Surgical fastening apparatus with suture array

An apparatus for simultaneously applying to body tissue at least one surgical suture in conjunction with a plurality of surgical fasteners arranged end to end in rows. The apparatus preferably includes a knife for making an incision in the body tissue sealed in each side by at least one row of fasteners. The fasteners are two-part fasteners fabricated from bioabsorbable material. The incision is closed by pulling the ends of the suture(s).

BACKGROUND OF THE INVENTION 
1. Field of the Invention 
The present invention relates to an apparatus for applying surgical 
fasteners to body tissue, and more particularly to an apparatus which 
applies a suture array in conjunction with the surgical fasteners. 
2. Background of the Art 
It is well known that surgical stapling, as compared to suturing, requires 
less tissue manipulation, reduces blood loss, and reduces trauma to the 
patient. The faster wound closure and reduced operative time resulting 
from surgical stapling reduces patient anesthesia requirements and the 
possibility of inflammation and infection. 
Various types of instruments for applying surgical staples are known. 
Several of these instruments, such as that disclosed in U.S. Pat. No. 
4,354,628, have a cartridge jaw containing two or more rows of metal 
staples and an anvil jaw having a corresponding number of depressions. In 
an operation, the anvil and cartridge jaws are approximated to clamp 
tissue therebetween, and the instrument handle is actuated to fire the 
rows of staples simultaneously through the tissue and against the anvil 
where they are crimped into a B-shaped configuration. 
Instruments for simultaneously applying two or more rows of two pare 
fasteners are also currently in use. These fasteners comprise a tissue 
piercing fastener portion and a receiver portion, both of which are 
composed of materials which are totally absorbed by the body. The 
instruments operate similarly to those which apply metal staples in that 
the fastener holding jaw and receiver holding jaw are approximated, and 
the instrument handle is subsequently actuated to force the fastener 
portions through the tissue and into interlocking arrangement with the 
corresponding receivers. The instruments may also include a knife 
positioned between the rows of fasteners, such as in U.S. Pat. Nos. 
4,665,916 and 5,116,349, both of which are herein incorporated by 
reference. The knife creates an incision in tissue as the fasteners are 
applied to the tissue. 
The instruments described above may be used in abdominal surgery for the 
removal or repair of organs, in gynecological surgery such as performing 
cesarean sections, and in many other types of operations which are 
familiar to those with skill in the surgical arts. 
In certain types of procedures, such as joining tubular tissue, a suture is 
employed as a "purse string" to manipulate the tissue to facilitate the 
joining procedure. Instruments to apply a suture to body tissue in 
conjunction with metal staples arranged side to side are known and 
described in U.S. Pat. Nos. 4,749,114; 4,773,420; and 4,821,939. The 
sutures in these instruments are placed around the tissue structure and 
tightened, i.e. pulled, to compress the tissue. 
There exists a need for an improved instrument to apply arrayed suture(s), 
in conjunction with one piece staples or with two-part surgical fasteners. 
Such instrument would have broader applications than the purse string 
instrument discussed above as it could function to place sutures in 
conjunction with fasteners adjacent an incision, thereby enabling quick 
closure of the incision by tightening the sutures. 
One application for such an improved instrument would be in hysterotomy 
procedures. Hysterotomy procedures performed in cesarean sections are now 
performed with a surgical fastener applying apparatus such as described in 
U.S. Pat. No. 5,116,349. This instrument, which is capable of making an 
incision in tissue and simultaneously applying at least one row of 
two-part bioabsorbable fasteners to the tissue on each side of the 
incision, provided a marked advance in obstetrical surgery as it reduced 
infection rate, reduced blood loss, and controlled uterine opening to 
facilitate delivery of the baby. The fasteners helped to minimize the 
amount of bleeding by creating a hemostatic seal along the edges of the 
incised tissue. 
After the hysterotomy has been performed with this instrument, and the baby 
delivered through the incision, surgeons close the incision by passing a 
suture between the backspan and retainer portions of the fasteners while 
stitching across the incision. The suture is tugged slightly to cinch the 
suture. The procedure is repeated with the suture running back and forth 
across the incision through each of the fasteners until the sides of the 
incision are drawn into close juxtaposition. 
Although stitching the incision by hand with a needle and suture is 
effective in closing the wound, this procedure is time consuming because 
the suture has to be passed individually through each of the fasteners. 
Additionally, the required repeated manipulation of the needle increases 
the likelihood of doctors sticking themselves with needles. Moreover, in 
manual suturing, wound closure can vary with the skills of the particular 
surgeon. It would be advantageous to provide an instrument which can 
eliminate these disadvantages and shorten the time period involved in 
suturing since this would not only reduce blood loss and trauma to the 
patient, but would reduce hospital costs. Such an instrument would have 
applications beyond hysterotomy procedures as it would enable placement of 
sutures in conjunction with fasteners to expedite wound closure. Up to 
now, there has been no instrument for accomplishing this stitching 
function automatically. 
SUMMARY OF THE INVENTION 
The present invention advantageously provides an apparatus which can 
simultaneously apply fasteners and one or more sutures to the body tissue 
to thereby facilitate and expedite wound closure. 
The surgical fastener applying apparatus of the present invention includes 
a frame, a cartridge mounted to the frame for holding a plurality of 
surgical fasteners in at least two rows, and means for applying the 
surgical fasteners to body tissue. The individual fasteners in each row 
are preferably oriented in end to end fashion. The applying means 
simultaneously applies at least one, and preferably up to four, suture(s) 
in conjunction with the fasteners, such that a portion of the suture 
extends across the rows from a fastener on one of said rows to a fastener 
on another of said rows. 
The surgical fasteners are preferably of two part construction and are 
fabricated from a bioabsorbable material such as homopolymers and 
copolymers of glycolide, lactide, dioxanone, caprolactone, trimethylene 
carbonate and blends thereof. The suture is also preferably composed of 
bioabsorbable materials. Alternatively, the fasteners can be an integral 
single piece construction such as metal staples. 
The cartridge for holding the fasteners includes a tissue contacting face, 
the portion of the suture extending across the rows being at least 
partially positioned in a loop located away from the tissue contacting 
face. Means may be included for releasably holding the loop until the 
fasteners are applied. 
The ends of the suture(s) may be anchored to the apparatus by tensioned 
rotatable spools contained in a housing releasable from the apparatus when 
the fasteners are fired.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENT 
Although the principles of the invention are applicable to other types of 
surgical stapler apparatus, the invention will be understood clearly from 
an explanation of its application to the surgical stapler apparatus of the 
type described in U.S. Pat. No. 5,116,349 mentioned above and hereby 
incorporated by reference in its entirety. The invention is applicable 
also to both permanent and disposable apparatus. Accordingly, although the 
invention will be illustrated in an embodiment in which a cartridge 
comprising a fastener holder and an anvil assembly is mounted in a 
disposable instrument, the invention could equally be described in use in 
a non disposable embodiment. 
Turning now to FIG. 1 which illustrates a surgical fastener applying 
apparatus 100, the apparatus includes a body portion 110, having a 
longitudinally extending portion 111 and a handle 112. The distal portion 
150 of body portion 110 is U-shaped and includes distal leg 151 and 
proximal leg 152. 
Cartridge 160 is located at the proximal leg 152 of distal portion 150 of 
the apparatus and has distal tissue contacting surfaces 166a (FIG. 2) and 
166b (not shown) through which the fasteners described below exit. The 
anvil assembly 170 is fixedly positioned at the distal leg 151 of the 
U-shaped distal portion 150. Spacer pin 153 is a cross pin which serves to 
space the left and right frames apart. 
Approximating lever 140 is pivotally mounted to the apparatus and controls 
the approximation or closing of the jaws of the instrument. When the 
approximating lever 140 is pressed downwardly in the direction of arrow A, 
the cartridge 160 is distally advanced (arrow B) to come into close 
contact and clamp the body tissue between the jaws of the instrument. 
Trigger 130, which is an actuator for the fastener driving mechanism, is 
pivotally mounted to the apparatus such that squeezing the trigger 130 
effects driving of the fasteners. 
Trigger lock 120 is pivotally mounted to the handle 112 and has prongs 122 
for snap-fit engagement into slot 131 in the trigger. Once the apparatus 
is fully fired, the trigger is locked in the actuated position and cannot 
be refired. 
Contained within the cartridge 160 and anvil assembly are the two-part 
bioabsorbable fasteners 10, illustrated in FIG. 1A. The fasteners 
generally comprise a staple or fastener (tissue piercing) portion 11 
having a backspan 13 and prongs 15 with barbs 17 at the tips thereof. The 
fastener portions 11 (referred to herein also as the fasteners) are 
initially located in slots in the cartridge, each fastener portion 11 
being in a separate slot, and the fastener portion 11 being oriented in 
parallel rows with the fastener portions in each row being oriented in end 
to end fashion. End to end means that a line defining the extension of the 
row of fastener portions coincides with a single straight line extending 
lengthwise through the backspan of each fastener portion in the row. 
At least one row of fasteners is positioned on each side of a knife blade 
such that when the instrument is fired, an incision is made by the knife 
in body tissue, the tissue being sealed on both sides of the incision by 
the rows of fasteners. The fasteners are all applied substantially 
simultaneously with the making of the incision. The retainer portion 12 of 
the two-part fastener comprises a base 14 with columnar members 16 having 
apertures 18 for receiving the barbed prongs 15 of the fastener portion 
11. Once engaged, the fastener portion and the retainer lock together. It 
is desirable to fabricate the fasteners from a bioabsorbable material such 
as polyglycolide, polylactide or copolymers thereof to eliminate the need 
for removing the fasteners at a later time. 
It should be noted that the term "fasteners" as used herein is a generic 
term including not only the two-part resinous surgical fasteners having a 
staple shaped fastener portion and an interlocking retainer portion 
described above, but can also include metal surgical staples as shown in 
U.S. Pat. No. 4,354,628, which are crimped and can be made of metal, 
staples composed of polymeric material, and their equivalents. Similarly, 
the term "anvil assembly" is used herein as a generic term to include the 
anvil used to clinch metal surgical staples, the retainer holder and 
retainer member of two-part resinous surgical fasteners, and the 
equivalent of these elements. 
Referring to FIG. 2, the apparatus further includes a suture array assembly 
200, which includes two spool boxes 210 and 220 (only spool box 210 is 
shown) and a suture array 230 comprising sutures 232, 234, 236 and 238. 
The spool boxes 210 and 220 are mounted at the proximal leg 152 of the 
apparatus, one spool box on each side of the apparatus. 
Spool box 210 includes a housing 211 having a cover (not shown) with four 
apertures 212a, 212c, 212d, and 212b, each dimensioned to-allow passage of 
respective sutures 232, 234, 236 238 therethrough. As shown in the 
drawings, sutures 234, 236 and 238 are wound around spools 213c, 213d and 
213a, respectively. Suture 232 is held in spool box 210 at area 213a by a 
knot or by crimping. Housing 211 includes a pronged catch 214 which is 
adapted to resiliently engage a laterally projecting pin 154 protruding 
from proximal leg 152 of the U-shaped distal portion. A pin is positioned 
on the opposite side of the housing to receive a similar pronged catch of 
spool box 220 in the same fashion. 
Cartridge 160 of the embodiment of FIGS. 1-4, includes a slot 163 to 
receive pin 161. A relatively wider flat plate 162 is attached to the end 
of pin 161 to maintain the sutures in contact with pin 161. Loop retaining 
pin 165 is fixedly attached to cam bar 180 and extends through aperture 
164 in the rear of the cartridge (FIG. 3) so as to project at least 
partially out of the cartridge 160 when the cartridge is in the prefired 
configuration. 
In general, once the instrument is assembled, each of the four sutures 232, 
234, 236 and 238 extends from spool box 210, around pin 161, and through 
the area of the cartridge containing the fasteners. The sutures then exit 
from the fasteners and extend through anchor post 171, along the top of 
the cartridge 160 (underneath spacer pin 153) and down along the back of 
the cartridge 160 where they are looped around (collectively referred to 
as loop 231) and held in place by anchor 165. The sutures then extend back 
along the top of the cartridge, through the fasteners and into spool box 
220. Note that loop 231 is positioned away from the knife slot 169 of the 
tissue contacting faces 166a, 166b to prevent the suture portions in the 
loop from interfering with the incision of the tissue and from being cut 
by the knife when it emerges from knife slot 169 during firing of the 
apparatus. 
In an alternate, preferred, embodiment shown in FIGS. 5a and 5b, the 
cartridge 360 includes a pair of spaced apart ears 362 (only one of which 
is shown) and a centrally positioned loop anchor 364. Ears 362 extend 
upwardly from the top of the cartridge and are fixedly positioned thereon. 
Loop anchor 364 is pivotably attached at the top of the cartridge by pivot 
pin 366 for movement to loosen and allow release of the sutures. All four 
sutures extend from their respective spool boxes, around pin 161 and 
through the cartridge in the manner described above for the previous 
embodiment. However, instead of anchor post 171 and anchor 165, the 
sutures in this embodiment extend through the opening between spaced apart 
ears 362 and are looped around loop anchor 364. This reduces the extent 
the sutures travel on the outside of the cartridge. When the instrument is 
fired, the tension of the sutures will pivot loop anchor 364 distally 
(arrow D) so that the sutures are no longer tensioned. Upon retraction of 
the knife 369, anchor 364 is pivoted further distally as step 368 contacts 
the bottom portion 365 of anchor 364. Thus, anchor 364 does not interfere 
with retraction of the knife and the non-tensioned position of the sutures 
is maintained. 
The positioning of the sutures with respect to the fastener portions is 
illustrated in detail in FIGS. 8-12. In these figures, the fastener slots 
for holding the fasteners are shown without the fasteners for ease of 
explanation. Note that this description of the position of each individual 
suture is the route of the suture once the instrument is assembled. The 
suture may not necessarily be threaded i.e. assembled in this order. For 
example, each suture can be threaded through its respective fasteners 
first, and then each end wrapped around the pin and connected to its 
respective spools in opposing spool boxes. 
SUTURE 232 
Suture 232 is positioned as follows: 
a) through aperture 212a of spool 210 and around pin 161 (FIG. 2); 
b) across the side of the cartridge and through the fastener slot 163a in 
region 167a (corresponding to the approximate mid portion of the backspan 
of the fastener portion) (FIGS. 8 and 9); 
c) a short distance parallel to the central knife slot 169 of the fastener 
cartridge; 
d) through gap 167b between fastener slots 163a and 163b; 
e) along the side of the tissue contacting surface 166a (FIGS. 2, 8, 9); 
f) along the top of cartridge 160 (through post 171 and under pin 153); 
g) down along the back of cartridge 160 and around into loop 231 (held in 
place by loop retaining pin 165); 
h) up the back and along the top of cartridge 160 in the opposite 
direction; 
i) along the side of the tissue contacting face 166b of the cartridge; 
j) through gap 168b between fastener slots 163l and 163m; 
k) parallel to knife slot 169 and through region 168c of slot 163l; 
l) again up along the side of the tissue contacting face 166b of the 
cartridge and around into loop 231; 
m) back over the top of the cartridge, down through tissue contacting face 
166a and through gap 167d between fastener slots 163c and 163b; 
n) parallel to knife slot 169 and through region 167c of fastener slot 
163b; 
o) along the side of the tissue contacting face 160 of the cartridge, 
around into loop 231, back along the top of the cartridge and down through 
opposing contacting face 166b; 
p) through gap 168b between fastener slot 163l and lowermost fastener slot 
163k; 
q) through region 168a of slot 163k; and 
r) around the other side of the cartridge, around pin 161, and down into 
spool box 220 which is located on the opposite side of the cartridge from 
spool 210. 
SUTURE 234 
Suture 234 is positioned as follows: 
a) through aperture 212c of spool 210 and around pin 161 (FIG. 2); 
b) across the side of the cartridge and through the fastener slot 163c in 
region 167e (corresponding to the approximate mid portion of the backspan 
of the fastener portion) (FIGS. 8 and 9); 
c) a short distance parallel to the central knife slot 169 of the fastener 
cartridge; 
d) through gap 167f between fastener slots 163c and 163d; 
e) along the side of the tissue contacting surface 166a (FIGS. 2, 8, 10) 
f) along the top of cartridge 160 (through post 171 and under pin 153); 
g) down along the back of cartridge 160 and around into loop 231 (held in 
place by loop retaining pin 165); 
h) up the back and along the top of cartridge 160 in the opposite 
direction; 
i) along the side of the tissue contacting face 166b of the cartridge; 
j) through gap 168j between fastener slots 163o and 163p; 
k) parallel to knife slot 169 and through region 168i of slot 163o; 
l) again up along the side of the tissue contacting face 166b of the 
cartridge and around into loop 231; 
m) back over the top of the cartridge, down through tissue contacting face 
166a and through gap 167j between fastener slots 163f and 163e; 
n) parallel to knife slot 169 and through region 167i of fastener slot 
163e; 
o) along the side of the tissue contacting face of the cartridge, around 
into loop 231, back along the top of the cartridge and down through 
opposing contacting face 166b; 
p) through gap 168f between fastener slots 163m and 163n; 
q) through region 168e of slot 163m; and 
r) around the other side of the cartridge, around pin 161, and down 
into spool box 220 which is located on the opposite side of the cartridge 
from spool box 210. 
Suture 236 
Suture 236 is positioned as follows: 
a) through aperture 212d of spool 210 and around pin 161 (FIG. 2); 
b) across the side of the cartridge and through the fastener slot 163f in 
region 167k (corresponding to the approximate mid portion of the backspan 
of the fastener portion) (FIGS. 8 and 11); 
c) a short distance parallel to the central knife slot of the fastener 
cartridge; 
d) through gap 167l between fastener slots 163f and 163g; 
e) along the side of the tissue contacting surface 166a (FIGS. 2, 8, 11) 
f) along the top of cartridge 160 (through post 171 and under pin 153); 
g) down along the back of cartridge 160 and around into loop 231 (held in 
place by loop retaining pin 165); 
h) up the back and along the top of cartridge 160 in the opposite 
direction; 
i) along the side of the tissue contacting face 166b of the cartridge; 
j) through gap 168p between fastener slots 163s and 163r; 
k) parallel to knife slot 169 and through region 168o of slot 163r; 
l) again up along the side of the tissue contacting face 166b of the 
cartridge and around into loop 231; 
m) back over the top of the cartridge, down through tissue contacting face 
166a and through gap 167p between fastener slots 163i and 163h; 
n) parallel to knife slot 169 and through region 167o of fastener slot 
163h; 
o) along the side of the tissue contacting face 166a of the cartridge, 
around into loop 231, back along the top of the cartridge and down through 
opposing contacting face 166b; 
p) through gap 168l between fastener slots 163p and 163q; 
q) through region 168k of slot 163p; and 
r) around the other side of the cartridge, around pin 161, and down into 
spool box 220 which is located on the opposite side of the cartridge from 
spool box 210. 
Suture 238 
Suture 238 is positioned as follows: 
a) through aperture 212b of spool 210 and around pin 161 (FIG. 2); 
b) across the side of the cartridge and through the fastener slot 163i in 
region 167q (corresponding to the approximate mid portion of the backspan 
of the fastener portion) (FIGS. 8 and 12); 
c) a short distance parallel to the central knife slot 169 of the fastener 
cartridge; 
d) through gap 167r between fastener slots 163i and 164j; 
e) along the side of the tissue contacting surface 166a (FIGS. 2, 8, 12) 
f) along the top of cartridge 160 (through post 171 and under pin 153); 
g) down along the back of cartridge 160 and around into loop 231 (held in 
place by loop retaining pin 165); 
h) up the back and along the top of cartridge 166 in the opposite 
direction; 
i) along the side of the tissue contacting face 166b of the cartridge; 
j) through gap 168t between uppermost fastener slot 163t and the uppermost 
portion of the cartridge; 
k) parallel to knife slot 169 and through region 168s of slot 163t; 
l) again up along the side of the tissue contacting face 166b of the 
cartridge and around into loop 231; 
m) back over the top of the cartridge, down through tissue contacting face 
166a and through gap 167t between uppermost fastener slot 163j and the 
uppermost portion of the cartridge; 
n) parallel to knife slot 169 and through region 167s of fastener slot 
163j; 
o) along the side of the tissue contacting face of the cartridge, around 
into loop 231, back along the top of the cartridge and down through 
opposing contacting face 166b; 
p) through gap 168r between fasteners slot 168s and 168t; 
q) through region 168q of slot 163t; and 
r) around the other side of the cartridge, around pin 161, and down into 
spool box 220 which is located on the opposite side of the cartridge from 
spool box 210. 
Turning now to the operation of the apparatus, before the apparatus is 
fired, the tissue to be fastened is positioned in the gap between the 
distal leg 151 and cartridge 160. Lever 140 is pressed downwardly so that 
the cartridge 160 is approximated towards anvil assembly 170 to clamp the 
body tissue (See FIG. 3). 
Upon squeezing of trigger 130 to fire the apparatus, the cam bar 180 is 
moved distally so as to apply force to the fastener pusher 182 and the 
knife 184 to drive out the fasteners 11 i.e. the fastener portions of the 
two part fasteners) and the knife 184 from their respective slots. When 
the cam bar 180 is moved forwardly as shown in FIGS. 4a and 4b, the loop 
retaining pin 165 is moved upwardly and inwardly in aperture 164 and pin 
161 is moved upwardly and distally in slot 163. This movement of pin 165 
releases loop 231, which is no longer held in place, i.e. tensioned, along 
the rear of the cartridge. The tension applied to the sutures when pin 161 
is moved upwardly and forwardly is sufficient to disengage the catch 
members of spool boxes 210, 220 from the pins as the boxes 210, 220 are 
pulled upwardly along the respective sides of the cartridge. Note that in 
the embodiment of FIGS. 5a, 5b, firing of the apparatus pivots the loop 
retainer 364 distally as described above to release the suture loop of the 
sutures. 
The configuration of sutures with the fired fasteners applied to tissue 300 
is illustrated in FIGS. 6 and 7. As can be seen, fully engaged fasteners 
10 extend in end to end fashion along two rows, one row on each side of 
incision 301. The sutures extend underneath the backspans of the fastener 
portions, between the legs of the fasteners and around into the loop 231 
so as to be positioned out of the cutting line of the apparatus when 
fired. However, as shown in FIG. 7, when the ends of the sutures are 
pulled, the suture loop 231 tightens up and the edges of the incision are 
brought together such that the sutures are arrayed in crisscross fashion 
across the incision in the tissue. 
Note that in the preferred embodiment, the lengths of sutures 232, 234, 236 
and 238 are equal. Each suture is wrapped around its respective spool to a 
different degree, corresponding to the length of suture required to wind 
through the fasteners in the pre-fired position. For example, suture 238 
wraps around spool 213b a greater amount than suture 236 wraps around 
spool 213d to account for the slack which would otherwise occur since 
suture 236 is wound along a shorter route through the fasteners than 
suture 236. Consequently, when the apparatus is fired, pulling the spool 
boxes will tension each suture sequentially, i.e. suture 232 will be 
tensioned first, followed by sutures 234, 236 and 238, until all four 
sutures are tensioned. 
It should also be appreciated that a fewer or greater number of sutures can 
be provided to achieve the wound closure function of the present 
invention. Moreover, the sutures can be threaded through the fasteners and 
connected to the cartridge in other ways than those described above and 
sutures of different sizes can be provided. The sutures may also be color 
coded to facilitate identification of the two suture ends. 
FIGS. 13, 14, 15 and 16 illustrate a hysterotomy such as is performed 
during a cesarean section using the instrument of the present invention. 
To perform the cesarean section in accordance with the method of the 
present invention, the abdomen of the patient is cut and the peritoneal 
muscle tissue is incised to create a bladder flap. Retractors 301 may be 
used to facilitate access to the uterus. A small (about 1 cm.) lateral 
incision 302 is made in the uterus 303 with care to avoid rupture of the 
amniotic sac. A finger is then inserted to clear away fetal tissue from 
the area to be stapled. Allis clamps 304 may be placed along the edges of 
the uterine incision to assist in stabilizing the uterus. The apparatus 
100 is inserted through incision 302 as shown in FIG. 13, the cartridge 
160 is approximated to the uterine tissue by pressing lever 140 into 
position as shown, and the trigger 130 is squeezed to fire the instrument. 
When the apparatus 100 is opened and withdrawn, the suture array assembly 
200 remains behind in conjunction with the applied fasteners 10. 
The same procedure is repeated with a fresh apparatus on the other side of 
the uterus as shown in FIG. 14. 
The resulting simultaneous application of sutures and fasteners is shown in 
FIG. 15. The baby is delivered through incision 302, with the tissue 300 
at the edge of the incision 302 sealed and hemostasis is achieved by the 
rows of fasteners 10 on both sides of the incision. 
After the delivery, the surgeon closes the incision by pulling the opposing 
spool boxes 210, 220, thereby reducing the loops 231 and drawing the edges 
of the tissue together into close contact to close incision 302. The spool 
boxes are cut away from the sutures by means of a scissor or other cutting 
instrument the sutures tied off to prevent loosening. Thereafter, the 
procedure is concluded in the usual manner by stitching the incisions in 
the peritoneal tissue and abdominal skin. 
The simplicity of closing the uterine incision with the suture array of the 
present invention, as contrasted with the prior known method, is 
advantageous insofar as operating time, blood loss and trauma are even 
further reduced.