closely or snugly receive 
the filamentous material. Opening 48 is of a size just large enough to 
permit a second segment of the length of suture material 16 to be 
positioned in passage 50, in which case the suture material extends from 
hook member 44 in a direction transverse to the longitudinal axis of the 
knotting element 12 while being captured, held or retained in passage 50 
by hook member 44. Opening 48 is smaller in cross-sectional size than 
passage 50, and opening 48 can be of a size to prevent withdrawal of the 
filamentous material from passage 50 in the absence of a manual withdrawal 
force applied thereto. Inner surfaces 28 and 30 are configured or provided 
with gripping ridges 52 extending in a direction transverse to the 
direction in which the suture material extends, i.e. in the direction of 
the knotting element longitudinal axis in the case of knotting element 12. 
It should be appreciated that no lugs and only hook members can be 
provided in knotting element 12 as shown in dotted lines in FIG. 2 wherein 
lug 40 is replaced with hook member 44'. 
The lug 40, hook member 44 and recesses 42 and 46 are arranged such that 
each inner surface has a lug or a hook member and a recess longitudinally 
aligned with the lug or the hook member and with the lug or hook member of 
each inner surface positioned to be received in the recess of the opposite 
inner surface when the knotting element is moved from the open position to 
the closed position as explained further below. As shown in FIGS. 1, 2 and 
3, knotting element 12 is normally disposed in an open position with inner 
surfaces 28 and 30 spaced from one another to define a mouth 54 
therebetween and with lug 40 and hook member 44 not received in recesses 
42 and 46, respectively. Accordingly, lug 40 and hook member 44 are 
disposed in mouth 54 between inner surfaces 28 and 30 with opening 48 and 
passage 50 disposed externally of recess 46. Recesses 42 and 46 have 
configurations corresponding to the external configurations of lug 40 and 
hook member 44, respectively, to closely or snugly receive lug 40 and hook 
member 44, respectively, in the manner of a friction, press or snap fit. 
The knotting element 12 can be formed of any suitable medical grade 
materials including metals, plastics and rubbers as well as bioabsorbable 
and non-bioabsorbable materials. 
Needle 14, which can be curved as shown in FIG. 1, is coupled with the 
length of suture material 16 and has a distal end 56 for penetrating 
anatomical tissue. In the case of suture apparatus 10, a distal end of the 
suture material 16 is coupled with a proximal end of needle 14; however, 
the attachment position at which the suture material is coupled to the 
needle can be anywhere along the body of the needle. The needle can have 
various configurations including curved, circular, arcuate, decreasing and 
increasing spiral, straight and bent configurations. When the needle is to 
be used with a suture supply having a length of suture material carrying a 
plurality of knotting elements, the needle is preferably hollow to have a 
lumen through which the suture material passes. Where the knotting 
elements have a size larger than the lumen of the needle and are not 
compressible, a longitudinal slot is provided in communication with the 
lumen of the needle to allow the knotting elements to pass externally 
along the needle while the suture material passes internally through the 
needle lumen as disclosed in the prior applications. Where the knotting 
elements are compressible, the knotting elements can pass through the 
needle lumen along with the suture material without the need for a slot in 
the needle; and, similarly, no slot is required where the knotting 
elements have a size to pass through the lumen as also disclosed in the 
prior applications. 
FIGS. 4-7 illustrate one method of use of the suture apparatus 10 during 
which the needle 14 can be manipulated with a needle holder (not shown) or 
another instrument as described in prior application Ser. No. 08/366,285 
incorporated herein by reference. To suture tissue portions T1 and T2, the 
needle tip 56 is driven distally or forwardly through an entry point 58 in 
tissue portion T1 and then through tissue portion T2 and out of tissue 
portion T2 at an exit point 60 carrying the suture material 16 through the 
tissue portions as shown in FIG. 4. Once needle 14 has passed through 
tissue portion T2, the segment 62 of suture material extending from exit 
point 60 is pulled until the knotting element 12 contacts or is adjacent 
tissue portion T1 at the entry point 58. Segment 62 is drawn back over 
tissue portions T1 and T2 to the entry point 58. The segment 62 is 
positioned in mouth 54 as shown in FIG. 5 and then in passage 50 defined 
by hook member 44, the segment 62 being placed in the passage 50 via 
opening 48 as shown in FIG. 6. Accordingly, the segment 62 of suture 
material will be movably captured, retained or held by hook member 44 such 
that an adjustable stitch is formed extending from the knotting element 12 
through the tissue portions T1 and T2 and back to the knotting element 12 
with the knotting element effecting or serving as a knot for the suture 
stitch. Tension is applied to the suture material to tighten the suture 
stitch to adjustably approximate tissue portions T1 and T2 as shown in 
FIG. 7. Knotting element 12 is plastically deformed, "crunched" or 
"crushed" with a grasping instrument for movement from the open position 
to the closed position as disclosed in prior application Ser. No. 
08/366,285 and as illustrated in FIG. 12 for movement of knotting element 
112 to a further closed position. Movement of knotting element 12 to the 
closed position causes legs 20 and 22 to be moved toward one another such 
that lug 40 and hook member 44 enter the corresponding recesses 42 and 46, 
respectively, as shown in FIGS. 7 and 8. In the closed position, the inner 
surfaces 28 and 30 of the legs are disposed adjacent one another with 
locking teeth 36 engaged with locking teeth 38 to lock the knotting 
element in the closed position. The first segment of suture material 
extending through lug 40 will be fixedly secured to knotting element 12 at 
the attachment site, and the second segment 62 will be fixedly secured to 
the knotting element 12 at a grasping site defined by hook member 44 
received in recess 46. As shown in FIG. 9 for second segment 62, the first 
and second segments of suture material extending through lug 40 and hook 
member 44, respectively, are held by ridges 52 and are bent since the 
passages of the lug and hook member are disposed within the associated or 
corresponding recess such that the segments of suture material extend into 
and out of the associated recesses for secure fixation and redundant 
protection. In addition, the opening 48 is disposed within the recess 46 
to prevent disengagement of the suture material from the hook member 44 
and the innermost end of the hook member 44 is entirely, internally 
disposed within the leg 22. The locking protrusion 32 overlaps or extends 
over the angled end surface 34, and the knotting elements have a 
substantially oval profile or contour with no sharp edges. The tail 43 and 
any excess suture material can be severed from the knotting element 
subsequent to formation of the stitch. 
An alternative embodiment of a knotting element according to the present 
invention is illustrated at 112 in FIG. 10 incorporated in a suture 
apparatus 110. Suture apparatus 110 is similar to suture apparatus 10 and 
includes a suture supply comprising knotting element 112 and a length of 
filamentous material 116 carrying knotting element 112 and a needle 114 
coupled with the suture supply. Knotting element 112 is substantially the 
same as knotting element 12 except that knotting element 112 is 
spring-biased or spring-loaded to be normally disposed in the closed 
position illustrated in FIG. 11 and except that knotting element 112 is 
movably attached to the first segment of filamentous material to be 
slidable when the knotting element is in the open position shown in FIG. 
10. Accordingly, knotting element 112 includes lug 140 slidably receiving 
a first segment 141 of the filamentous material in the passage of lug 140 
to movably attach the first segment of filamentous material to the 
knotting element 112 at an attachment site defined by lug 140. Knotting 
element 112 has a spring 166, such as a coil or torsion spring, disposed 
at base 123 and connected between legs 120 and 122 to bias the knotting 
element 112 to the closed position. Various types of springs can be 
utilized to bias the knotting element 112 to be normally disposed in the 
closed position, and the springs can be disposed externally of or within 
the body of the knotting element. In addition to the use of separate or 
distinct springs, it should be appreciated that the knotting element 
itself can be made of spring materials or with a shape memory biasing the 
knotting element to the closed position. Engaging members 168 and 170 in 
the form of protruding ears or handles are disposed along the outer 
surfaces of legs 120 and 122, respectively, for being grasped to move the 
knotting element from the closed position to the open position shown in 
FIG. 10 and as described in the aforementioned prior applications 
incorporated herein by reference. Knotting element 112 is illustrated as 
having locking teeth 136 and 138 for redundant fixation with the spring 
closure force; however, it should be appreciated that the locking teeth 
136 and 138 need not be provided. Knotting element 112 is made of 
plastically deformable or malleable material to be compressed, "crushed" 
or "crunched" for movement to a further closed position shown in FIG. 12 
and as explained further below and in the prior applications. 
During one manner of use of suture apparatus 110, the first segment 141 of 
filamentous material 116 attached to knotting element 112 at lug 140 will 
be immovably fixed to the knotting element when the knotting element is in 
the normally closed position. The knotting element 112 is moved from the 
normally closed position to the open position by application of an opening 
force, via engaging members 168 and 170, sufficient to overcome the 
closing force of spring 166 as well as the locking force of teeth 136 and 
138 where the locking teeth are provided. With the knotting element 112 
moved to the open position shown in FIG. 10, the lug 140 and the hook 
member 144 will be moved out of recesses 142 and 146, respectively. 
Accordingly, the knotting element 112 can be selectively moved along the 
length of filamentous material 116 in accordance with the procedure to be 
performed. With the knotting element 112 held in the open position, 
another segment 162 of the length of filamentous material is positioned in 
the passage of hook member 144 to be movably held thereby. When it is 
desired to immovably fixate both segments 141 and 162 of filamentous 
material to the knotting element, the opening force on the knotting 
element is removed or released, such as by releasing the engaging members 
168 and 170, causing the knotting element to return automatically to the 
closed position. Once the segments 141 and 162 of the filamentous material 
have been immovably secured to the knotting element 112, the knotting 
element 112 can be plastically deformed, compressed, "crushed" or 
"crunched" with instrument I for movement to a further closed position as 
shown in FIG. 12 for additional securement and protection. Various types 
of instruments can be utilized to engage the engaging members when opening 
the knotting element 112 as described in the aforementioned prior 
applications as well as in prior application Ser. No. 08/401,002 filed 
Mar. 9, 1995 and incorporated herein by reference. 
In addition to the procedures described above, the knotting elements 
according to the present invention can be used in the various other 
procedures such as the various procedures described in the prior 
applications incorporated herein by reference. For example, the suture 
apparatus can be used to form a loop segment of the suture material 
extending from tissue portion T2. The loop segment, as well as the segment 
of suture material extending from tissue portion T1, can be placed within 
the hook member of the knotting element. An alternative procedure involves 
placing the loop segment behind or around the knotting element and 
positioning only the segment extending from tissue portion T1 in the hook 
member of the knotting element. As a further alternative, the loop segment 
can be placed within the hook member of the knotting element, and the 
segment of suture material extending from tissue portion T1 is passed 
through the loop segment. Where the suture supply includes a plurality of 
knotting elements carried by the length of suture material, the suture 
supply can be coupled with a hollow needle which is driven through tissue 
portions T1 and T2 to exit tissue portion T2. The needle is backed out 
through tissue portions T1 and T2 to exit the tissue portions at the entry 
point and is moved proximally until the distal end of the needle is 
positioned just proximally of the distalmost knotting element. The suture 
material is pulled through the tissue until the distalmost knotting 
element is adjacent or in contact with tissue portion T1, and the segment 
of suture material extending from the exit point is positioned in the hook 
member of the knotting element. One or more knotting elements can be 
carried by first and second length portions of filamentous suture material 
such that two length portions of suture material extend between a knotting 
element and the needle and/or between adjacent knotting elements to define 
one or more contractible loops. Accordingly, the needle is driven distally 
through tissue portions T1 and T2 and is passed through the contractible 
loop defined by the first and second length portions. The length portions 
are pulled to contract, tighten or close the loop, and the segments of the 
suture material length portions passing through the loop are positioned 
within the hook of the knotting element. 
The knotting elements according to the present invention can also be 
utilized without a needle in various ligating procedures as disclosed in 
the prior applications incorporated herein by reference. For example, the 
knotting elements of the present invention can be utilized with one or 
more lengths of filamentous material to define one or more contractible 
loops. The knotting element can be movably attached to the filamentous 
material to allow the contractible loops to be reduced in size, contracted 
or tightened around anatomical tissue to form ligatures when the knotting 
elements are in the open position. Once the ligatures are formed with a 
desired tension, the knotting elements are moved to the closed position 
and plastically deformed to secure the thusly formed ligatures. 
It should be appreciated that the knotting elements according to the 
present invention can be attached to the filamentous material in many 
various ways and that the length of filamentous material can terminate at 
the knotting elements or pass entirely or partly through the knotting 
elements. The filamentous material can be attached to or terminate at the 
knotting elements at various locations thereon, and the mouths of the 
knotting elements can be positioned or oriented to optimally position the 
knotting elements in accordance with procedural use. Although the knotting 
elements have been illustrated herein with a lug, it should be appreciated 
that no lugs need be provided in the knotting elements in that the hook 
members can be provided in place of the lugs. The knotting elements can be 
provided with any number of lugs and/or hook members, and the lugs and/or 
hook members can be provided anywhere along one or both of the inner 
surfaces of the knotting elements. Where no lugs and only hook members are 
provided in the knotting elements, the knotting elements can be moved 
along the filamentous material prior to being moved to the closed 
position. Accordingly, the filamentous material remains held by the 
knotting elements during the procedure being performed and thusly 
facilitates the performance of various endoscopic and open suturing and 
ligating procedures. The spaces or openings at the free or unattached ends 
of the hook members can face in any direction to optimally position the 
hook members to receive the filamentous material in accordance with 
procedural use, and the hook members can face in opposite directions. 
Inasmuch as the present invention is subject to many variations, 
modifications and changes in detail, it is intended that all subject 
matter discussed above or shown in the accompanying drawings be 
interpreted as illustrative only and not be taken in a limiting sense.