# Patent

## Title
Compact suture punch with malleable needle

## Abstract

A suture punch system is capable of directly passing braided suture through tissue in a simple, one-step process. The system includes three principle components: a malleable needle with braided suture attached, a handheld instrument for grasping tissue and controlling needle placement, and a trocar to supply the force required for needle placement. Needle deformation begins at the tip of the instrument, which preferably includes a curved segment. As the distal tip of the needle pierces the tissue, it continues its radial path through the tissue. When the proximal end of the needle exits from the instrument, the needle is entirely radial in shape and traverses an essentially radial path through the tissue. Non-radial linear or non-linear segments may alternatively be used. In one embodiment, the tissue to be sutured is constrained by pressure applied through closure between an upper, moveable jaw the distal portion of the instrument which acts as a fixed jaw. The upper, movable jaw contains a shaped passageway which allows the curved needle to pass therethrough during use. Once the needle has passed entirely through the tissue it is ready for retrieval using the jaws of the punch or another instrument. Different needle designs and separate instruments are also disclosed.

## Background
REFERENCE TO RELATED APPLICATION
This application claims priority from U.S. Provisional Patent Application Ser. No. 60/310,220, filed Aug. 6, 2001; the entire content of this application is incorporated herein by reference.


FIELD OF THE INVENTION
This invention relates generally to surgical suturing and, in particular, to improved articles, instrumentation, and methods therefore.
BACKGROUND OF THE INVENTION
Suture passing is problematic for the arthroscopic surgeon because the braided suture preferred by most arthroscopists cannot be pushed through a cannulated instrument. Braided suture must be pulled into location because applying a push force causes the braid to expand in diameter, thereby wedging in the instrument.
Various solutions have been devised for passing braided suture. The Caspari Suture Punch (Linvatec Corporation, Largo, Fla.) has been a very useful arthroscopic suture-passing instrument. Tissues can be approached head on, grasped and punctured with a cannulated needle, then monofilament suture wheeled through the tissue. A doubled monofilament can be used as a shuttle to pass another braided suture or, alternatively, a Linvatec Suture Shuttle can be wheeled through a slotted Caspari Suture Punch and used to shuttle suture. Surgical Dynamics has a similar device that shuttles a needle from one side of the punch to the other, passing the needle and attached thread through tissue.
The Caspari suturing instrument, described in U.S. Pat. Nos. 4,890,615, 4,923,461 and 4,957,498, includes a hollow needle for penetrating tissue to be sutured within the body while the tissue is clamped between relatively movable jaws, and a suture feed mechanism for feeding suture material through the hollow needle such that the jaws can be opened and the suturing instrument withdrawn from the body pulling the free end segment of the suture material with the instrument. A knot can be tied in the suture material externally of the body and the knot moved back into the body at a position adjacent the tissue.
U.S. Pat. No. 5,254,126 discloses an endoscopic suture punch for use in endosurgical procedures having an elongate frame and a handle mounted to one end of the frame. A pair of opposed jaws having tissue punches is mounted to the other end of the frame. One jaw is rigidly mounted to the frame while the other jaw is movably mounted to the frame, although both jaws can be movably mounted. An actuation handle is mounted to the frame for actuating the jaws. The suture punch has a suture pathway through the frame, the punches and the jaws for receiving the suture. There is a suture drive mechanism mounted to the frame for moving the suture through the suture pathway.
The surgical suturing apparatus described in U.S. Pat. No. 5,454,823 comprises upper and lower jaw elements selectively movable relative to one another between open and closed position. Each jaw element is provided with a respective recess arranged to receive a portion of an elongate incision member or length of surgical thread and securing means is provided arranged to selectively secure the surgical incision member or length of surgical thread in a respective recess. The jaw elements are typically provided at an end of an elongate positioning and operating arm making the device particularly useful for use in laparoscopic surgery.
More recently, U.S. Pat. No. 6,051,006 describes a suture-passing forceps having a first jaw with a mount which supports a needled suture and a second jaw having a passage, which when aligned with the mount, is positioned to receive the needled suture. The second jaw is positioned relative to the mount in a manner which allows delivery of the instrument to a surgical site in a low profile, delivery position (e.g., with the jaws spaced relatively closely). The surgical instrument includes an elongated shaft having a distal region for supporting the jaws. The second jaw is pivotable, with respect to the mount, between the delivery position in which the second jaw is spaced relatively closely to the mount with the passage misaligned with the mount and an open, misaligned position, the second jaw being axially translatable relative to the mount to an open, aligned position in which the passage is aligned with the mount.
A shortcoming of these and other such devices is the lack of room available to open the jaws sufficiently in tight spaces (a clearance issue), difficulty in forcing the tooth through the full thickness of the tissue (the tip gradually dulls and some tissue like the rotator cuff is just too thick) and fairly large diameter cannulas are required for passage.
Other “blitzes” and similar devices also have rather large diameter cannulated needles that pierce the tissue then deploy a loop or other mechanism to transport suture through the tissue. These are cumbersome to use, often requiring skillful rotation and pushing of the device by the surgeon to accomplish the desired result. Additionally, some concern exists with regard to the size of the hole placed in the tissue and the amount of damage requiring repair. This is especially true of the newer “Arthropierce” instrument currently in use.
Common to existing devices is a body capable undergoing elastic deformation during use but which retains a preformed shape when in an unconstrained condition. Of particular usefulness in these devices is Nitinol, a so-called “shape retention” alloy having an extremely high yield point. Nitinol components are formed during manufacture to a desired shape, and will return to this shape when in an unconstrained condition even after undergoing significant deformation. Preformed Nitinol needles and shuttles can be passed through cannulated instruments and will return to their original shapes when in an unconstrained state. This allows shuttle loops to be passed through cannulated instruments without permanent deformation. All Nitinol components are formed to their desired shapes during manufacture.
As an example of an invention utilizing this effect, U.S. Pat. No. 5,607,435 describes a medical instrument including a tubular section having a leading end terminating in a sharp point and a surgical needle exhibiting “superelastic characteristics.” As such, the needle can remain straight as it is inserted through the delivery tube without developing substantial permanent deformation. While in the delivery tube and in this substantially straight condition, the needle is delivered to the suturing site. Once at the suture site, the surgical needle is extended out of the leading end of the delivery tube, returning it to its original curved or bent shape for suturing. A suture thread or wire is operatively disposed in the bore of the tubular section with one end extending out the tip through a slot so as to remain in position to form a suture upon removal of the tubular needle from tissue. A tweezers instrument may then be used to grip and tie the thread into a suture knot.
Similarly, U.S. Pat. No. 5,749,879 discloses a cannulated instrument for use in conjunction with “an elastic needle.” In the preferred embodiment, the needle is of a pseudoelastic shape memory alloy and has an arced shape while the needle's alloy is in a substantially austenitic phase, and the needle may be stressed into a more straight shape in which the needle's alloy enters an at least partially more martensitic phase. When the needle is held entirely within the cannula, the needle is straightened and contains more stress-induced-martensite phase. As the needle is extruded from the distal end portion of the cannula, that portion of the needle which extends beyond the cannula returns toward its original shape by a martensitic-to-austenitic shape memory phase change caused by at least partial relief of the stress-induced-martensite in the needle's alloy. A cannula insert includes a longitudinal bore which may be used to contain a suture attached to the needle. Suitably, the bore may extend longitudinally entirely through the cannula insert, to permit an unlimited length of suture to be pulled therethrough.
Despite these advances, the need remains for a suture punch capable of passing braided suture without the use of a shuttle or similar means. Preferably, such an instrument would be capable of passing suture while not requiring multiple or complex sequential operations or a high level of surgeon skill. It is also preferable that the suture punch pass through a small diameter (i.e., 8 mm or less) cannula, and that the hole created in the tissue for passage of the suture be as small as possible.
SUMMARY OF THE INVENTION
This invention overcomes deficiencies in the prior art by providing a suture punch system capable of directly passing braided suture through tissue in a simple, one-step process. The system includes three principle components: a malleable needle with braided suture attached, a handheld instrument for grasping tissue and controlling needle placement, and a trocar to supply the force required for needle formation and placement.
The needle differs from standard needles in terms of size, shape and material properties. In the preferred embodiment, the needle is shorter than standard needles, generally 10 to 13 mm in length, and has a cross-section which may be circular or noncircular, including rectangular with at least two parallel sides. Additionally, the needle is made of a malleable material allowing it to be shaped within the handheld instrument and to retain its form while passing through tissue. Similarly, the distal portion of the trocar is malleable allowing shaping within the handheld instrument.
In contrast to existing suture punches in which the needle or shuttle undergoes only an elastic deformation during use and the functional un-constrained shape of the needle or shuttle is produced during manufacture, the needle of the disclosed device is inelastically formed to its functional shape during use, allowing the needle to traverse a nonlinear path. More particularly, when passing through the distal tip of the hand instrument, the needle is inelastically formed by a radial path within the instrument, the plane of the radius being preferably perpendicular to the tissue through which suture is being passed. The formation of this radius is facilitated by the aforementioned parallel sides of the needle cross-section which are constrained by the instrument in such a manner as to place them essentially in the plane of the tissue.
Needle deformation begins as the tip of the needle passes through the radius within the instrument and continues as the needle is forced distally by the trocar. As the distal tip of the needle pierces the tissue, it continues its radial path through the tissue, the radius of the path being determined by the unconstrained radius of the needle. This unconstrained radius will be larger than that of the forming radius within the instrument due to “spring back” of the needle, the degree of which is determined by the material properties of the needle, its cross section, and features formed in the parallel surfaces of the needle during manufacture.
Forming of the needle along its length continues as it is passes from the distal tip of the instrument into the tissue. When the proximal end of the needle exits from the instrument, the needle is entirely radial in shape and traverses an essentially radial path through the tissue. After the proximal end of the needle exits the instrument, the needle is propelled further along its radial path by the trocar, the distal portion of the trocar being formed to a radial shape by the instrument in the same manner as the needle and the radial shapes of the needle and trocar being coplanar. Engagement of the trocar with the needle after the needle passes from the instrument may be facilitated by mating surfaces of the trocar and needle, shaped, for example, to prevent radial or lateral displacement of the needle proximal and trocar distal surfaces.
The passage in the instrument within which the needle travels, and the forming radius in the instrument distal tip, each comprise open-sided channels allowing the needle-attached suture to travel unimpeded during its forming and insertion into the tissue. As the trocar pushes the needle further into the tissue, the suture is pulled along by the needle through the passage formed in the tissue.
During use, the tissue to be sutured is constrained by pressure applied through closure between the upper, moveable jaw of the instrument and the distal portion of the instrument which acts as a fixed jaw. The upper, movable jaw contains a shaped passageway which allows the curved needle to pass therethrough during use. After the trocar has been fully inserted into the instrument and the needle has achieved maximum travel into and through the tissue, the trocar is withdrawn from the instrument.
When suturing thin sections, the needle will have passed completely through the tissue and is ready for retrieval using the jaws of the punch or another instrument. In the case of thick tissue, 70 percent or more of the needle will protrude from the tissue after the trocar is fully inserted, such that opening the upper jaw slightly and moving the instrument in a proximal direction will cause the needle to wedge in the upper jaw passage, allowing the needle to be withdrawn completely from the tissue. Following this procedure, the needle may be retrieved using the punch or another instrument.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a plan view of a suture punch formed in accordance with the principles of this invention;
FIG. 2 is a side view of the instrument of FIG. 1;
FIG. 3 is an end view of the instrument of FIG. 1;
FIG. 4 is an expanded view of the distal tip of the instrument of FIG. 1;
FIG. 5 is a sectional view of the distal tip of FIG. 2 at location A—A;
FIG. 6 is a sectional view of the distal tip of FIG. 2 at location B—B;
FIG. 7 is a sectional view of the instrument at location C—C;
FIG. 8 is a sectional view of the instrument at location D—D;
FIG. 9 is a sectional view of the instrument at location E—E with the trocar and needle removed;
FIG. 10 is an expanded view of the distal tip of the instrument;
FIG. 11 is a plan view of a needle constructed in accordance with the principles of this invention;
FIG. 12 is a side view of the needle of FIG. 5;
FIG. 13 is an end view of the needle of FIG. 5;
FIG. 14 is a plan view of the upper jaw of the instrument;
FIG. 15 is a side view of the upper jaw of FIG. 14;
FIG. 16 is a sectional view of the upper jaw of FIG. 14;
FIG. 17 is an end view of the upper jaw of FIG. 14;
FIG. 18 is a trocar used in accordance with this invention;
FIG. 19 is an expanded view of the distal end of the trocar of FIG. 18;
FIG. 20 is an expanded sectional view of the proximal end of the trocar of FIG. 18;
FIG. 21 is an expanded view of the distal portion of the trocar of FIG. 19;
FIG. 22 is an end view of the trocar of FIG. 18;
FIG. 23 is a sectional view of the instrument of FIG. 1 with trocar and needle in place;
FIG. 24 is an expanded view of the distal portion of FIG. 23;
FIG. 25 shows a needle and trocar loaded and the upper jaw open in preparation for use;
FIG. 26 is an expanded view of the distal end of the instrument of FIG. 25;
FIG. 27 depicts the instrument grasping tissue in preparation for passing a needle with suture therethrough;
FIG. 28 is an expanded view of the distal end of the instrument grasping tissue as shown in FIG. 27;
FIG. 29 shows the trocar now advanced so that the needle tip is beginning to pierce tissue grasped between the instrument jaws;
FIG. 30 is an expanded view of the distal end of the instrument shown in FIG. 29;
FIG. 31 shows the trocar advanced so that the needle has approximately 90 percent penetration of tissue grasped between the instrument jaws;
FIG. 32 is an expanded view of the distal end of the instrument shown in FIG. 31;
FIG. 33 shows the trocar advanced so that the needle has passed through tissue grasped between the instrument jaws and protrudes beyond the superior surface of the moveable jaw;
FIG. 34 is an expanded view of the distal end of the instrument of FIG. 33;
FIG. 35 shows the trocar fully advanced so that the trocar distal tip has forced the needle proximal end significantly through the tissue grasped between the instrument jaws;
FIG. 36 is an expanded view of the distal end of the instrument of FIG. 35;
FIG. 37 is similar to FIG. 35, but with the trocar retracted so that only the needle and suture remain within the tissue;
FIG. 38 is an expanded view of the distal end of the device of FIG. 37;
FIG. 39 is similar to FIG. 37, but with the moveable jaw retracted;
FIG. 40 is an expanded view of the distal end of FIG. 39;
FIG. 41 is similar to FIG. 30, but with the distal end retracted proximally from the tissue so that the needle is pulled from the tissue by the moveable jaw;
FIG. 42 is an expanded view of the distal end of FIG. 41;
FIG. 43 is similar to FIG. 41, but with the needle grasped between the jaws of the instrument;
FIG. 44 is an expanded view of the distal end of FIG. 43;
FIG. 45 is similar to FIG. 43, but with the needle rotated and grasped between the jaws in preparation for withdrawal through the cannula;
FIG. 46 is an expanded view of the distal end of FIG. 45;
FIG. 47 is a plan view of an alternate needle configuration according to the invention;
FIG. 48 is a side view of the needle configuration of FIG. 47;
FIG. 49 is an end view of the needle configuration of FIG. 47;
FIG. 50 is a plan view of yet a further alternate needle configuration according to the invention;
FIG. 51 is a side view of the alternate needle configuration of FIG. 50;
FIG. 52 is an end view of the alternate needle configuration of FIG. 50;
FIG. 53 is a plan view of an alternate top jaw configuration according to the invention;
FIG. 54 is a side view of the alternate top jaw configuration of FIG. 53;
FIG. 55 is an end view of the alternate top jaw configuration of FIG. 53;
FIG. 56 is a sectional view of the alternate top jaw configuration of FIG. 53;
FIG. 57 is a sectional view of upper and lower jaws with jaws closed and needle fully extended;
FIG. 58 is a sectional view of upper and lower jaws with jaws opened 50 percent and needle fully extended;
FIG. 59 is a sectional view of upper and lower jaws with jaws opened 100 percent and needle fully extended;
FIG. 60 is a sectional view of upper and lower jaws with jaws opened 100 percent and the suture being pulled through the tissue;
FIG. 61 is a plan view of yet a different alternate needle according to the invention;
FIG. 62 is a lateral side view of the different alternate needle of FIG. 61;
FIG. 63 is an end-on view of the alternate needle of FIG. 61 viewed from the distal tip;
FIG. 64 is a plan view of an alternate construction of the upper/moveable jaw;
FIG. 65 is a side view of the alternate construction of the upper/moveable jaw of FIG. 64;
FIG. 66 is a bottom-side plan view of the alternate construction of the upper/moveable jaw of FIG. 64;
FIG. 67 is an end view of the alternate construction of the upper/moveable jaw of FIG. 64 from the proximal end;
FIG. 68 is an end view of the alternate construction of the upper/moveable jaw of FIG. 64 from the distal tip;
FIG. 69 is a sectional view of the alternate construction of the upper/moveable jaw of FIG. 64 in direction J—J;
FIG. 70 Is a sectional view of the alternate construction of the upper/moveable jaw of FIG. 64 in direction K—K;
FIG. 71 is a sectional view of the alternate construction of the upper/moveable jaw of FIG. 64 in direction L—L;
FIG. 72 is a sectional view of the upper jaw of FIG. 64 assembled to the lower jaw and with the needle of FIG. 61 deployed in tissue and ready for retrieval;
FIG. 73 is a sectional view of the upper jaw of FIG. 64 assembled to the lower jaw and with the needle of FIG. 61 captured in the upper jaw;
FIG. 74 is a sectional view of the upper jaw of FIG. 64 assembled to the lower jaw and with the needle of FIG. 61 captured in the upper jaw and withdrawn from the tissue;
FIG. 75 is a sectional view of the upper jaw of FIG. 64 assembled to the lower jaw and with the needle of FIG. 61 captured by the instrument and positioned for withdrawal through a callula;
FIG. 76 is an alternate needle having a radial shape and made of Nitinol;
FIG. 77 is a plan view of the needle of FIG. 76 prior to forming;
FIG. 78 is an end view of the needle of FIG. 76;
FIG. 79 is a plan view of an alternate needle according to the invention;
FIG. 80 is a side view of the needle of FIG. 79;
FIG. 81 is an end view of the needle of FIG. 79;
FIG. 82 is a plan view of an alternate top jaw according to the invention;
FIG. 83 is a side view of the alternate top jaw of FIG. 82;
FIG. 84 is a side sectional view of the alternate top jaw of FIG. 82;
FIG. 85 is an end view of the alternate top jaw of FIG. 82;
FIG. 86 is a expanded lateral sectional view of the alternate top jaw of FIG. 82;
FIG. 87 is a drawing of a jawless suture punch according to the present invention;
FIG. 88 is a drawing of a trocar pusher adapted for use with the jawless punch of FIG. 87;
FIG. 89 is a drawing of the distal tip of an angled jaw or jaw-less design according to the present invention;
FIG. 90 is a drawing of a particularized capsular plication suture punch for the shoulder according to the present invention;
FIG. 91 is a simplified drawing which shows the way in which three rigidly positioned points may be used to curve a needle into a desired radius according to the present invention;
FIG. 92 is a drawing depicted in partial transparent form, illustrating a more sophisticated jawless punch according to the present invention;
FIG. 93 is an oblique view of the device of FIG. 92;
FIG. 94 is a close-up view of the distal end including the curved tip;
FIG. 95 is a side-view of the device of FIG. 93 with the needle loaded in position;
FIG. 96 is a perspective-view of the configuration shown in FIG. 95;
FIG. 97 is a side-view showing the trocar being advanced by pushing on the proximal end of the pusher rods;
FIG. 98 shows the needle being pushed passed the breached loading position, with the suture material extending out from a slot;
FIG. 99 shows the needle being deformed and pushed out the distal end;
FIG. 100 shows the needle fully advanced, now free of the distal tip of the instrument;
FIG. 101 is a close-up, detail view of the needle emerging from the curved distal tip of the instrument;
FIG. 102A shows the jaws open ready to grab the tip of the needle;
FIG. 102B shows the needle grasped;
FIG. 102C shows how, even once grasped, the tip of the needle may rotate within the jaws;
FIGS. 103A–103C are side views of the embodiments of FIGS. 102A–102C;
FIG. 104 is a perspective view of the grasping mechanism in conjunction with the tip of the needle;
FIG. 105A is a first view of a needle according to the invention particularly suited to certain shoulder procedures;
FIG. 105B is a different view of the needle of FIG. 105A;
FIG. 105C is a end-on view of the needle of the FIGS. 105A and 105B;
FIG. 106 is a retrieval instrument associated with the needle of FIG. 105;
FIG. 107A is a close-up view drawing of the retrieval tip of the instrument of FIG. 106;
FIG. 107B is a different view of the retrieval tip;
FIG. 107C is an end-on view of the retrieval tip;
FIG. 108 shows a distal portion of an insertion instrument; and
FIGS. 109A through 109K show the way in which the needle of FIG. 105, insertion of FIG. 108 and retrieval instrument of FIGS. 106 and 109 are used.



DETAILED DESCRIPTION OF THE INVENTION
Referring to the drawings, as best seen in FIGS. 1 through 9, the instrument body 11 has a proximal end 1 and a distal end 2. The distal end further includes a fixed portion (or fixed jaw) 3 and a movable portion (or moveable jaw) 4. The movable portion 4 is rotatable about pin 5 passing through the movable portion 4 and fixed portion 3 thereby forming a hinge.
The position of movable jaw 4 is determined by positioning rod 6 which transmits an opening or closing force to movable portion 4 via hinge pin 7. The position of positioning rod 6 is determined by the position of movable handle 8, which is connected to the proximal end of positioning rod 6 through pin 9. The positioning rod 6 passes through elongated section 18 of instrument body 11 and through passage 17.
Movable handle 8 is rotatably affixed to the instrument body 11 by pin 10 so that rotating movable handle 8 counterclockwise opens movable jaw 4 and rotating movable handle 8 clockwise closes movable jaw 4 with a closure force proportional to that applied between movable handle 8 and fixed handle 12. Closure pressure between the jaws may be maintained by a ratcheting action created through the interraction between tooth section 13 of movable handle 8 and serrations 14 on arcuate section 15 of fixed handle 12.
Closure pressure may be released by elastically deforming arcuate section 15 upward with pressure applied to proximal end 16 of the arcuate section. Fixed jaw 3 and movable jaw 4 preferably include serations 8 formed on their angularly transposed surfaces to facilitate the grasping of tissue placed between them. Removable trocar 70 protrudes from the proximal end of instrument body 11.
As is best seen in FIGS. 11 through 13, a preferred needle 20 has a proximal end 21 and a distal end 22, and a rectangular cross-section 27 with upper surface 28, lower surface 29 and lateral surfaces 30. The proximal end 21 includes a contoured proximal surface 23, preferably conical in shape, and having a conical angle 24 and a conical axis 25 coaxial with needle centerline 26. The distal end 22 is shaped to form a cutting edge 28 having included angle 27. Suture 31 is attached to a needle lateral surface 30 at a distance 32 from the needle proximal end.
As is best seen in FIGS. 4, 5, 9, and 10, the instrument body 11 has a continuous passage 40 of varying cross-section extending from the proximal-most face 41 of instrument body 11 to the upper surface 42 of fixed jaw 3 near the jaw's distal tip. In section 43, extending a distance 44 from proximal face 41, the passage has a cylindrical cross-section of a specified diameter 56 as shown in FIGS. 7 and 8. In section 45, extending a distance 46 from the distal end of section 43, the passage is a rectangular channel 44, the height of the channel 51 being slightly greater than the thickness 45 of needle 20. Distance 46 is sufficiently longer than the length of needle 20 to allow easy placement of the needle in the slot.
Section 47 of the slot extends from the distal end of section 45 to the termination of the slot at the top surface 42 of fixed jaw 3 and preferably includes of a linear portion 48 and a radial portion 49 having a known radius 50. As is best seen in FIG. 5, the cross-section of channel 40 in section 47 is rectangular having a height 51 slightly greater than the thickness 45 of needle 20 and a width 52 slightly greater than width 53 of needle 20. A slot 54 having a height 55 less than height 51 of passage 40 extends through the entirety of section 47.
As is best seen in FIGS. 14 through 17, upper jaw 4 contains a shaped passageway 60 having a width 61 slightly larger than width 52 of passage 40 and extending from the jaw's lower surface 63 to upper surface 64. As best seen in FIGS. 4 and 10, upper jaw 4 protrudes distally a distance 62 beyond lower jaw 3.
Referring to FIGS. 18 through 22, trocar 70 is an assembly including a stepped cylindrical rod 71 and hub 72 and having a distal end 73 and proximal end 74, with the hub being attached to proximal end 74. Stepped metallic cylindrical rod 71 features a larger diameter section 75 of specified length 76 and diameter 77, with the diameter being slightly smaller than diameter 56 of section 43 of passage 40 so allowing trocar 70 can move freely within instrument body 11 when inserted into passage 40. Cylindrical rod 71 has a smaller diameter section 78 of specified length 79 and diameter 80, with the diameter being slightly smaller than height 51 of sections 45 and 47 of passage 40 allowing trocar 70 to move freely within elongated section 18 of instrument body 11 when inserted into passage 40. Rod 71 is hardened throughout its length to prevent bending, except section 81 extending a length 82 from distal tip 73 is annealed for high malleability. Distal tip 73 is formed to a conical shape of conical angle 83, with the conical angle being equal to conical angle 24 on proximal end 21 of needle 20.
Referring to FIGS. 23 and 24, when prepared for use, needle 20 is inserted laterally into section 45 of passage 40 with the lateral surface 30 with suture 31 facing the open side of channel 40 and suture 31 extending from elongated section 18 of body 11. After insertion, needle 20 is moved distally to section 47 of channel 40; trocar 70 is inserted into channel 40 of instrument body 11, and positioned as shown in FIGS. 23 and 24.
Referring to FIGS. 25 and 26, when using the instrument to pass suture, movable jaw 4 is opened using movable handle 8. Trocar 70 is inserted into instrument body 11 until trocar distal end 73 engages needle proximal end 21. Suture 31 attached to needle 20 moves freely in slot 54.
During use of the device, as seen best in FIGS. 27 and 28 tissue is grasped between upper jaw 4 and lower jaw 3. Referring to FIGS. 29 and 30, advancing trocar 70 a distance 85 distally causes needle 20 to move distally in channel 20, the distal portion of said needle being formed to a radius 50 by the radial portion 49 of passage 40.
Referring to FIGS. 31 and 32, advancing the trocar an additional distance 86 causes needle 20 to be formed to a radial shape of radius 87, radius 87 being larger than radius 50 of section 49 of passage 40 due to springback of the needle after leaving the passage radial section 49. Needle 20 follows a radial path through the tissue. Advancing trocar 70 an additional distance 88 (see FIGS. 33 and 34) causes needle 20 to advance along its radial path until needle distal tip protrudes above top surface 64 of movable jaw 4, having passed through jaw 4 via passage 60.
As is best seen in FIGS. 35 and 36, advancing trocar 70 distally until hub 72 contacts distal face 41 of instrument body 11 advances needle 20 further through the tissue, with distal tip 73 of trocar 70 assuming a radial shape of radius 87 as it passes through radial portion 49 of passage 40. Alignment between trocar distal tip 73 and needle proximal end 21 is maintained by engagement of the needle proximal end conical recess with the with the trocar distal tip conical protrusion, needle proximal end conical radius 24 and trocar distal tip conical radius 83 being equal. In this manner, needle 20 and suture 31 are advanced a distance 89 into the tissue beyond the top surface of lower jaw 3.
As is best seen in FIGS. 37 and 38, withdrawing trocar 70 a distance 90 causes the trocar distal tip 73 to be withdrawn from the tissue into the distal portion of passage 40, leaving needle 20 and suture 31 in the tissue, with needle distal tip 22 protruding well above the top surface of upper jaw 3. As seen in FIGS. 39 and 40, upper jaw 3 is now retracted with needle 20 moving freely within passage 60. Referring now to FIGS. 41 and 42, withdrawing the instrument axially causes needle 20 in slot 60 of upper jaw 3 to be pulled free from the tissue with suture 31 now passing through the tissue. Referring to FIGS. 43 and 44, closing jaw 3 causes it to grasp needle 20, thereby allowing further retraction of the needle with suture attached. As seen in FIGS. 45 and 46, jaws 3 and 4 may be opened thereby freeing needle 20, and the needle rotated 90 degrees and re-grasped by jaws 3 and 4.
Although the above description references “needle 20,” various other needle designs are equally applicable to the invention. In another embodiment, shown in FIGS. 47 through 49, needle 92 has a cross-section with two parallel sides, the lateral faces having a nearly radial profile, a shape producable by coining a cylindrical needle. In another embodiment, shown in FIGS. 50 through 52, needle 94 has a non-uniform cross-section, upper and lower surfaces 95 and 96 having a plurality of angled surface segments 98 of angle 95 each surface terminating in a radius 96 so as to form a series of notches useful in engaging corners of passage 60 in upper jaw 3 so as to aid in needle retraction during axial withdrawal of the instrument.
In addition to alternative needle designs, jaw construction is likewise variable in accordance with the invention. In another embodiment, best seen in FIGS. 53 through 56, upper jaw 100 is of similar construction to upper jaw 3 except that passage 60 has been replaced with slot 101. As is best seen in FIGS. 57 through 59, the distal protrusion 62 of upper jaw 4 beyond lower jaw 3 is required to allow needle 20 to enter passage 60 throughout the range of positions of upper jaw 4. FIG. 60 is a sectional view of upper and lower jaws with jaws opened 100 percent and the suture being pulled through the tissue.
A further alternate needle 201 is shown in FIGS. 61 through 63. As is best seen in FIG. 62, the needle of thickness 220 has a distal end 202 and a proximal end 203, with the distal end formed to a wedge shape having included angle 204 so as to form a cutting edge 205. The proximal end 203 has a conical shape 206 formed therein and having an angle 207 equal to angle 83 on the distal tip of trocar 70 shown in FIGS. 18 through 22. As is best seen in plan view FIG. 61, needle 201 has three sections distinguished by their width. Proximal section 208 and distal section 209 have a width 210, while medial section 211 has a width of 212 than width 211. Distal section 209 is not of constant width, but rather tapers to a width 213 at its distal tip. The transition from middle section 211 to proximal section 208 is a taper of length 214 and angle 215. Suture 216 is attached to lateral surface 217 of proximal section 208 a distance 218 from proximal end 203.
An alternate upper jaw to be used in conjunction with alternate needle 201 is shown in FIGS. 64 through 71. As is best seen in FIGS. 64, 66 and 68, upper jaw 110 is constructed like upper jaw 4 having a distal end 111 and a proximal end 112, except that upper jaw 110 has a distal end slot 113, said distal slot having a proximal portion 114 and a distal portion 120, said portions being distinguished by their width. Proximal portion 114 has a length 125 and a width 115 which is slightly larger than width 210 of proximal section 208 and distal section 209 of needle 201 as shown in FIG. 61. Distal portion 120 has a width of 121 which is slightly larger than width 212 of middle section 211 of needle 201 shown in FIG. 61.
As is best seen when viewing jaw 110 laterally as in FIG. 65, distal portion 111 of jaw 110 has a hooked portion 126 formed therein, said hooked portion having a radius 127 and a height 128, height 128 being somewhat larger than thickness 220 of needle 201 as seen in FIG. 62. As is best seen in axial sectional view FIG. 71, proximal portion 114 of slot 113 has a portion 130 of height 131 with parallel sides and a portion 132 of height 133 whose lateral facing sides are angled outward at angle 134 so that the bottom of the slot is wider than the top of the slot.
The functioning of alternate needle 201 and alternate jaw 110 is best seen in FIGS. 72 through 75. Functioning of the needle and jaw are as explained previously except, referring to FIG. 72, needle 201 being of a shorter length than that of needle 20 and trocar 170 being of a shorter length than trocar 70, when trocar 70 is fully inserted to the limit of its travel, the portion of needle 201 remaining within tissue 171 is greater than that remaining in the previously explained embodiments. The length 175 of the portion of needle 201 protruding beyond tissue 171 is sufficient to cause the distal end of medial portion 211 of needle 201 to extend above surface 172, needle 201 having passed through proximal portion 114 of slot 113, and, as shown in FIG. 72 passed into distal portion 120 of slot 113 due to movement of the instrument proximally.
In this embodiment, needle 201 is prevented from disengagement from the distal portion 120 of slot 113 because the width 210 of needle distal portion 209 is greater than width 121 of slot distal portion 120. Needle 201 is able to move freely within slot 113 parallel to the axis of the slot as width 212 of needle medial portion 211 is less than width 121 of distal portion 209 of slot 113. Referring to FIG. 73, withdrawing the instrument proximally causes needle 201 to move distally and pivot within distal portion 120 of slot 113 so as to engage with the hook segment 126 of jaw 110, thereby allowing needle 201 to be extracted from tissue 171, causing suture 216 to be pulled through the tissue. As is best seen in FIG. 74, after needle 201 is free of tissue 171 upper jaw 110 may be closed and additional suture pulled through the tissue. As seen in FIG. 75, jaw 110 may be closed totally thereby allowing needle 201 with suture 216 attached to be withdrawn through a cannula.
An alternate needle made of Nitinol and formed to a radial shape during manufacture is shown in FIGS. 76 through 78. Manufacture of needle 400 is accomplished in two steps, namely the cutting of the needle blank profile 401 from sheet material, and forming of the needle to a shape having radius 402, with radius 402 being equal to forming radius 50 of lower jaw 3 as shown in FIG. 10. Needle 400 may be used in the same manner as previous embodiments as it will be constrained in a straightened state by channel 47 (FIG. 9) prior to deployment. Needle capture and retrieval are accomplished in the same manner as needle 201 described previously and shown in FIGS. 72 through 75.
An alternate needle 500 having multiple “barbs” displaced along its lateral surfaces is shown in FIGS. 79 through 81. The needle features a distal end 501 shaped to a cutting edge 506 having included angle 507, and a proximal end 502 having a convex conical shape 503 with conical angle 504. The conical angle is preferably equal to distal tip angle 83 of trocar 70, shown in FIG. 21. Suture 508 is attached to a lateral face 510 a distance 511 from distal end 502. Needle 500 has a width 507 and a number of pyramid-shaped “barbs” 512 displaced along lateral surfaces 510, the lateral distance 513 between barb tips being greater than width 507. The barb protrusions are pyramidal in shape having a length 514, width 515 and height 516, the distal edge 517 forming an angle 518 with the lateral surface 510.
FIGS. 82 through 86 show an alternate upper jaw for use with needle 500. Jaw 600 in constructed in the manner of jaw 4, except that jaw 600 includes a hollow structure of wall thickness 602 forming a capture space 601. The capture space 601 is defined by the walls of the jaw and by the inner surface 603 of the jaw lower wall 604. Jaw lower wall 604 has a slot 605 of width 606, width 606 being greater than width 507 of needle 500, but less than distance 513 between barb tips of needle 500. The lower section of slot 605 is tapered outward so as to aid needle 500 in entering slot 605.
Needle 500 and upper jaw 600 are used in the same manner as needle and jaw configurations previously disclosed; that is, needle 500 is formed to a radial shape by the instrument, passes through tissue confined by pressure from the upper and lower jaws, and enters the upper jaw where it is captured for retrieval. Needle 500 and jaw 600 vary in the method of capture. Distal tip 501 of needle 500 enters slot 605 of jaw 600, and via said slot enters space 601. Slot 605, being less in width than distance 513 between the needle barb tips, causes the barb tips to deform as they pass into space 601 via slot 605. Also, because wall thickness 602 is rather thin, jaw 600 will spread slightly so as to allow the barbs to pass. Because the barb proximal surfaces are square rather than tapered, the needle is retained in the slot.
The embodiments described thus far included a pair of jaws, preferably a fixed jaw and movable jaw, with the later being additionally responsible for capture of a needle having been radially deformed and passed through tissue. Although the invention has been described in terms of a fixed jaw and a movable jaw, it will be apparent to those of skill in the art of mechanical design that versions of the invention wherein both jaws move are also anticipated, assuming appropriate interaction associated with needle curvature and capture.
In addition, there are situations, and embodiments of this invention, where capture is performed not by a jaw coupled to the same instrument, but rather, through the use of an additional instrument. Reference to FIGS. 87–91, which illustrate a simpler suture punch according to the invention, which is similar to the embodiments described above, but does not include an upper jaw to hold tissue and/or retain a needle once formed. Nevertheless, the same type of malleable (yet stiff) needle according to the invention having a suture/suture loop is inserted into these simpler devices, and pushed down the channel by a trocar pusher. Since the terminal action of the needle is the same as that used with the more sophisticated device as described herein, the shaft of the channel must be stiff enough to resist a perpendicular vector force required to push the needle through the tissue. One advantage of these alternative designs is that such instruments can be used to plicate the shoulder capsule from the inside arthroscopically. FIG. 87 is a drawing of a jawless suture punch according to the invention, including a curved distal end 802, and a proximal end 804 including an insertion point 806. FIG. 88 is a drawing of a trocar pusher adapted for use with the jawless punch of FIG. 87. The trocar pusher includes a sharpened malleable/spring steel tip 812 coupled to a blunt 814 through an eyelet 816 to receive a thread or suture loop. In operation, the curved tip 802 is placed next to tissue to be sutured, and the sharp tip inserted into the insertion point 806. The sharp tip is then advanced with the trocar pusher of FIG. 88 through the tissue, allowing the suture to be pulled through the tissue as well.
FIG. 89 is a drawing of a lower jaw of a suture punch or a jaw-less design according to the invention. According to this embodiment, a malleable needle is inserted into a loading slot 820 such that the tip of the needle is proximate to the distal end by a distance of 1⁄8 inch, or thereabouts. The instrument is inserted through cannula, upon which time the tissue is grasped and a flexible trocar is pushed down trocar channel 822. As the flexible tip of the trocar nears the needle slot 820, the bend in the channel directs the tip down the needle slot, engaging the proximal end of the needle. As the trocar is advanced further, the needle is pushed through the forming section of the lower jaw, resulting in a deformation similar if not identical to the other embodiments described herein. FIG. 90 is a drawing of a particularized capsular plication suture punch for the shoulder according to the invention. Distance d indicates the portion of the capsule to be plicated, with the capsule surface being shown at 902. A malleable needle is inserted into the proximal end of the device, which penetrates into and out of the capsule, with the entire instrument remaining on one side of the surface 902. The depth of the penetration can be controlled for the curvature of the insertion channel, and the malleability characteristics of the needle. FIG. 91 is a simplified drawing which shows the way in which three rigidly positioned points may be used to curve a needle into a desired radius according to the invention. Once the needle and suture passes through the capsule, a separate needle capture mechanism 910 may be used to pull the suture through, as described elsewhere herein.
FIG. 92 is a drawing depicted in partial transparent form, illustrating a more sophisticated jawless punch according to the invention, including yet a further alternative needle including a distal tip configured for grasping with a separate instrument. The instrument depicted generally at 920 includes a body portion having a squeeze handle 922 coupled to a ratchet 924 which engages with barbs 926 on a pusher mechanism. The pusher mechanism extends through the barrel of the instrument down to the distal tip 930, which terminates in a curved portion 932, and includes a breach loading slot 934 to receive a needle 940 attached to suture 941 and including a distal tip 942 configured for grasping. FIG. 93 is an oblique drawing of the device of FIG. 92. FIG. 94 is a close-up view drawing of the distal end 930 including curved tip 932, breach loading slot 934 and specialized needle 940 having a tip 942 configured for manual grasping, the needle 940 being attached at its proximal end to suture material 941. FIG. 95 is a side-view drawing of the device of FIG. 93 with the needle loaded in position; FIG. 96 is a perspective-view drawing of the configuration shown in FIG. 95. FIG. 97 is a side-view drawing showing the trocar being advanced by pushing on the proximal end of the pusher rods. FIG. 98 is a detail drawing showing the needle being pushed passed the breached loading position, with the suture material extending out from a slot, and with the needle in position just prior to deformation. FIG. 99 is a drawing which shows the needle being deformed and pushed out the distal end, as handle 922 is compressed, causing the ratchet 924 to advance the barbs 926 on the pusher rod. FIG. 100 is a drawing which shows the needle fully advanced, now free of the distal tip of the instrument. FIG. 101 is a close-up, detail view of the needle emerging from the curved distal tip of the instrument.
As discussed above, with respect to the jawless embodiments of this invention, a separate instrument would generally be used to grasp the formed needle, having passed through tissue to be sutured. While conventionally available tools such as forceps, and the like, may be used for such purpose, particularly with respect to the specialized needle shown in FIG. 94 and elsewhere herein, specialized needle grasping instruments may be provided, as shown in FIGS. 102–104. FIG. 103A is a drawing which shows a grasping mechanism 1002 having a specially shaped set of jaws to capture the tip of certain needles described herein. In particular, the embodiment of FIGS. 102–104 are specially suited to grasp the tip of the needle best seen in FIG. 94. FIG. 102A shows the jaws open ready to grab the tip of the needle. FIG. 102B shows the needle grasped, and FIG. 102C shows how, even once grasped, the tip of the needle may rotate within the jaws. FIGS. 103A–103C are side views of the embodiments of FIGS. 102A–102C, and FIG. 104 is a perspective view of the grasping mechanism in conjunction with the tip of the needle.
Yet a further embodiment, intended for applications such as the repair of torn meniscus, torn labrum, capsular reefing to the labrum and other applications, is described in the following text and FIGS. 105 through 109. This embodiment is different from the previous embodiments in that the distal end of the insertion instrument is configured so that the needle exits the instrument in a direction that is axial to the instrument, wherein a normal to the distalmost surface is parallel to the axis of the instrument. The needle is formed to a somewhat larger radius so that when it is fully inserted the needle tip protrudes from the upper (or lower) surface of the tissue undergoing repair, the needle being formed preferably less than 90 degrees. When the needle is fully inserted, the insertion instrument is removed leaving the needle with suture attached embedded in the tissue with its distal tip exposed.
The retrieval instrument distal end is somewhat like the upper jaw of certain previous embodiments in that it has a hook shape designed to allow the captured needle to pivot freely in the plane in which it is formed. A feature allows the tool to exert a force on a needle tip in the distal as well as the proximal direction. The retrieval instrument distal end is also slotted, the slot having a width slightly greater than that of the reduced width region of the needle, but less than the width of the needle distal tip.
In use, the wedge shaped distal end of the instrument is inserted so that the reduced region of the needle is engaged by the slot in the instrument. Moving the instrument distally causes the needle to be pulled further through the tissue. When the head is fully engaged in the slot the needle is pulled the rest of the way through the tissue by moving the instrument distally a distance sufficient to free the needle from the tissue and expose a short length of suture. The retrieval instrument is then moved proximally with the needle pivoting in the distal hook so that it can be withdrawn through the cannula. After the needle is freed from the tissue, the retrieval instrument may be rotated about its axis so that the needle pivots in a plane in which there is sufficient space for this to occur.
Referring to the drawings, as best seen in FIGS. 105A through 105C, needle 2001 of width W1 (2004) and height H1 (2005) has a distal end 2002 and a proximal end 2003. A middle region 2009 having a width W2 (2006) forms “shoulders” 2012 at its distal end 2002 which is sharpened. A suture 2007 is attached to lateral surface 2008 a distance L1 (2010) from distalmost surface 2011.
Referring to FIG. 106, retrieval instrument 2020 has a proximal portion 2021 formed to a handle shape and an elongated distal portion 2022 terminating in distal tip 2023. Referring to FIGS. 107A through 107C, distal tip 2023 has a slot 2024 of width W3 (2025) which is slightly larger than width W2 (2006 in FIG. 105A) but less than W1 (2004). The profile of distal end 2023 has a distal surface 2026 inclined at an angle A1 (2027) and a capture region 2028 bounded on its distal end by hook-shaped surface 2029 and on its proximal end by lateral surface 2030 displaced from surface 2029 a distance L2 (2031) and surface 2032.
FIG. 108 shows the distal portion 2040 of an insertion instrument of this embodiment. Needle 2001 is positioned in the forming channel 2047 and suture 2007 is affixed to the needle. Distal portion 2040 has two radii, R1 (2041) and R2 (2042) which together displace forming channel 2045 a distance D1 (2046). Radius R2 (2042) forms the needle to a radial shape having a radius R3 (2049 in FIG. 109C) slightly larger than R2 (2042). A normal to distalmost surface 2048 is coaxial with the axis of the axis of portion 2040.
Referring to FIG. 109A, tissue 43 is to be sutured to tissue 2044. In FIG. 109B, the “tear” is closed by applying force to tissue 2043 using distal portion 2040. In FIG. 109C, needle 2001 has been inserted in the same manner as in the previous embodiment. In FIG. 109D, the insertion instrument has been removed and needle 2001 remains in place with attached suture 2007. In FIG. 109E, retrieval instrument 2020 has been brought into position. FIG. 109F, distal tip 2023 has been inserted such that needle 2001 is engaged in slot 2024 and surface 2026 (see FIG. 107B) acting on shoulders 2012 (FIG. 105A) of needle 2001 has displaced the needle distally in tissue 2043 and 2044.
Referring to FIG. 109G, distal end 2002 of needle 2001 is captured in region 20028 (FIG. 107B). Displacing retrieval instrument 2020 distally (FIG. 109H) causes needle 2001 to be extracted from tissue 2043 thereby pulling suture 2007 through the tissue. In FIG. 1091 additional suture has been pulled through the tissue. In FIG. 109J, retrieval instrument 2020 has been moved proximally causing needle 2001 to pivot in distal tip 2023. In FIG. 109K, needle 2001 has pivoted into position for retrieval through a cannula.

## Claims

1. Suturing instrumentation adapted for use with a malleable needle having a sharpened distal tip and proximal end attachable to a length of suture material, the instrumentation comprising:
an elongated, cannulated tube having a distal end terminating in a nonlinear portion; and
a trocar configured for introduction into the elongated, cannulated tube, and
the cannulated tube having a linear slot in a side wall proximate to the distal end of the elongated cannulated tube to receive a linear malleable needle,
the trocar including a distal end operative to push the malleable needle through the nonlinear portion,
such that when the distal end of the cannulated tube is positioned proximate to a tissue to be sutured the needle is pushed by the distal end of the trocar through the nonlinear portion, the needle is deformed, causing the needle and suture material to enter into, and exit from, the tissue such that at least a portion of a distal tip of the needle protrudes from the tissue.

2. The suturing instrumentation as set forth in claim 1, wherein the nonlinear portion of the elongated, cannulated tube assumes a continuous curve.

3. The suturing instrumentation as set forth in claim 1, wherein:
the elongated, cannulated tube defines a primary axis; and
the nonlinear portion is off-axis.

4. The suturing instrumentation as set forth in claim 1, wherein the elongated, cannulated tube includes a proximal insertion opening to receive the distal end of the trocar.

5. The suturing instrumentation as set forth in claim 1, wherein:
the slot transitioning to a narrower slit along the nonlinear portion, enabling the suture material to extend from the slit as the needle is pushed through the nonlinear portion.

6. The suturing instrumentation as set forth in claim 1, further including:
a handle coupled to a ratchet; and
wherein the trocar includes serrations that engage with the ratchet, such that when the handle is pressed, the needle is pushed by the distal end of the trocar through the nonlinear portion.

7. The suturing instrumentation as set forth in claim 1, further including apparatus for grasping the deformed needle upon exiting the tissue.

8. The suturing instrumentation as set forth in claim 7, wherein the apparatus for grasping the deformed needle includes a jaw pivotally coupled to the distal end of the cannulated tube.

9. The suturing instrumentation as set forth in claim 8, wherein the jaw has an opened position with a feature to receive and retain the deformed needle.

10. The suturing instrumentation as set forth in claim 9, wherein the feature to receive and retain the deformed needle is an aperture, slot, or cavity.

11. Suturing instrumentation adapted for use with a malleable needle having a sharpened distal tip and a proximal end attachable to a length of suture material, the instrumentation comprising:
an elongated, cannulated tube having a distal end terminating in a nonlinear portion;
a trocar configured for introduction into the elongated, cannulated tube,
the cannulated tube having a linear slot in a side wall proximate to the distal end of the elongated cannulated tube to receive a linear malleable needle,
the trocar including a distal end operative to push the malleable needle through the nonlinear portion,
such that when the distal end of the cannulated tube is positioned proximate to a tissue to be sutured the needle is pushed by the distal end of the trocar through the nonlinear portion, the needle is deformed, causing the needle and suture material to enter into, and exit from, the tissue such that at least a portion of a distal tip of the needle protrudes from the tissue; and
a jaw pivotally coupled to the distal end of the cannulated tube for holding tissue as the needle enters into the tissue and for retaining the needle upon exiting the tissue.

12. The suturing instrumentation as set forth in claim 11, wherein the jaw includes an aperture, slot, or cavity to receive and retain the deformed needle upon exiting the tissue.

13. The suturing instrumentation as set forth in claim 11, wherein the nonlinear portion of the elongated, cannulated tube assumes a continuous curve.

14. The suturing instrumentation as set forth in claim 11, wherein:
the elongated, cannulated tube defines a primary axis; and
the nonlinear portion is off-axis.

15. The suturing instrumentation as set forth in claim 11, wherein the elongated, cannulated tube includes a proximal insertion opening to receive the distal end of the trocar.

16. The suturing instrumentation as set forth in claim 11, wherein:
the slot transitioning to a narrower slit along the nonlinear portion, enabling the suture material to extend from the slit as the needle is pushed through the nonlinear portion by the trocar.

17. The suturing instrumentation as set forth in claim 11, further including:
a handle coupled to a ratchet; and
wherein the trocar includes serrations that engage with the ratchet, such that when the handle is pressed, the needle is pushed by the distal end of the trocar through the nonlinear portion.

18. The suturing instrumentation as set forth in claim 11, further including a manually operated control enabling a user to open and close the jaw.

19. Suturing instrumentation adapted for use with a malleable needle having a sharpened distal tip and a proximal end attachable to a length of suture material, the instrumentation comprising:
a hand-held tool having proximal and distal ends;
an elongated, cannulated tube extending the length of the tool and terminating distally in a nonlinear portion;
the cannulated tube having a linear slot in a side wall proximate to the distal end of the elongated cannulated tube to receive a linear malleable needle,
a trocar having an elastically deformable distal end disposed within the elongated, cannulated tube and an exposed proximal end,
such that when the distal end of the cannulated tube is positioned proximate to a tissue to be sutured and the exposed proximal end of the trocar is pushed, the needle inelastically deforms as it passes through the nonlinear portion, causing the needle and suture material to enter into, and exit from, the tissue such that at least a portion of a distal tip of the needle protrudes from the tissue;
a jaw pivotally coupled to the distal end of the cannulated tube for holding tissue as the needle enters into the tissue and for retaining the needle upon exiting the tissue; and
a manually operated control at the proximal end of the hand-held tool enabling a user to open and close the jaw.

20. The suturing instrumentation as set forth in claim 19, wherein:
the slot transitioning to a narrower slit along the nonlinear portion, enabling the suture material to extend from the slit as the needle is pushed through the nonlinear portion.

21. The suturing instrumentation as set forth in claim 19, wherein the jaw includes an aperture, slot, or cavity to receive and retain the deformed needle upon exiting the tissue.

22. The suturing instrumentation as set forth in claim 19, wherein the nonlinear portion of the elongated, cannulated tube assumes a continuous curve.

23. The suturing instrumentation as set forth in claim 19, wherein:
the elongated, cannulated tube defines a primary axis; and
the nonlinear portion is off-axis.

24. The suturing instrumentation as set forth in claim 19, wherein the elongated, cannulated tube includes a proximal insertion opening to receive the trocar.

25. Suturing instrumentation, comprising:
a linear malleable needle having a sharpened distal tip and proximal end attachable to a length of suture material;
an elongated, cannulated tube having a distal end terminating in a nonlinear portion;
the cannulated tube having a liner slot in a side wall proximate to the distal end of the elongated cannulated tube to receive a linear malleable needle; and
a trocar configured for introduction into the elongated, cannulated tube,
the trocar including a distal end operative to push the malleable needle through the nonlinear portion,
such that when the distal end of the cannulated tube is positioned proximate to a tissue to be sutured the needle is pushed by the distal end of the trocar through the nonlinear portion, the needle is deformed by the nonlinear portion, causing the needle and suture material to enter into, and exit from, the tissue such that at least a portion of a distal tip of the needle protrudes from the tissue.

26. The suturing instrumentation as set forth in claim 25, wherein the nonlinear portion of the elongated, cannulated tube assumes a continuous curve.

27. The suturing instrumentation as set forth in claim 25, wherein:
the elongated, cannulated tube defines a primary axis; and
the nonlinear portion is off-axis.

28. The suturing instrumentation as set forth in claim 25, wherein:
the slot transitioning to a narrower slit along the nonlinear portion, enabling the suture material to extend from the slit as the needle is pushed through the nonlinear portion.

29. The suturing instrumentation as set forth in claim 25, further including a jaw pivotally coupled to the distal end of the cannulated tube for holding tissue as the needle enters into the tissue and for retaining the needle upon exiting the tissue.

30. The suturing instrumentation as set forth in claim 29, wherein the jaw includes an aperture, slot, or cavity to receive and retain the deformed needle.

31. The suturing instrumentation as set forth in claim 29, further including a manually operated control enabling a user to open and close the jaw.

32. The suturing instrumentation as set forth in claim 25, wherein the malleable needle and cannulated tube have at least one flat side to resist rotation of the needle as it passes through the non-linear portion.

33. The suturing instrumentation as set forth in claim 25, wherein the malleable needle and cannulated tube have opposing flat sides to resist rotation of the needle as it passes through the non-linear portion.

34. The suturing instrumentation as set forth in claim 25, wherein the malleable needle includes one or more indented portions to assist with deformation as the needle passes through the non-linear portion.

35. The suturing instrumentation as set forth in claim 25, wherein:
the distal tip of the needle includes a grasping feature; and
a jaw pivotally coupled to the distal end of the cannulated tube, the jaw including an aperture, slot, or cavity to receive and retain the grasping feature of the needle.