Abstract:
A suturing method for a penetrating hole formed in a luminal organ using a suture material to close the penetrating hole according to the present invention includes the steps of: inserting a needle at a position that is removed from the open edge of the penetrating hole by a distance that is less than the thickness of the wall of the luminal organ and passing the needle through the wall; sending out from the needle an anchor affixed to the end of the suture material; placing the anchor in place by pulling the needle through the wall and passing the suture material through the wall; and tightening the suture material after passing the suturing material in the same direction through the wall at multiple sites interposing the penetrating hole.

Description:
BACKGROUND OF THE INVENTION  
       [0001]     1. Field of the Invention  
         [0002]     The present invention relates to a suturing method that employs an endoscope. For example, the present invention relates to a method for suturing a penetrating hole that is formed in the wall of a luminal organ.  
         [0003]     2. Description of Related Art  
         [0004]     When a procedure is to be carried out inside the body of a patient, the procedure may be performed by surgically incising the patient&#39;s body, or via oral or rectal endoscopy. Procedures employing endoscopy are performed by passing forceps, high-frequency surgical instruments, dissecting instruments, suturing instruments and the like through channels in the endoscope. For example, in the case where a medical procedure is to be carried out inside the abdominal cavity using an endoscope inserted into the lumen of an organ via one of the body&#39;s natural orifices, such as the mouth or rectum, a hole is formed by resecting or dissecting tissue from inside the abdominal cavity. The medical procedure is then carried out by approaching the abdominal cavity from the lumen via this hole. After the procedure has been performed, suturing instruments are employed to close the hole that was formed.  
       SUMMARY OF THE INVENTION  
       [0005]     A suturing method for a penetrating hole according to the present invention comprises the steps of: inserting a needle at a position that is removed from the open edges of the penetrating hole by a distance that is less than the thickness of the wall of the luminal organ, and passing the needle through the wall; sending out from the needle an anchor affixed to the end of the suture material; placing the anchor in place by pulling the needle through the wall and passing the suture material through the wall; and tightening the suture material after passing the suturing material in the same direction through the wall at multiple sites interposing the penetrating hole. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0006]      FIG. 1  is a diagram showing the schematic structure of an endoscope and suturing device.  
         [0007]      FIG. 2  is a cross-sectional view of the end portion of the suturing device and endoscope.  
         [0008]      FIG. 3  is a perspective view of the end portion of the suturing device and endoscope.  
         [0009]      FIG. 4  is a diagram showing the structure of the suturing instrument.  
         [0010]      FIG. 5  is a diagram showing the step for inserting the endoscope into the patient&#39;s stomach and visualizing the area to be incised from within the stomach.  
         [0011]      FIG. 6  is a diagram showing the step for carrying out a procedure inside the abdominal cavity by passing the instrument through a penetrating hole  
         [0012]      FIG. 7  is a diagram showing the position for inserting the needle.  
         [0013]      FIG. 8  is a diagram in which the anchor has been pushed out after the needle has pierced and passed through the wall of the organ.  
         [0014]      FIG. 9  is a diagram in which the suturing instrument is attached.  
         [0015]      FIG. 10  is a diagram showing the forceps for tightening the suturing instrument.  
         [0016]      FIG. 11  is a diagram showing the step for tightening the suturing instrument using the outer sheath of the forceps.  
         [0017]      FIG. 12  is a diagram showing the state in which the penetrating hole has been closed through the process of tightening the suturing instrument.  
         [0018]      FIG. 13  is a diagram in which the insertion positions are substantially apposed by tightening the suturing instrument.  
         [0019]      FIG. 14  is a diagram for explaining the case where the positions of insertion exceed the thickness of the wall.  
         [0020]      FIG. 15  is a diagram in which the insertion positions are substantially apposed by tightening the suturing instrument, for the case where the positions of exertion exceed the thickness of the wall.  
         [0021]      FIG. 16  is a diagram in which two suturing devices are inserted in parallel into the insertion section of an endoscope. 
     
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT  
       [0022]     The endoscope and suturing device employed in a present embodiment are shown in  FIG. 1 . An endoscope  1  (flexible endoscope) has an endoscope control section  2  which is manipulated by the operator. The endoscope control section  2  is connected to a control device by a universal cable  3 , and is provided with a variety of switches  4  and angle knobs  5 . A flexible, long endoscope insertion section  6  is provided extending from the end of the endoscope control section  2 . An observation device  7 , for capturing images within the body, an illuminating device  8 , and the end openings of channels  9  are provided at the end of the endoscope insertion section  6 . An image capturing device provided with a CCD (Charge Coupled Device), an optical fiber and the like, are employed in the observation device  7 . The illuminating device  8  has an optical fiber for guiding light from a light source. The channels  9  pass through the endoscope insertion section  6  and open on the side portion  2   a  of the endoscope control section  2 . A cover  10  is attached to an opening of the side portion  2   a . An insertion hole is formed on the cover  10 , through which treatment instruments, such as a suturing device  11 , or observation devices, are inserted into the channel  9 .  
         [0023]     As shown in  FIGS. 1 through 3 , the suturing device  11  is designed such that a flexible inner sheath  13  can pass within a flexible outer sheath  12  in a freely advancing and retracting manner. A needle  14  is affixed to the end of the inner sheath  13 . A slit  15  extends in the longitudinal direction from the end of the needle  14 . A suturing instrument  16  is housed inside the needle  14 . The lengths of the outer sheath  12  and the inner sheath  13 , respectively, are greater than the length of the channel  9  of the endoscope  1 . A control section  17  is attached to the base of the inner sheath  13 . The control section  17  has a handle  19  that is freely sliding with respect to a control section main body  18 . The base of a pusher  20  is fixed in place to the handle  19 . The pusher  20  passes though the inside of the inner sheath  13  and extends to the needle  14 . The end  21  of the pusher  20  comes into contact with the suturing instrument  16 .  
         [0024]     As shown in  FIG. 4 , the suturing instrument  16  is provided with suture material  25 . The suture material  25  is folded over approximately in half, and has a knot  31  provided near the folding back point. The suture material  25 , with the ends thereof bundled together, is passed through a stopper  26 , which is approximately triangular in shape. Respective anchors  27  are affixed to each end of the suture material  25 . The anchor  27  has a columnar shape, and the suture material  25  is fixed in place at a position that is substantially in the center of the longitudinal direction of the anchor  27 . The stopper  26  has a hole  28  at the center of the longitudinal direction of its long narrow plate member through which the suture material  25  is passed. The ends  29  in the longitudinal direction of the stopper  26  are bent back diagonally, thereby gripping the suture material  25 . The ends  29  in the longitudinal direction of the stopper  26  are cut into triangularly shaped cut pieces  30 . By bending the back ends  29  diagonally so that the cut pieces  30  intersect, the suture material  25  is gripped by the stopper  26 . As a result, the suture material  25  does not fall out from between the ends  29 . Further, if the knot  31  of the suture material  25  is pulled in a direction moving away from the stopper  26 , the ends  29  of the stopper  26  open slightly. Accordingly, the stopper  26  permits movement of the suture material  25  in this direction. On the other hand, when the end of the suture material  25  is pulled from the anchor  27  side, then the suture material  25  begins to move in the direction indicated by the arrow in  FIG. 4 . However, in this case, the ends  29  of the stopper  26  close, tightening on the suture material  25 , so that the suture material  25  does not move.  
         [0025]     As shown in  FIG. 3 , the two anchors  27  of the suturing instrument  16  are sequentially housed in internal holes in the needle  14 . The suture material  25  is pulled out from the slit  15  of the needle  14 . As shown in  FIG. 2 , the stopper  26  is housed further toward the tip of the outer sheath  12  than the needle  14 . Note that the number of the anchors  27  and the shape of the stopper  26  are not limited to the embodiment shown in the figures.  
         [0026]     Next, the suturing method according to this embodiment will be explained with reference to  FIGS. 5 through 15 . Note that  FIGS. 5 through 12  are schematic views for explaining technique, and employ the stomach as an example of a luminal organ.  
         [0027]     As shown in  FIG. 5 , the endoscope insertion section  6  is inserted via the oral cavity (or other such natural orifice of the body as the anus, nose, ears, etc.) of a patient  41 , who has been equipped with a mouthpiece  40 . The end of the endoscope insertion section  6  is bent using the angle knob  5 . A needle-shaped knife, which is a high frequency resecting instrument, is passed into the channel  9  of the endoscope insertion section  6 , and is used to form a penetrating hole by incising the tissue in the wall of his stomach  43 . As shown in  FIG. 6 , the endoscope insertion section  6  is passed through a penetrating hole  52  formed in the stomach  43  and is guided into abdominal cavity  53 . Forceps  54  are passed through the channel  9  and are employed to carry out the procedure in abdominal cavity  53 . Once the procedure is completed, the endoscope insertion section  6  is withdrawn from the stomach  43 .  
         [0028]     When suturing together the penetrating hole  52 , the suturing device  11  is passed through the channel  9  of the endoscope insertion section  6 , and the needle  14  of the suturing device  11  is pushed out from the outer sheath  12 . At this time, the stopper  26  falls into the stomach  43 . The suturing device  11  is advanced forward with respect to the endoscope  1 , and the needle  14  is inserted substantially perpendicularly into the tissue around the penetrating hole  52 , passing from the inside (the mucosa  45  side) to the outside (the abdominal cavity  53  side) of the stomach  43 . As shown in  FIG. 7 , an insertion position  47  is located at a length L away from the open edge of the penetrating hole  52 . The length L is smaller than the thickness t of a wall  44  of the stomach  43 . Note that the wall  44  is comprised of a mucosa  45  on the inside and a muscular tunic  46  on the outside.  
         [0029]     The suturing device  11  is advanced forward until the needle  14  passes through the tissue of the wall  44 . The handle  19  (see  FIG. 1 ) of the control section  17  is manipulated to advance the pusher  20  forward. As shown in  FIG. 8 , one anchor  27  is pushed out into the abdominal cavity  54 . Once the one anchor  27  is pushed out, the needle  14  is pulled out from the wall  44 . One anchor  27  is thus retained in abdominal cavity  53 , and the suture material  25  passes through the wall  44 . Next, the needle  14  is again inserted substantially perpendicular to the tissue at a substantially symmetrical position with respect to the insertion position  47 , with the penetrating hole  52  interposed therebetween. The needle  14  is inserted from the inside (mucosa  45  side) to the outside (abdominal cavity  53  side) of the stomach  43 . The insertion position  48  of the needle  14  is located at a length L from the open edge of the penetrating hole  52 , as indicated by the imaginary line in  FIG. 8 . When the needle  14  passes though the wall  44 , the second anchor  27  is pushed out on the abdominal cavity  53  side, and the needle  14  is withdrawn. The suture material  25  passes substantially perpendicularly through the wall  44 . As shown in  FIG. 9 , in the suturing instrument  16 , the two anchors  27  are each retained at positions that are, respectively, the length L from the open edge of the penetrating hole  52 .  
         [0030]     The suturing instrument  16  is tightened using forceps  60  as shown in  FIG. 10 , for example. The forceps  60  possess an outer sheath  61  that has an external diameter that is larger than the anchor  27 . An inner sheath  62  passes through the inside of an outer sheath  61  in a freely advancing and retracting manner. A support member  63  is present at the end of the inner sheath  62 . A pair of gripping pieces  64  are supported by this support member  63  to enable opening and closing thereof.  
         [0031]     The knot  31  of the suture material  25  of the suture instrument  16  is gripped by the gripping pieces  64 , after which the outer sheath  61  is advanced forward, so that the end of the outer sheath  61  comes into contact with the stopper  26 . As shown in  FIG. 11 , when the outer sheath  61  is further advanced, the stopper  26  is pushed into the wall  44  of the stomach  43 . Since it is designed to enable movement in this direction, the stopper  26  moves toward the wall  44 . Since the position of the pair of the gripping pieces  64  does not change, the stopper  26  advances relative to the suture material  25 . The distance between the stopper  26  and the anchors  27  is thereby decreased and the suture material  25  is tightened. As a result, the tissue surrounding penetrating hole  42  is drawn together and penetrating hole  42  is sutured closed by the suture material  25 .  
         [0032]     As shown in  FIG. 12 , the surfaces of the inner periphery of the penetrating hole  52  are adhered closely together. If the suture material  25  is further tightened, then, as shown in  FIG. 13 , the insertion positions  47 ,  48  are drawn together so as to be substantially apposed. Since the length L is smaller than the thickness t of the wall  44 , the tissue near the insertion positions  47 ,  48  is compressed and partially crushed, and a state in which the surfaces of the inner periphery of the penetrating hole  52  are adhered closely together is maintained. Specifically, the mucosa  45  surfaces adhere closely together, and the muscular tunic  46  surfaces adhere closely together.  
         [0033]     Once the penetrating hole  42  has been sutured using the suturing instrument  16 , the outer sheath  61  is retracted, the gripping pieces  64  open, and the forceps  60  release the suture material  25 . While movement of the ends of the stopper  26  is possible in the direction which tightens the tissue with the suture material  25 , the stopper  26  ends work to tighten the suture material  25  in the direction in which the suture material  25  relaxes. Accordingly, even if the suturing instrument  16  is retained inside the stomach  43 , the suture material  25  does not slacken.  
         [0034]     In this embodiment, the insertion positions  47 ,  48  for the needle  14  were set according to the thickness of the wall  44 . As a result, the penetrating hole can be sutured with greater surety irrespective of the type of luminal organ. Since the insertion positions  47 ,  48  are located a length L from the open edges of the penetrating hole  52 , and this length L is smaller than the thickness t of the wall  44  which is to be sutured, it becomes possible to adhere the muscular tunics  46  with even greater surety. Since the muscular tunics  46  adhere together more readily then the mucosa  45 , closing up of the penetrating hole  52  proceeds quickly, resulting in faster healing.  
         [0035]     Note that when suturing an opening in the abdominal wall, because the abdominal wall is thick, it will adhere together easily simply by tightening with the suture material. In the case of digestive organs such as the stomach  34 , however, the wall  44  is thin, so that suturing is difficult due to the softness of the tissue. In particular, in the case where the endoscope  1  is employed, since the suturing is carried out from the mucosa  45  side, it was difficult for the tissues to adhere together using conventional suturing methods. For example, as shown in  FIG. 14 , when the length L from the penetrating hole  52  to the insertion positions  49 ,  50  is greater than the thickness t of the wall  44 , the insertion positions  49 ,  50  approach one another when the suture material  25  is tightened. Since the tissue between the insertion positions  49 ,  50  is long, these tissues become everted as shown in  FIG. 15 . As a result, the respective mucosa  45  adheres tightly together, but the muscular tunics  46  cease to be in contact with one another. It is typically said that the mucosa  45  does not readily adhere together. Accordingly, if suturing such that only respective mucosa  45  is apposed is performed, it becomes difficult for the penetrating hole  52  to close. This type of problem is resolved in the present embodiment.  
         [0036]     Note that the present invention is not limited to the various embodiments disclosed above, but can be employed in a broad range of applications.  
         [0037]     For example, the suture material  25  was passed though the wall  44  by passing from the inside to the outside of the stomach  43 . However, it is also acceptable to pass the suture material  25  through the wall  44  by passing it from the outside to the inside of the stomach  43 . In this case, the suturing device  11  is passed through the penetrating hole  52  and relayed out to the abdominal cavity  53  side. The needle  14  is inserted into the wall  4  from the abdominal cavity  53  side. The insertion point is at length L from the open edge of the penetrating hole  52 . Once the suture material  25  has passed through the wall in the same direction, interposed about the penetrating hole  52 , and the two anchors  27  are each retained inside the stomach  43 , the stopper  26  is pulled into the stomach  43 , and the suturing instrument  16  is tightened. When the suturing instrument  16  is tightened such that the insertion points are apposed, the penetrating hole  52  is sutured together in a state such that the respective muscular tunics are closely adhered.  
         [0038]     In the case where the endoscope insertion section  6  has two channels  9  as shown in  FIG. 16 , one suturing device  11  each can be passed through the channels  9 . In this case, an anchor  27  may be housed in the respective needles  14  of each suturing device  11 .