Abstract:
An instrument and method for suturing wound closures is provided having a handle, shaft and suture engagement mechanism. The instrument provides for multiple placements or “bites” of suture in tissues to enable a wide variety of suturing techniques, including the ability to “run” a suture. The instrument further facilitates suture knot tying. The method of this instrument provides for rapid and effective remote suture placement and knot tying.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS  
       [0001]     This application is a continuation-in-part of commonly-assigned U.S. patent application Ser. No. 10/757,042 filed Jan. 14, 2004, entitled SEW-RIGHT RUNNING STITCH INSTRUMENT by Jude S. Sauer, et al., the disclosure of which is incorporated herein. 
     
    
     STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT  
       [0002]     Not applicable.  
       REFERENCE TO A “SEQUENCE LISTING” 
       [0003]     Not applicable.  
       BACKGROUND OF THE INVENTION  
       [0004]     1. Field of the Invention  
         [0005]     This invention relates generally to surgical suturing instruments and more particularly to a surgical suturing instrument in which a needle can be selectively engaged with a fitting at the end of the suture for pulling the suture through a tissue section and released from the suture for permitting subsequent stitches to be made.  
         [0006]     2. Description of Related Art  
         [0007]     Invasive therapeutic interventions typically provide for the removal of problematic tissue structures from the body followed by a need to reconstruct the involved tissues. Many alternatives are available for reconstructive interventions. Bandages can often close external wounds. The use of sutures placed within wound edges to draw tissues together to permit enhanced healing has become commonplace in modern medicine. Metallic or plastic staples and clips also can be used to appose tissue for healing.  
         [0008]     To minimize the invasiveness of therapeutic procedures, efforts to create smaller access wounds that minimize iatrogenic tissue disruption have lead to better patient outcomes. For example, a minimally invasive surgical procedure, like laparoscopic partial colonic resection with intestinal reconnection (anastomosis), can facilitate less peri-operative pain, more rapid return of normal functions, earlier return to home and work. The placement of sutures during laparoscopic surgery can be slow, tedious and often not successful. Existing specialized instruments for minimally invasive surgery (Sauer) have recognized limitations. An instrument to enable the rapid, precise placement of multiple suture bites with the same suture and then facilitate rapid, secure knot creation would be a significant advance.  
       BRIEF SUMMARY OF THE INVENTION  
       [0009]     Briefly stated and in accordance with certain presently preferred embodiments of the invention, a surgical suturing instrument includes an elongated shaft, a tissue engaging gap formed in an end of the shaft, a needle reciprocally movable across the gap from a proximal end of the gap to a distal end of the gap, the needle having a ferrule engaging tip and a ferrule receiving aperture at a distal end of the gap for selectively holding and releasing a ferrule so that in a first mode the needle engages the ferrule and draws the suture across the gap and in a second mode, the ferrule is retained in the aperture and the needle separates from the ferrule and is retracted across the gap leaving the ferrule in the aperture.  
         [0010]     In accordance with another aspect of the invention, a surgical suturing instrument for placing multiple suture loops in tissue comprises on elongated shaft, a reciprocal suture pick up member mounted on the shaft, a suture holder engaged by the reciprocating suture pick up member for selectively coupling a suture to the pick up member for drawing the suture through a first tissue section and releasing the suture from the pick up member for repeated coupling and drawing the suture through a second tissue section spaced from the first tissue section.  
         [0011]     In accordance with another aspect of the invention, a surgical suturing instrument includes reciprocating tissue penetrating member, a suture holder, and apparatus for alternately coupling the reciprocating tissue penetrating member to the suture holder for drawing a length of suture through a tissue section and releasing the reciprocating tissue penetrating member from the suture holder.  
         [0012]     In accordance with another aspect of the invention, a method of closing a wound includes the steps of disposing a suture on one side of a tissue section proximal to the wound, passing a needle through the section of tissue proximal to the wound, capturing the suture with the needle, drawing the suture through the section of tissue, releasing the suture from the needle, and repeating the passing capturing drawing and releasing steps.  
         [0013]     In accordance with another aspect of the invention, a method of securing a suture at a wound site comprises passing an end of the suture through bolster and securing the suture with a bolster disposed between the end of the suture and the wound.  
     
    
     BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWING(S)  
       [0014]     The foregoing objects, features and advantages of the invention will become more apparent from a reading of the following description in connection with the accompanying drawings, in which:  
         [0015]      FIG. 1  is a perspective view of the tissue suturing instrument in accordance with the present invention;  
         [0016]      FIG. 2  is a partial side view of the tissue suturing instrument of  FIG. 1  in which the right cover of the housing of the instrument is removed;  
         [0017]      FIG. 3  is an exploded perspective view of the tissue suturing instrument of  FIG. 1  in which the right cover of the housing is removed;  
         [0018]      FIGS. 4A-4C  are perspective views of the thumb slide holder of  FIG. 3  showing this component from the top left, top right and bottom right perspectives, respectively;  
         [0019]      FIG. 5A  is a partially exploded perspective view of the thumb slide mechanism of  FIG. 3  highlighting the thumb button and the retaining lock features;  
         [0020]      FIG. 5B  is a perspective view of an assembled thumb slide mechanism of  FIG. 3  showing the thumb button in its fully out position;  
         [0021]      FIG. 6A  is a left perspective view of the thumb slide mechanism of  FIG. 3  with its balled needle fully back and its accompanying lever fully out;  
         [0022]      FIG. 6B  is a left perspective view of the thumb slide mechanism of  FIG. 3  with its balled needle fully forward and its accompanying lever fully retracted;  
         [0023]      FIG. 7A  is a right perspective view of the thumb slide mechanism of  FIG. 3  with its thumb button and ferrule stripper fully back and its accompanying lever fully out;  
         [0024]      FIG. 7B  is a right perspective view of the thumb slide mechanism of  FIG. 3  with it thumb button and ferrule stripper fully forward and its accompanying lever fully retracted;  
         [0025]      FIG. 8A  is an exploded perspective view of the distal tip of the instrument of  FIG. 1  showing the distal tube, jaw, needle, ferrule stripper and ferrule retainer;  
         [0026]      FIG. 8B  is a perspective view of the underside of the distal tip of  FIG. 1  showing the ferrule stripper alignment ramp and the ferrule holding compartment;  
         [0027]      FIG. 9A  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed and both the thumb button and the lever are fully out;  
         [0028]      FIG. 9B  is a right perspective view of the distal tip of the components of  FIG. 9A  showing the ferrule in its compartment;  
         [0029]      FIG. 9C  is a partial cross-sectional view of the distal tip of the components of  FIG. 9A  with the ferrule in its compartment and the needle and ferrule stripper fully back;  
         [0030]      FIG. 9D  is a side view of the proximal components of  FIG. 9A  showing the lever and thumb button fully out;  
         [0031]      FIG. 9E  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with its thumb slide holder removed, the lever partially retracted and the thumb button fully out;  
         [0032]      FIG. 9F  is a right perspective view of the distal tip of the components of  FIG. 9E  with the needle partially advanced and the ferrule in its compartment;  
         [0033]      FIG. 9G  is the partial cross-sectional view of the distal tip of the components of  FIG. 9E  showing the ferrule in its compartment, the needle partially advanced and the ferrule stripper fully back;  
         [0034]      FIG. 9H  is a side view of the proximal components of  FIG. 9E  showing the lever partially retracted and the thumb button fully out;  
         [0035]      FIG. 9J  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed, the lever fully retracted and the thumb button fully out;  
         [0036]      FIG. 9K  is a right perspective view of the distal tip of the components of  FIG. 9J  showing the needle fully advanced and engaging the ferrule in its compartment;  
         [0037]      FIG. 9L  is a partial cross-sectional view of the distal tip of the components of  FIG. 9J  with the needle engaging the ferrule in its compartment and the ferrule stripper fully back;  
         [0038]      FIG. 9M  is a side view of the proximal components of  FIG. 9J  showing the lever fully retracted and the thumb button fully out;  
         [0039]      FIG. 10A  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed, with the thumb button fully out, the lever partially forward and the needle attached to the ferrule and suture partially back;  
         [0040]      FIG. 10B  is a right perspective view of the distal tip of the components of  FIG. 10A  showing the needle attached to the ferrule with suture partially retracted;  
         [0041]      FIG. 10C  is a partial cross-sectional view of the distal tip of the components of  FIG. 10A  showing the needle attached to the ferrule and suture partially retracted and the ferrule stripper fully back;  
         [0042]      FIG. 10D  is a side view of the proximal components of  FIG. 10A  showing the lever partially back and the thumb button fully out;  
         [0043]      FIG. 10E  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed, the lever fully out and the thumb button fully out;  
         [0044]      FIG. 10F  is a right perspective view of the distal tip of the components of  FIG. 10E  showing the needle attached to the ferrule and suture fully retracted and the ferrule stripper fully back;  
         [0045]      FIG. 10G  is a perspective side view of the distal tip of the components of  FIG. 10E  showing the needle attached to the ferrule and suture fully retracted and the ferrule stripper fully back;  
         [0046]      FIG. 10H  is a side view of the proximal components of  FIG. 10E  showing the lever fully out and the thumb button fully out;  
         [0047]      FIG. 11A  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed, the lever partially retracted, the needle with its ferrule and suture partially advanced and the thumb button fully out;  
         [0048]      FIG. 11B  is a right perspective view of the distal tip of the components of  FIG. 11A  showing the needle attached to the ferrule and the suture partially advanced;  
         [0049]      FIG. 11C  is a partial cross-sectional view of the distal tip of the components of  FIG. 11A  showing the needle attached to the ferrule and the suture partially advanced and the ferrule stripper fully back;  
         [0050]      FIG. 11D  is a side view of the proximal components of  FIG. 11A  showing the lever partially retracted and the thumb button fully out;  
         [0051]      FIG. 11E  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed and the lever fully retracted and the thumb button fully out;  
         [0052]      FIG. 11F  is a right perspective view of the distal tip of the components of  FIG. 11E  with the needle fully advanced along with its attached ferrule and suture;  
         [0053]      FIG. 11G  is a partial cross-sectional view of the distal tip of the components of  FIG. 11E  showing the needle along with its attached ferrule and suture fully advanced into the ferrule compartment;  
         [0054]      FIG. 11H  is a side view of the proximal components of  FIG. 11E  showing the lever fully retracted and the thumb button fully out;  
         [0055]      FIG. 11J  is a close-up side view of the lock features of the components of  FIG. 11H  showing the flat engagement surface of the actuating member raising the proximal spring lock to disengage it from the timing tube;  
         [0056]      FIG. 12A  is a right partial view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed, the lever fully retracted, the needle with its attached ferrule and suture fully advanced and the thumb button partially advanced;  
         [0057]      FIG. 12B  is a right perspective view of the distal tip of the components of  FIG. 12A  showing the needle with its ferrule and suture fully advanced into the ferrule compartment and the ferrule stripper partially advanced;  
         [0058]      FIG. 12C  is a partial cross-sectional view of the distal tip of the components of  FIG. 12A  showing the needle attached to the ferrule and suture fully advanced and the ferrule stripper partially advanced;  
         [0059]      FIG. 12D  is a side view of the proximal components of  FIG. 12A  showing the lever fully retracted and the thumb button partially forward;  
         [0060]      FIG. 12E  is a close-up side view of the lock features of the components of  FIG. 12D  showing the flat engagement surface of the actuating member raising the proximal spring lock and the timing tube partially forward;  
         [0061]      FIG. 12F  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed, the lever fully retracted, the needle with its attached ferrule and suture fully advanced, and the thumb button and ferrule stripper fully forward;  
         [0062]      FIG. 12G  is a right perspective view of the distal end of the components of  FIG. 12F  showing the needle with its ferrule and suture fully advanced and the ferrule stripper fully advanced and engaging the ferrule;  
         [0063]      FIG. 12H  is a partial cross-sectional view of the distal tip of the components of  FIG. 12F  showing the needle attached to the ferrule and the suture and the ferrule stripper fully advanced engaging the ferrule;  
         [0064]      FIG. 12J  is the side view of the proximal components of  FIG. 12F  showing both the lever and the thumb button fully forward;  
         [0065]      FIG. 12K  is a close-up side view of the lock features of  FIG. 12J  showing the flat engagement surface of the actuating member raising the proximal spring lock, the timing tube fully forward and engaging the released distal spring lock;  
         [0066]      FIG. 13A  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed, the lever partially released, the needle partially retracted, the ferrule stripper engaging the ferrule in its ferrule compartment and the thumb button fully forward;  
         [0067]      FIG. 13B  is a right perspective view of the distal tip of the components of  FIG. 13A  showing the needle partially retracted and the ferrule stripper fully forward;  
         [0068]      FIG. 13C  is a partial cross-sectional view of the distal tip of the components of  FIG. 13A  showing the needle partially retracted and the ferrule stripper fully forward engaging the ferrule in its compartment;  
         [0069]      FIG. 13D  is a side view of the proximal components of  FIG. 13A  showing the lever partially out and the thumb button fully forward;  
         [0070]      FIG. 13E  is a close-up side view of the lock features of  FIG. 13D  showing the convex engagement surface of the actuating member raising the distal spring lock and the thumb button released but still fully forward;  
         [0071]      FIG. 13F  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed, the lever, needle, thumb button and ferrule stripper partially back;  
         [0072]      FIG. 13G  is a right perspective view of the distal tip of the components of  FIG. 13F  with the needle and ferrule stripper partially retracted and the ferrule back into its compartment;  
         [0073]      FIG. 13H  is a partial cross-sectional view of the distal tip of the components of  FIG. 13F  showing the needle and the ferrule stripper partially back and the ferrule and suture in the ferrule compartment;  
         [0074]      FIG. 13J  is a side view of the proximal components of  FIG. 13F  showing the lever and the thumb button partially back;  
         [0075]      FIG. 13K  is a close-up side view of the lock features of  FIG. 13F  showing the engagement surfaces of the actuating member not raising either of the spring locks;  
         [0076]      FIG. 13L  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder removed, the lever, needle, thumb button and ferrule stripper fully back and the ferrule and suture reloaded into the ferrule compartment;  
         [0077]      FIG. 13M  is a perspective view of the distal tip of the components of  FIG. 13L  showing the needle and ferrule stripper fully retracted and the ferrule and suture in the ferrule compartment;  
         [0078]      FIG. 13N  is a partial cross-sectional view of the distal tip of the components of  FIG. 13L  showing the needle and ferrule stripper fully back and the ferrule and suture in the ferrule compartment;  
         [0079]      FIG. 13P  is a side view of the proximal components of  FIG. 13L  showing the lever and the thumb button fully back;  
         [0080]      FIG. 13R  is a close-up side view of the lock features of  FIG. 13L  showing the proximal spring clip engaging the timing tube;  
         [0081]      FIGS. 14A-14E  show an example of the suturing procedure using the tissue suturing instrument of  FIG. 1  for placement of suture at the first site of the wound closure;  
         [0082]      FIGS. 15A-15E  show an example of the suturing procedure using the tissue suturing instrument of  FIG. 1  for placement of suture at the second site of the wound closure;  
         [0083]      FIGS. 16A-16D  show an example of the suturing procedure using the tissue suturing instrument of  FIG. 1  for placement of suture at the third site of the wound closure;  
         [0084]      FIGS. 17A-17D  show an example of the suturing procedure using the tissue suturing instrument of  FIG. 1  for placement of suture at the fourth site of the wound closure;  
         [0085]      FIGS. 18A-8E  show an example of the use of the instrument of  FIG. 1  to enable suture loop construction to initiate the tying of a suture knot;  
         [0086]      FIGS. 19A-19F  show an example of the instrument of  FIG. 1  to construct further suture loops used to secure a suture knot;  
         [0087]      FIG. 20  shows the suturing instrument of  FIG. 1  used with a surgical grasper, which pulls on the free end of the suture to deliver the suture knot to the wound closure site;  
         [0088]      FIG. 21  shows both the suturing instrument of  FIG. 1  and a surgical grasper pulling on either ends of the suture to lock the knot in place to secure the wound closure;  
         [0089]      FIGS. 22A-22C  show an alternate method of securing the ends of the suture used in the suturing procedure illustrated in  FIGS. 14A-17D  by crimping a sleeve member over the ends of the suture;  
         [0090]      FIGS. 23A-23D  illustrate a running suturing procedure created using the tissue suturing instrument of  FIG. 1  being secured by bolsters and a crimped sleeve member;  
         [0091]      FIG. 24A  is a perspective view of the distal tip of the second preferred embodiment of the tissue suturing instrument of  FIG. 1  in which a stripper wedge causes a flexible member to grasp the ferrule;  
         [0092]      FIG. 24B  is a partial cross-sectional view of the distal tip of the second preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the needle engaging the ferrule and partial deployment of the stripper wedge;  
         [0093]      FIG. 24C  is a partial cross-sectional view of the distal tip of the second preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the stripper wedge engaging the flexing member which grasps the ferrule and allows the needle to retract leaving the ferrule in its ferrule compartment;  
         [0094]      FIG. 25A  is a perspective view of the distal tip of the third preferred embodiment of the tissue suturing instrument of  FIG. 1  in which a stripper rod passes through the distal tip and engages the proximal face of the ferrule to enable stripping;  
         [0095]      FIG. 25B  is a broken-out section of the distal tip of the third preferred embodiment of the tissue suturing instrument of  FIG. 1  in which a stripper rod rests in its internal chamber as the needle engages the ferrule in its ferrule pocket;  
         [0096]      FIG. 25C  is a broken-out section of the distal tip of the third preferred embodiment of the tissue suturing instrument of  FIG. 1  in which the stripper rod protrudes from its internal chamber to engage the proximal face of the ferrule as the needle disengages the ferrule and retracts;  
         [0097]      FIG. 26  is a partially exploded isometric view of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  in which a cam and follower mechanism and faceted needle are utilized to allow for automatic ferrule pick-up and release;  
         [0098]      FIG. 27A  is a close-up isometric view of the cam and follower mechanism of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  illustrating the needle fully retracted;  
         [0099]      FIG. 27B  is a close-up perspective view of the tip of faceted needle of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  shown in its ferrule engaging configuration;  
         [0100]      FIG. 27C  is a close-up isometric view of the cam and follower mechanism of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  illustrating the needle partially advanced and the follower mechanism actuating the cam and rotating the needle;  
         [0101]      FIG. 27D  is a close-up perspective view of the tip of faceted needle shown partially rotated as it is advancing;  
         [0102]      FIG. 27E  is a close-up isometric view of the cam and follower mechanism of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  illustrating the needle fully advanced;  
         [0103]      FIG. 27F  is a close-up perspective view of the tip of faceted needle of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  shown fully advanced and rotated to its ferrule stripping configuration;  
         [0104]      FIG. 28  is a close-up perspective view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing a partially advanced faceted needle, the ferrule in its ferrule compartment and a ferrule latch adjacent to the ferrule pocket;  
         [0105]      FIG. 29A  is a close-up perspective view of the stripping mechanism of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the ferrule latch disengaged and allowing the faceted needle to retrieve the ferrule;  
         [0106]      FIG. 29B  is a close-up perspective view of the stripping mechanism of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the ferrule latch engaged and enabling the stripping of the faceted needle from the ferrule;  
         [0107]      FIG. 30A  is a partial cross-sectional view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the faceted needle fully retracted and the ferrule in its ferrule compartment;  
         [0108]      FIG. 30B  is a partial cross-sectional view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the faceted needle fully extended, disengaging the ferrule latch, and connecting with the ferrule in its ferrule compartment;  
         [0109]      FIG. 30C  is a partial cross-sectional view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the faceted needle beginning to retract with its attached ferrule and suture;  
         [0110]      FIG. 30D  is a partial cross-sectional view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the faceted needle retracting with its attached ferrule and suture and the ferrule latch returning to its normal state;  
         [0111]      FIG. 30E  is a partial cross-sectional view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the faceted needle fully retracted with its attached ferrule and suture;  
         [0112]      FIG. 30F  is a partial cross-sectional view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the faceted needle extending and returning the ferrule and its suture to the ferrule compartment;  
         [0113]      FIG. 30G  is a partial cross-sectional view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the faceted needle fully extended, the ferrule and its suture returned to the ferrule compartment and the ferrule latch engaged with the proximal face of the ferrule;  
         [0114]      FIG. 30H  is a partial cross-sectional view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the faceted needle retracting and the ferrule latch retaining the ferrule in its ferrule compartment;  
         [0115]      FIG. 30J  is a partial cross-sectional view of the distal tip of the fourth preferred embodiment of the tissue suturing instrument of  FIG. 1  showing the faceted needle fully retracted and awaiting the next cycle of firing of the instrument;  
         [0116]      FIG. 31  is a perspective view of the tissue suturing instrument in accordance with another embodiment of the present invention;  
         [0117]      FIG. 32  is a partial side view of the tissue suturing instrument of  FIG. 31  in which the right cover of the housing has been removed;  
         [0118]      FIG. 32A  is an enlarged partial side view of the distal tip of the tissue suturing instrument of  FIG. 31 .  
         [0119]      FIG. 33  is an exploded perspective view of the tissue suturing instrument of  FIG. 31  in which the right cover of the housing has been removed.  
         [0120]      FIG. 34A and 34B  are perspective views of the lever of  FIG. 33  showing this component from the distal top and proximal top perspectives, respectively;  
         [0121]      FIG. 35  is a perspective view of the selector mechanism of  FIG. 33  highlighting the balled needle selection and balled needle liberation features;  
         [0122]      FIG. 36  is perspective view of the selector shuttle of  FIG. 33  highlighting the balled needle retention features;  
         [0123]      FIG. 37A  is a right perspective view of the lever and balled needle selector mechanism of  FIG. 33  with the lever fully advanced and its accompanying balled needles fully back and the selector mechanism positioned over the left balled needle;  
         [0124]      FIG. 37B  is a right perspective view of the lever and balled needle selector mechanism of  FIG. 33  with the lever fully retracted forcing the left balled needle to advance while allowing the right balled needle to remain retracted;  
         [0125]      FIG. 38A  is a right perspective view of the lever and balled needle selector mechanism of  FIG. 33  with the lever fully advanced and its accompanying balled needles fully back and the selector mechanism positioned over the right balled needle;  
         [0126]      FIG. 38B  is a right perspective view of the lever and balled needle selector mechanism of  FIG. 33  with the lever fully retracted forcing the right balled needle to advance while allowing the left balled needle to remain retracted;  
         [0127]      FIG. 39A  is a right perspective view of the lever and selector mechanism of  FIG. 33  with the lever fully advanced and its accompanying balled needles fully back and the selector mechanism positioned over the left balled needle with its follower in the left advancing track of the lever;  
         [0128]      FIG. 39B  is a right perspective view of the lever and selector mechanism of  FIG. 33  with the lever fully retracted forcing the left balled needle to advance while allowing the right balled needle to remain retracted with the follower of the selector mechanism in the left advancing track of the lever;  
         [0129]      FIG. 39C  is a right perspective view of the lever and selector mechanism of  FIG. 33  with the lever returned to its fully advanced position and its accompanying balled needles fully back and the selector mechanism positioned over the left balled needle with its follower in the left advancing track of the lever;  
         [0130]      FIG. 39D  is a right perspective view of the lever and selector mechanism of  FIG. 33  with the lever fully advanced and its accompanying balled needles fully back and the selector mechanism now positioned over the right balled needle with its follower traversing the selection track of the lever;  
         [0131]      FIG. 39E  is a right perspective view of the lever and selector mechanism of  FIG. 33  with the lever fully retracted forcing the right balled needle to advance while allowing the left balled needle to remain retracted with the follower of the selector mechanism in the right advancing track of the lever;  
         [0132]      FIG. 39F  is a right perspective view of the lever and selector mechanism of  FIG. 33  with the lever returned to its fully advanced position and its accompanying balled needles fully back and the selector mechanism positioned over the right balled needle with its follower in the right advancing track of the lever;  
         [0133]      FIG. 40A  is an exploded perspective view of the adapter and spring arms of  FIG. 33  as they are used in the actuation of the rotation cam;  
         [0134]      FIG. 40B  is a left perspective view of the adapter and spring arms of  FIG. 33  showing the suture routing tube slot and cam bores;  
         [0135]      FIG. 41A  is a side view of the rotation cam of  FIG. 33  showing the advance/retract tracks, the rotation tracks, and the motion prevention lock-outs;  
         [0136]      FIG. 41B  is a cross-sectional view of  FIG. 41A  showing the needle bore, and the ramped track surfaces;  
         [0137]      FIG. 41C  is a flat-pattern view of the cam profile of  FIG. 41A  showing the advance/retract tracks, the rotation tracks, and the motion prevention lock-outs;  
         [0138]      FIG. 41D  is a perspective view of the rotation cam of  FIG. 33  showing the needle bore, advancing and rotation tracks, advancing and rotation stops, and advancing and rotation ramps;  
         [0139]      FIG. 41E  is a cross-sectional view of  FIG. 41D  showing the needle bore as it passes centrally through the rotation cam and the profile of the advancing track with its ramp and stop;  
         [0140]      FIG. 42  is a right perspective view of the balled needle of  FIG. 33  showing the ferrule latch engaging and disengaging surfaces;  
         [0141]      FIG. 42A  is a partial side view of  FIG. 42  illustrating the ferrule latch disengaging surfaces without facets;  
         [0142]      FIG. 42B  is a partial side view of  FIG. 42  illustrating the faceted ferrule latch engaging surface;  
         [0143]      FIG. 43  is a right perspective view of the fully advanced lever and a partial cross-section of the adapter of  FIG. 33  as they interface with the fully retracted balled needle and its accompanying rotation cam;  
         [0144]      FIG. 43A  is a right perspective view of a partial cross-section of the adapter of  FIG. 43  showing the spring arm as it engages in a fully retracted rotation cam;  
         [0145]      FIG. 43B  is a partial right perspective view of the tip of the balled needle of  FIG. 43  showing the orientation of the ferrule latch engaging and disengaging faces;  
         [0146]      FIG. 44  is a right perspective view of the partially retracted lever and a partial cross-section of the adapter of  FIG. 33  as they interface with the partially advanced balled needle and its accompanying rotation cam;  
         [0147]      FIG. 44A  is a right perspective view of a partial cross-section of the adapter of  FIG. 44  showing the spring arm as it engages in a partially advanced rotation cam;  
         [0148]      FIG. 45  is a right perspective view of the fully retracted lever and a partial cross-section of the adapter of  FIG. 33  as they interface with the fully advanced balled needle and its accompanying rotation cam;  
         [0149]      FIG. 45A  is a right perspective view of a partial cross-section of the adapter of  FIG. 45  showing the spring arm as it engages in a fully advanced rotation cam;  
         [0150]      FIG. 45B  is a partial right perspective view of the tip of the balled needle of  FIG. 45  showing the orientation of the ferrule latch engaging and disengaging faces;  
         [0151]      FIG. 46  is a right perspective view of the lever partially returned to its fully advanced state and a partial cross-section of the adapter of  FIG. 33  as they interface with the balled needle and its accompanying rotation cam as they are partially returned to their fully retracted state;  
         [0152]      FIG. 46A  is a right perspective view of a partial cross-section of the adapter of  FIG. 46  showing the spring arm as it engages in the rotation cam as it rotates during its partial return to its fully retracted position;  
         [0153]      FIG. 46B  is a partial right perspective view of the tip of the balled needle of  FIG. 46  showing the orientation of the ferrule latch engaging and disengaging faces as the cam begins to rotate as it is being retracted;  
         [0154]      FIG. 47  is a right perspective view of the now fully advanced lever and a partial cross-section of the adapter of  FIG. 33  as they interface with the balled needle and its accompanying rotation cam as they are fully retracted;  
         [0155]      FIG. 47A  is a right perspective view of a partial cross-section of the adapter of  FIG. 47  showing the spring arm as it engages in the rotation cam as it completes its rotation upon returning to its fully retracted position;  
         [0156]      FIG. 47B  is a partial right perspective view of the tip of the balled needle of  FIG. 47  showing the orientation of the ferrule latch engaging and disengaging faces as the cam completes its rotation and is fully retracted;  
         [0157]      FIG. 48  is an exploded perspective view of the underside of the distal tip of the instrument of  FIG. 31  showing the sew tip and the ferrule latch;  
         [0158]      FIG. 49A  is a perspective view of the ferrule latch of  FIG. 48  depicting how the ferrule latch flexes in relation to the pocketed ferrules when encountered by the ferrule latch engaging face of left balled needle;  
         [0159]      FIG. 49B  is a perspective view of the ferrule latch of  FIG. 48  depicting how the ferrule latch flexes in relation to the pocketed ferrules when encountered by the ferrule latch engaging face of right balled needle;  
         [0160]      FIG. 50A  is a perspective view of the underside of the distal tip assembly of the instrument of  FIG. 31  illustrating both balled needles fully retracted and the ferrule latch retaining both sutures and attached ferrules best depicting the lever and cam operations shown in  FIGS. 43 and 43 A, respectively;  
         [0161]      FIG. 50B  is a perspective view of the underside of the distal tip assembly of the instrument of  FIG. 31  illustrating the right balled needle fully retracted, the left balled needle partially advanced, and the ferrule latch retaining both sutures and attached ferrules best depicting the lever and cam operations shown in  FIGS. 44 and 44 A, respectively;  
         [0162]      FIG. 50C  is a perspective view of the underside of the distal tip assembly of the instrument of  FIG. 31  illustrating the right balled needle fully retracted, the left balled needle fully advanced and engaging the ferrule latch to release only the left suture and attached ferrule best depicting the lever and cam operations shown in  FIGS. 45 and 45 A, respectively;  
         [0163]      FIG. 50D  is a perspective view of the underside of the distal tip assembly of the instrument of  FIG. 31  illustrating the right balled needle fully retracted, the left balled needle beginning its retraction and rotation while retaining the left suture and attached ferrule and disengaging the ferrule latch allowing it to return to its normal state best depicting the lever and cam operations shown in  FIGS. 46 and 46 B, respectively;  
         [0164]      FIG. 50E  is a perspective view of the underside of the distal tip assembly of the instrument of  FIG. 31  illustrating the right and left balled needles fully retracted and pulling the left suture and attached ferrule across the jaw best depicting the lever and cam operations shown in  FIGS. 47 and 47 A, respectively;  
         [0165]      FIG. 50F  is a perspective view of the underside of the distal tip assembly of the instrument of  FIG. 31  illustrating the right balled needle fully retracted, the left balled needle partially advanced and beginning to return the left suture and attached ferrule to its pocket best depicting the lever and cam operations shown in  FIGS. 44 and 44 A, respectively;  
         [0166]      FIG. 50G  is a perspective view of the underside of the distal tip assembly of the instrument of  FIG. 31  illustrating the right balled needle fully retracted, the left balled needle fully advanced and returning the left suture and attached ferrule to its pocket while not engaging the ferrule latch best depicting the lever and cam operations shown in  FIGS. 45 and 45 A, respectively;  
         [0167]      FIG. 50H  is a perspective view of the underside of the distal tip assembly of the instrument of  FIG. 31  illustrating the right balled needle fully retracted, the left balled needle beginning its retraction and rotation while both sutures and attached ferrules are retained by the ferrule latch allowing it to return to its normal state best depicting the lever and cam operations shown in  FIGS. 46 and 46 A, respectively;  
         [0168]      FIG. 50J  is a perspective view of the underside of the distal tip assembly of the instrument of  FIG. 31  illustrating both balled needles fully retracted and the ferrule latch retaining both sutures and attached ferrules best depicting the lever and cam operations shown in  FIGS. 47 and 47 A, respectively;  
         [0169]      FIGS. 51A-51H  illustrate a method of tying a unique knot with the instrument  16  of  FIG. 31 . 
     
    
     DETAILED DESCRIPTION OF THE INVENTION  
       [0170]     The first preferred embodiment of this invention, suturing instrument  16 , is represented in  FIGS. 1-13R . Referring to  FIGS. 1-3 , show the suturing instrument  16 , which represents the S EW -R IGHT SR· 5 manufactured by LSI  SOLUTIONS,  Inc. (formerly LaserSurge, Inc.) of Victor, N.Y., that has been modified to provide a means for selectably stripping its ferrule  103  from the needle  34  at its tissue engaging end  16   a.  The tissue engaging end  16   a  and needle  34  thereto may be similar to that shown in U.S. Pat. Nos. 5,431,666, 5,766,183, European Patent No. EP 0669101, filed Feb. 23, 1995 and granted Oct. 14, 1998, or U.S. Patent Application Publication No. US 2002/0107530 A1, filed Feb. 2, 2001, which are herein incorporated by reference.  
         [0171]     The housing  30  has a body shaped like a pistol having a handle portion  30   a,  and may be made of a two-piece construction of molded plastic. A needle  34  extends from housing  30  through the shaft  16   b  into the tissue engaging end  16   a.  Needle  34  has a non-tissue engaging end  34   b  in the housing  30  having a spherical member  34   a,  such as a ball or bearing, respectively, attached thereto. The needle  34  and spherical member  34   a  may be made of metal, such as surgical stainless steel. The spherical member  34   a  may have a bore into which the non-tissue engaging end  34   b  of the needle  34  extends and joins thereto, such as by welding or brazing.  
         [0172]     The suturing instrument  16  includes an actuating member  36  representing a lever  36   a  having two pins  36   b  extending into holes  30   b  in the sides of housing  30  upon which the actuating member  36  is pivotally mounted in the housing  30 . Actuating member  36  has a portion which extends through a lever opening  30   c  ( FIG. 2 ) in housing  30  to enable pivotal movement about pins  36   b.  An extension spring  38  is provided which hooks at one end in a notch  36   c  of actuating member  36  and is wound at the other end around a pin  40  located in holes  30   f  in the sides of housing  30 , such that the actuating member  36  is spring biased to retain actuating member  36  normally in a forward position, fully out, as shown for example in  FIG. 2 . The body of housing  30  has a front pivot stop  30   e  ( FIG. 3 ) providing a stop that limits the pivotal movement of the actuating member  36 . A notch  36   c  is provided in the actuating member  36  which is shaped to receive the non-engaging end of needle  34 , i.e., spherical member  34   a,  to be driven forward by an operator pulling actuating member  36  to pivot actuating member  36  towards handle portion  30   a.  The groove  36   d  ( FIG. 3 ) is provided by two fingers  36   e  into which the needle  34  near the spherical member  34   a  may lie.  
         [0173]     As shown in  FIGS. 4B and 4C , a thumb slide holder  42  is fixed in housing  30  by two flanges  42   a  above actuating member  36 . As best shown in  FIG. 4A , the thumb slide holder  42  has a chamber  42   b  with a groove  42   d  formed by fingers  42   e  which allow the needle  34  to be received in chamber  42   b  to restrict movement of the needle  34  when held therein. The lower surface  42   f  of thumb slide holder  42  is curved and faces correspondingly curved upper surface  36   f  of actuating member  36 , such that the actuating member  36  is slidable along lower surface  42   f  responsive to the operator pulling the actuating member  36 .  
         [0174]     The adapter  48  has a bore extending there through in which a needle spreader  50  is located. Needle spreader  50  has two channels  50   b  and  50   c  into which needle  34  and ferrule stripper  35  are respectively located to increase the distance between the needle  34  and the ferrule stripper  35  as they extend toward thumb slide holder  42 , such that the needle  34  and ferrule stripper  35  are properly aligned.  
         [0175]     A suture routing tube  47  is provided for suture thread in housing  30 . Suture routing tube  47  has one end received in a valve assembly  19 , at the bottom of handle portion  30   a  of housing  30  and then extends through the suture routing tube notch  30   d  ( FIG. 3 ) along the interior of the left side of housing  30 , and a groove  50   a  along needle spreader  50  ( FIG. 3 ). The other end of the suture routing tube  47  is then mounted in suture routing tube hole  51   a  through gasket  51 . Gasket member  51  further has two holes  51   b  and  51   c  through which needle  34  and ferrule stripper  35 , respectively extend. The gasket  51  may be made of medical grade rubber, such as Santoprene.  
         [0176]     A longitudinal guide member  53  is provided multiple tracks along its length, including two tracks  53   a  and  53   b  for needle  34  and ferrule stripper  35 , respectively, and a suture track  53   c  for suture  105  extending from opening  51   a  of gasket  51 . The guide member  53  may be made of extruded flexible material, such as Tecoflex®. A D-tube  52  is provided which is D-shaped at one end  52   a  is registered into a corresponding shaped opening in adapter  48 , and a threaded nut  54  having an opening which extends over D-tube  52 , screws onto the end of the adapter  48  to secure D-tube  52  to housing  30 . With the gasket  51  loaded first into D-tube  52 , guide member  53  extends from the gasket  51  through the D-tube  52 . In this manner, tracks  53   a,    53   b,  and  53   c  each form a channel with the interior surface of D-tube  52 . D-tube  52  may be made of stainless steel, or other rigid material, and has for example, D-tube  52  has an outside diameter of 0.203 inches. (Note for other applications, such as flexible endoscopy, this tube could be flexible.) Inside D-tube  52 , gasket  51  has a ring  51   d,  which frictionally engages the interior surface of D-tube  52 . Hole  51   a  of the gasket  51  is of a diameter such that the suture tube  47  tightly fits therein and provides a seal around suture tube  47 . The suture tube  47  may be held in place in hole  51   a  by friction, but adhesive may also be used. Holes  51   b  and  51   c  are of a larger diameter than the needle  34 , except for a small section of holes  51   b  and  51   c  where the diameter reduces to form flaps of gasket material which seal around needle  34  and ferrule stripper  35 , respectively. This enables movement of the needle  34  and ferrule stripper  35  tube back and forth while maintaining a seal about the needle  34  and ferrule stripper  35 . One feature of the gasket  51  is that it enables sealing the shaft  16   b  as well.  
         [0177]     The guide member  53  is received into the D-tube  52 , such that guide member  53  abuts gasket  51  and engages distal tip  98 . Distal tip  98  is attached to the D-tube  52  by mechanical fastening by forming small dents  52   c  in the metal of the D-tube  52  with a press into recessed four pockets  98   b  ( FIG. 3 ), i.e., two on each side of the distal tip  98 .  
         [0178]     An optional valve assembly  19  can be provided at the bottom of handle portion  30   a,  as shown in  FIG. 3 , having a valve seat  19   a  and a valve controller  19   b.  Valve seat  19   a  is composed of medical grade rubber, such as Santoprene®, and has a through hole extending into an interior chamber. A valve controller  19   b  composed of molded plastic, or other rigid material, has a circular section through an opening and a surface forming a cam that can be turned to select a valve fully open to intermediate partially open to a fully closed position. The suture routing tube  47  is received in hole  76  of valve seat  19   a,  as shown in  FIG. 3 , such that suture  105  material from the tube can pass through openings of the valve seat  19   a  and then through the valve controller  19   b.    
         [0179]     Referring to  FIGS. 2 and 3 , the tissue engaging end  16   a  of the suturing instrument  16  is shown having the distal tip  98  which is mounted in a D-tube  52 , such that the front section  98   a  of the distal tip  98  extends from D-tube  52 .  
         [0180]     Referring to  FIGS. 4A-4C , the thumb slide holder  42  is shown. The thumb slide holder  42  may be made of a one-piece construction of molded plastic. The thumb slide holder  42  is fixed in the housing  30  above the actuating member  36  by two opposing flanges  42   a,  as best shown in  FIG. 4B .  
         [0181]     As best represented in  FIG. 4A , the thumb slide holder  42  has a chamber  42   b  through which the positive stop  41   b  of the timing tube  41   c  is located. One groove  42   d  formed by two fingers  42   e  allows the needle  34  ( FIG. 3 ) to pass through the thumb slide holder  42  through the groove  36   d  formed by the two fingers  36   e  of the actuating member  36  and enables the spherical member  34   a  to rest in the notch  36   c  of the actuating member  36 . The lower curved surface  42   f  extends over the curved upper surface  36   f  of the actuating member  36  to further retain the needle  34  and spherical member  34   a  in the notch  36   c  throughout the entire range of motion of the actuating member  36 .  
         [0182]     The housing  42   g  of the thumb slide holder  42  is fashioned to accommodate and guide the thumb button  41   e  ( FIG. 3 ). The thumb button stop  42   k  serves as a motion-limiting surface to prevent the thumb button  41   e  from traveling farther than intended. The thumb slide holder  42  has a bore  42   c  for the timing tube  41   c  ( FIG. 3 ) is located. Contained within the housing  42   g  is a raised region  42   h  to enable alignment of the return spring  46  ( FIG. 3 ) and resting surface  42   j  which seats and retains the return spring  46 .  
         [0183]      FIG. 4C  shows a perspective view of the thumb slide holder  42  and timing tube stop  42   l  which provides a positive engagement surface for the positive stop  41   b  to limit the advance of the timing tube  41   c.  The thumb slide holder  42  may further have a channel  42   p  forward of the groove  42   d  to provide clearance for suture routing tube  47  ( FIG. 3 ). The body of the thumb slide holder  42  has lock spring bores  42   n  and spring lock channels  42   m  to provide for the assembly, alignment, and retaining of the lock springs  45  and distal spring lock  43  and proximal spring lock  44 , respectively and best represented in  FIGS. 5A and 5B .  
         [0184]      FIG. 5A  shows the push button assembly  41  interfacing with other components. The timing tube  41   c  is shown with the thumb button  41   e  attached thereto. Housed inside the thumb button  41   e  is the return spring  46  which serves as a return mechanism for the assembly. The ferrule stripper  35  is received into the distal opening  41   d  and coupled to the timing tube  41   c  via an insert molding or adhesive process. The lock springs  45  are inserted into the thumb slide holder  42  and followed with the proximal spring lock  44  and the distal spring lock  43 . With the proximal spring lock  44  and the distal spring lock  43  inserted in the thumb slide holder  42  and compressed, the push button assembly  41  with attached ferrule stripper  35  is inserted into the thumb slide holder  42  such that the positive stop  41   b  passes into the chamber  42   b  and the proximal spring lock engages in the spring lock engagement slot  41   a.  The ferrule stripper  35  continues through the adapter  48 .  
         [0185]      FIG. 5B  shows a perspective view of the underside of assembled push button assembly  41 , thumb slide holder  42 , adapter  48 , nut  54 , and D-tube  52  and highlights the relative location of the proximal spring lock  44  and distal spring lock  43 .  
         [0186]     Referring to  FIGS. 6A and 6B , the operation of the actuating member  36  and the needle  34  is described. As the actuating member  36  is engaged, rotating about the pins  36   b,  the needle  34  and the attached spherical member  34   a  are advanced as the spherical member  34   a  is in contact with the notch  36   c  of the actuating member  36 .  
         [0187]      FIGS. 7A and 7B  illustrate the operation of the push button assembly  41  and the ferrule stripper  35 . The actuating member  36  is engaged, rotating about the pins  36   b  until the flat engagement surface  36   g  comes into contact with and forces the proximal spring lock  44  out of the spring lock engagement slot  41   a  ( FIG. 5A ) allowing the forward motion of the push button assembly  41  and the coupled ferrule stripper  35 . This forward motion is limited primarily by the engagement of distal spring lock  43  with spring lock engagement slot  41   a  ( FIG. 5A ). Advancement of timing tube  41   c  is also limited by engaging the adapter  48 .  
         [0188]      FIG. 8A  shows the assembly of the distal tip  98  and the ferrule retainer  99  with the D-tube  52 , the needle  34 , and the ferrule stripper  35 . The distal tip  98  has a gap  104  in a c-shaped jaw  104  having two openings  98   c  at one side of the gap through which each needle  34  and ferrule stripper  35  may extend The needle  34  and the ferrule stripper  35  are received into the needle/stripper openings of the distal tip  98  and the distal tip  98  is then coupled to the D-tube  52  which may be achieved by mechanical fastening forming small dents in the metal of the D-tube  52  with a press into four recessed pockets  98   b,  i.e., two on each side of the distal tip  98 . The ferrule retainer  99  is inserted into the ferrule retainer hole  98   e  until the ring  99   a  seats into the opening created where the ferrule retainer hole  98   e  intersects the ferrule pocket  107  as best shown in  FIG. 8B . The suture  105  attached to the ferrule  103  enters the ferrule compartment  107  through the open slot located on the side of the ferrule chamber opposite from the ferrule retainer  99 .  
         [0189]      FIGS. 9A-13R  represent highlights of twelve sequential steps overviewing the loading, reloading and locking operations through one complete cycle of use of instrument  16 . For example, the first three steps presented in  FIGS. 9A-9M , illustrate the needle  34  first advancing into the ferrule  103 .  
         [0190]      FIGS. 9A-9D  show the instrument loaded and ready for use, the first step.  FIG. 9A  shows a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed and both the thumb button  41   e  and the lever  36   a  are fully out; the proximal spring lock  44  engages the timing tube  41   c.    FIG. 9B  is a right perspective view of the distal tip  98  of the components of  FIG. 9A  showing the ferrule  103  in its ferrule compartment  107  and the jaw  104 .  FIG. 9C  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 9A  with the ferrule  103  in its ferrule compartment  107 , and the needle  34  and ferrule stripper  35  fully back.  FIG. 9D  is a side view of the proximal components of  FIG. 9A  showing the lever  36   a  and thumb button  41  fully out. Proximal spring lock  44  is shown engaging spring lock engagement slot  41   a  of timing tube  41   c.    
         [0191]      FIGS. 9E-9H  show partial advancement of the needle  34  as part of the second step.  FIG. 9E  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with its thumb slide holder  42  removed, the lever  36   a  partially retracted and the thumb button  41   e  fully out.  FIG. 9F  is a right perspective view of the distal tip  98  of the components of  FIG. 9E  with the needle  34  partially advanced and the ferrule  103  in its ferrule compartment  107 . FIG.  9 G is the partial cross-sectional view of the distal tip  98  of the components of  FIG. 9E  showing the ferrule  103  in its ferrule compartment  107 , the needle  34  partially advanced and the stripper  35  fully back.  FIG. 9H  is a side view of the proximal components of  FIG. 9E  showing the lever  36   a  partially retracted and the thumb button  41   e  fully out.  
         [0192]      FIGS. 9J-9M  show the needle  34  fully advanced and engaged inside of the ferrule  103  as part of the third step.  FIG. 9J  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed, the lever  36   a  fully retracted and the thumb button  41   e  fully out.  FIG. 9K  is a right perspective view of the distal tip  98  of the components of  FIG. 9J  showing the needle  34  fully advanced to engage the ferrule  103  in its ferrule compartment  107 ; best shown in  FIG. 9L .  FIG. 9L  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 9J  with the needle  34  engaging the ferrule  103  in its ferrule compartment  107  and the ferrule stripper  35  fully back.  FIG. 9M  is a side view of the proximal components of  FIG. 9J  showing the lever  36   a  fully retracted and the thumb button  41   e  fully out. Note that the flat engagement surface  36   g  is shown raising the proximal spring lock  44  out of the spring lock engagement slot  41   a.    
         [0193]     The next two steps presented in  FIGS. 1A-10H , illustrate the needle  34 , now attached to the ferrule  103  and its suture  105 , being retracted fully back.  FIGS. 1A-10D  show the needle  34  pulling its ferrule  103  back through jaw  104 .  FIG. 10A  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed, with the thumb button  41   e  fully out, the lever  36   a  partially forward and the needle  34  attached to the ferrule  103  and suture  105  partially back.  FIG. 10B  is a right perspective view of the distal tip  98  of the components of  FIG. 10A  showing the needle  34  attached to the ferrule  103  with suture  105  partially retracted.  FIG. 10C  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 10A  showing the needle  34  attached to the ferrule  103  and suture  105  partially retracted and the ferrule stripper  35  fully back.  FIG. 10D  is a side view of the proximal components of  FIG. 10A  showing the lever  36   a  partially back and the thumb button  41   e  fully out;  
         [0194]      FIGS. 10E-10H  show this instrument  16  with the ferrule  103  and its suture  105  attached to the fully retracted needle  34 .  FIG. 10E  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed, the lever  36   a  fully out and the thumb button  41   e  fully out.  FIG. 10F  is a right perspective view of the distal tip  98  of the components of  FIG. 10E  showing the suture  105  fully retracted and the ferrule stripper  35  fully back.  FIG. 10G  is a perspective side view of the distal tip  98  of the components of  FIG. 10E  showing the needle  34  attached to the ferrule  103  and suture  105  fully retracted and the ferrule stripper  35  fully back.  FIG. 10H  is a side view of the proximal components of  FIG. 10E  showing the lever  36   a  fully out and the thumb button  41   e  fully out.  
         [0195]      FIGS. 11A-11J  show the next two steps representing reinsertion of the ferrule  103  into it ferrule compartment  107 .  FIGS. 11A-11E  show the partial advancement of the needle  34  with its attached ferrule  103  and suture  105 .  FIG. 11A  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed, the lever  36   a  partially retracted, the needle  34  with its ferrule  103  and suture  105  partially advanced and the thumb button  41   e  fully out.  FIG. 11B  is a right perspective view of the distal tip  98  of the components of  FIG. 11A  showing the needle  34  attached to the ferrule  103  and the suture  105  partially advanced.  FIG. 11C  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 11A  showing the needle  34  attached to the ferrule  103  and the suture  105  partially advanced and the ferrule stripper  35  fully back.  FIG. 11D  is a side view of the proximal components of  FIG. 11A  showing the lever  36   a  partially retracted and the thumb button  41   e  fully out.  
         [0196]      FIGS. 11E-11J  show the needle  34  fully advanced attached to the ferrule  103  and its suture  105 . Note that at this step of the operation,  FIG. 11J  is provided to show an enlarged view of the distal spring lock  43  and proximal spring lock  44 .  FIG. 11E  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed and the lever  36   a  fully retracted and the thumb button  41   e  fully out.  FIG. 11F  is a right perspective view of the distal tip  98  of the components of  FIG. 11E  with the needle  34  fully advanced into the ferrule  103 .  FIG. 11G  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 11E  showing the needle  34  along with its attached ferrule  103  and suture  105  fully advanced into its ferrule compartment  107 .  FIG. 11H  is a side view of the proximal components of  FIG. 11E  showing the lever  36   a  fully retracted and the thumb button  41   e  fully out.  FIG. 11J  is a close-up side view of the lock features of the components of  FIG. 11H  showing the flat engagement surface  36   g  of the actuating member  36  raising the proximal spring lock  44  to disengage it from the spring lock engagement slot  41   a  of the timing tube  41   c.    
         [0197]      FIGS. 12A-12K  illustrate the next two steps to complete advancement of the ferrule stripper  35 .  FIGS. 12A-12E  show the advancing of the push button assembly  41  to partially advance towards stripping the ferrule  103  from the fully advanced needle  34 .  FIG. 12A  is a right partial view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed, the lever  36   a  fully retracted, the needle  34  with its attached ferrule  103  and suture fully advanced and the thumb button  41   e  partially advancing the ferrule stripper  35 .  FIG. 12B  is a right perspective view of the distal tip  98  of the components of  FIG. 12A  showing the needle  34  with its ferrule  103  and suture  105  fully advanced into its ferrule compartment  107  and the ferrule stripper  35  partially advanced.  FIG. 12C  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 12A  showing the needle  34  attached to the ferrule  103  and suture  105  fully advanced and the ferrule stripper  35  partially advanced.  
         [0198]      FIG. 12D  is a side view of the proximal components of  FIG. 12A  showing the lever  36   a  fully retracted and the thumb button  41   e  and its attached timing tube  41   c  partially forward.  FIG. 12E  is a close-up side view of the lock features of the components of  FIG. 12D  showing the flat engagement surface  36   g  raising the proximal spring lock  44  out of the spring lock engagement slot  41   a  and the timing tube  41   c  partially forward.  
         [0199]      FIGS. 12F-12K  show the full advancement of both the needle  34  and ferrule stripper  35 .  FIG. 12F  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed, the lever  36   a  fully retracted, the needle  34  with its attached ferrule  103  and suture  105  fully advanced, and the thumb button  41   e  advancing its ferrule stripper  35  fully forward.  FIG. 12G  is a right perspective view of the distal end of the components of  FIG. 12F  showing the needle  34  with its ferrule  103  and suture  105  fully advanced and the ferrule stripper  35  fully advanced and engaging the proximal edge of the ferrule  103 , as best shown in  FIG. 12H .  FIG. 12H  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 12F  showing the needle  34  attached to the ferrule  103  and the suture  105  and the ferrule stripper  35  fully advanced and flexed onto the needle  34  to engage the proximal edge of the ferrule  103 .  FIG. 12J  is the side view of the proximal components of  FIG. 12F  showing both the lever  36   a  and the thumb button  41   e  fully forward.  FIG. 12K  is a close-up side view of the lock features of  FIG. 12J  showing the actuating member  36  raising the proximal spring lock  44 , allowing the distal spring lock  43  to engage the spring lock engagement slot  41   a  in the timing tube  41   c.  Note a relief  36   j  in the top of the actuating member  36  allows the distal spring lock  43  to travel downward and engage the spring lock engagement slot  41   a.    
         [0200]     The last three steps,  FIGS. 13A-13R , illustrate the complete retraction of both the needle  34  and ferrule stripper  35 .  FIGS. 13A-13E  show the lever  36   a  partially forward to retract the needle  34  to strip the ferrule  103  by engaging ferrule  103  with the fully advanced ferrule stripper  35 .  FIG. 13A  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed, the lever  36   a  partially released, the needle  34  partially retracted, the ferrule stripper  35  engaging the ferrule  103  in its ferrule compartment  107  and the thumb button  41   e  fully forward.  
         [0201]      FIG. 13B  is a right perspective view of the distal tip  98  of the components of  FIG. 13A  showing the needle  34  partially retracted from its ferrule  103  (not visible in this view) and the ferrule stripper  35  fully forward.  FIG. 13C  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 13A  showing the needle  34  partially retracted and the ferrule stripper  35  fully forward engaging the ferrule  103  in its ferrule compartment  107 .  FIG. 13D  is a side view of the proximal components of  FIG. 13A  showing the lever  36   a  partially out and the thumb button  41   e  fully forward.  FIG. 13E  is a close-up side view of the lock features of  FIG. 13D  showing the convex engagement surface  36   h  of the actuating member  36  ( FIG. 13D ) raising the distal spring lock  43  to disengage the spring lock engagement slot  41   a  of the timing tube  41   c.    
         [0202]      FIGS. 13F-13K  show both the needle  34  and ferrule stripper  35  partially returning with the ferrule  103  replaced back into its ferrule compartment  107 .  FIG. 13F  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed, the lever  36   a,  needle  34 , thumb button  41   e  and ferrule stripper  35  partially back.  FIG. 13G  is a right perspective view of the distal tip  98  of the components of  FIG. 13F  with the needle  34  and ferrule stripper  35  partially retracted and the ferrule  103  back into its ferrule compartment  107 .  FIG. 13H  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 13F  showing the needle  34  and the ferrule stripper  35  partially back and the ferrule  103  and suture  105  in the ferrule compartment  107 .  FIG. 13J  is a side view of the proximal components of  FIG. 13F  showing the lever  36   a  and the thumb button  41   e  partially back.  FIG. 13K  is a close-up side view of the lock features of  FIG. 13F  showing the engaging surfaces  36   f - 36   h  of the actuating member  36  not raising the proximal spring lock  44  or the distal spring lock  43  with the spring lock engagement slot  41   a  released.  
         [0203]      FIGS. 13L-13R  show the instrument reloaded, ready for use and are identical to  FIGS. 9A-9D , respectively, while  FIG. 13R  highlights re-engagement of the proximal spring lock  44  with the spring lock engagement slot  41   a.    FIG. 13L  is a right perspective view of the drive mechanism of the instrument of  FIG. 3  with the thumb slide holder  42  removed, the lever  36   a,  needle  34 , thumb button  41   e  and ferrule stripper  35  fully back and the ferrule  103  and suture  107  reloaded into the ferrule compartment  107 .  FIG. 13M  is a perspective view of the distal tip  98  of the components of  FIG. 13L  showing the needle  34  and ferrule stripper  35  fully retracted and the ferrule  103  and suture  107  in the ferrule compartment  107 .  FIG. 13N  is a partial cross-sectional view of the distal tip  98  of the components of  FIG. 13L  showing the needle  34  and ferrule stripper  35  fully back and the ferrule  103  and suture  107  in the ferrule compartment.  FIG. 13P  is a side view of the proximal components of  FIG. 13L  showing the lever  36   a  and the thumb button  41   e  fully back.  FIG. 13R  is a close-up side view of the lock features of  FIG. 13L  showing the proximal spring lock  44  engaging the spring lock engagement slot  41   a  of the timing tube  41   c.    
         [0204]     Now referencing  FIGS. 14A-17D , showing the multiple placement of sutures to form a wound closure.  FIGS. 14A-14E  illustrate the use of this instrument for the placement of the first suture of a wound closure and the readiment of the instrument for subsequent bites.  FIG. 14A  shows the distal tip  98  of the instrument  16  above a wound closure  110 . Note the distal side of the wound closure  110  has crosshatching for purposes of this illustration.  FIG. 14B  shows the device  16  with the needle  34  passing through the first bite  124  of the distal side of the wound  110 .  FIG. 14C  shows the needle  34  retracted back with its ferrule  103  and suture  105  pulled through the wound  110 .  FIG. 14D  shows the needle  34  now advanced through to place the ferrule  103  back into its ferrule compartment  107 .  FIG. 14E  shows the needle  34  back after having its ferrule  103  stripped. The instrument is now ready for another bite.  
         [0205]     Now referencing  FIGS. 15A-15E , the device  16  is again placed into the wound  110  this time with the proximal side of the wound  110  in the instrument&#39;s jaw  104 . The needle  34  will enter the tissue  120  as shown in  FIG. 15A , traverse the tissue  120  and enter the ferrule compartment  107  as shown in  FIG. 15B .  FIG. 15C  illustrates the needle  34 , ferrule  103  and suture  107  pulled back leaving suture  105  through the first bite  126  on the proximal side of the wound closure  110 .  FIG. 15D  shows the needle  34  advanced yet again.  FIG. 15E  shows the ferrule  103  back in its ferrule compartment  107 .  
         [0206]      FIG. 16A-16D  shows the second suture placement on the distal side of the wound  110 .  FIG. 16A  shows the needle  34  traversing the second site  127  on the distal wound  110  aspect.  FIG. 16B  shows the suture  105  through the second bite  127  on the distal side of the wound  110 .  FIG. 16C  shows the needle  34 , ferrule  103  and suture  105  advanced to the ferrule pocket.  FIG. 16D  shows the instrument again ready for the bite.  
         [0207]      FIG. 17A-17D  show the second bite  128  on the proximal side of the wound closure  110 .  FIG. 17A  shows the needle  34  going through the second site  128  of the proximal side of the wound closure  110 .  FIG. 17B  shows the needle  34 , ferrule  103  and suture  105  advanced back into its ferrule compartment  107 .  FIG. 17C  shows the instrument with the ferrule  103  reloaded and the needle  34  and ferrule stripper  35  retracted back.  FIG. 17D  illustrates the appearance of the wound closure  110 . If the sutures  105  were to be tied at this time, this type of closure is commonly called a figure of eight suture closure. If the process were to continue with further placements of suture  105  running along the distal and proximal aspects of the wound closure, this type of closure is typically be called a running suture wound closure.  
         [0208]     Now referencing  FIGS. 18A-21 ,  FIG. 18A  shows the instrument  16  of this invention with the distal tail of the suture  105  exposed and the distal tip  98  of the instrument  16  ready for knot tying.  FIGS. 18A-19B  show the first throw of the knot tying process.  FIGS. 19C-19F  show the second throw of the knot tying process.  FIGS. 21 and 22  show the cinching down of the knot. In  FIG. 18B , a surgical grasper  129 , is used to grab the free end of the suture  105  and to wrap the suture  105  around the jaw  104  of the instrument  16 . Note that to construct the unique knot of this invention, which we have named the “Super Surgeon&#39;s knot,” the first wrapping of suture  105  around the jaw  104  consists of two complete loops wrapped around the jaw  104 .  FIG. 18C  shows the advancement of the needle  34 , ferrule  103  and suture  105  back into its ferrule compartment  107 , best shown in  FIG. 18A , after the double wrap has been placed around the jaw  104  of the instrument  16 .  FIG. 18D  shows the now stripped ferrule  103  in its ferrule compartment  107 .  FIG. 18E  shows the knot forming double loops being slid down towards the wound closure site  110 .  FIG. 19A  shows the grasper  129  further cinching the knot down to the wound closure site  110 .  FIG. 19B  shows the suture  105  now fully retracted back on its needle  34  to further expose the jaw  104  of the knot tying instrument  16 .  FIG. 19C  shows a second wrapping of a single loop placed around the distal tip  98  of the instrument  16  to secure the knot.  FIG. 19D  shows the needle  34  again advanced to replace the ferrule  103  in its ferrule compartment  107  along with the suture  105 .  FIG. 19E  shows the ferrule  103  in its ferrule compartment  107  with the needle  34  and ferrule stripper  35  now back.  FIG. 19F  shows the second throw, a single loop throw, of the Super Surgeon&#39;s knot being slid over the ferrule  103  and suture  105  down towards the wound closure  110 .  FIG. 20D  illustrates that by pulling on the surgical grasper  129  on the free end of the suture  105 , the suture loops are further slid towards and down onto the wound closure  110  to begin to pull (also called approximate or appose) the edges of the wound  110  together, but not fully locking the knot in place.  FIG. 21  shows by pulling on the surgical grasper  129  holding the free end of the suture  105 , and now by simultaneously pulling on instrument  16  holding the ferrule  103  end of the suture  105 , both ends of the suture  105  are drawn tight, thereby locking the Super Surgeon&#39;s knot in place. The distinct advantage of the Super Surgeon&#39;s knot is that it permits the user to place the knot above the wound closure and appropriately appose the wound edge by pulling only on the free end of the suture, and then, once the correct tissue apposition is achieved, the user can pull on the ferrule end of the suture to lock the knot down. Locking down the Super Surgeon&#39;s knot alone provides adequate holding force, at least temporarily, to hold together many types of wound closures. For example, a Super Surgeon&#39;s knot made with 2-0 STRONGSORB® suture by LSI  SOLUTIONS,  Inc., achieves an average tissue holding strengths of approximately 0.5 kg knot holding force to temporarily secure and tissue edges together. Subsequent throws on top of the Super Surgeon&#39;s knot will add additional knot holding force up to the native strength of the suture (e.g., with 2-0 STRONGSORB®, up to 5 to 6 kg tensile pull). No other knot is known (to the inventors) that can be constructed under such surgically relevant conditions and provides excellent tissue holding force immediately when the first throws are drawn together by pulling on both ends of the suture.  
         [0209]      FIGS. 22A-22C  illustrate an alternate method of securing the free ends of the suture  105  left by the instrument  16 , used to close the wound  110  in the tissue  120 .  FIG. 22A  represents an instrument  130 , which crimps a sleeve member  121  to secure suture  105  together and is commercially available as a Ti-K NOT® TK· 5. Device manufactured by LSI  SOLUTIONS,  Inc., under at least the following patents U.S. Pat. Nos.: 5,520,702; 5,643,289 and 5,669,917. The free ends of the suture  105  are passed through the instrument  130  and the instrument  130  is passed closer to the wound closure  110 .  FIG. 22B  illustrates the instrument  130  being applied directly to the wound closure  110  and both free ends of the suture  105  drawn tight, removing any slack and drawing the opposing sides of the wound closure  110  closer together.  FIG. 22C  shows the sleeve member  121  crimped around the suture  105  at the wound closure  110 . Note that the suture  105  has been trimmed.  
         [0210]     After using instrument  16  to place suture  105  for running a wound closure  110 , one or both ends of the suture  105  may remain unsecured. These free ends of the suture  105  can be attached to pledgets or bolsters  122   a  and  122   b  to prevent their ability to be pulled into or away from the wound site  110 . A pledget is typically a pliable, non-reactive piece of material, such as polyester mesh, Gortex®, or the like, that is often used in conjunction with sutures or staples to augment wound closures. In this invention, a bolster  122   a  is attached (e.g., by tying or sewing) to one end of an additional segment of suture  123   a.  By placing the free end of this bolstered suture  123   a,  along with one free end of the suture  105 , the bolster  122   a  and its attached suture  123   a  can be passed down using suture  105  as a guide. Bolster  122   a,  suture  123   a  and one end of suture  105  can be secured at one end of the wound site  110  with a sleeve member  121 . The bolster  122   a  can hold this end of the running suture  105  from being pulled into the wound  110 . By repeating a similar bolstered suture  123   b  placement at the opposite end of the wound  110 , the second bolster  122   b  and its suture  123   b  can hold the second suture  105  end from being pulled into the wound  110 . Bolsters  122   a  and  122   b  secured at each end of the wound  110 , prevent the suture  105  from being pulled out of the wound  110  from either direction.  
         [0211]      FIGS. 24A-24C  illustrate a second preferred embodiment of this invention. The main difference between this embodiment and the first preferred embodiment, is that instead of stripping the ferrule  103  with the ferrule stripper  35  traversing the gap and engaging the ferrule  103 , the member that directly contacts the ferrule  103  for ferrule stripping is incorporated in the distal tip  98 . The thumb button  41   e  drive mechanism for this embodiment can be the same as in the first preferred embodiment.  FIG. 24A  shows a perspective of the distal jaw, which looks similar to the first embodiment, except instead of a slope to direct the stripper wedge  131  towards the ferrule, the stripper wedge  131  enters a chamber  141  and subsequently wedges member  133  against ferrule  103  to permit removal of the needle  34 .  FIG. 24B  shows needle  34  engaging ferrule  103  in ferrule compartment  107  with the stripper wedge  131  traveling toward chamber  141 .  FIG. 24C  shows the ferrule  103  held in its ferrule compartment  107  by stripper wedge  131  forcing over member  133 . Needle  34  can now be extracted from ferrule  103 . Stripper wedge  131  can be subsequently withdrawn leaving the ferrule  103  in it reloaded position.  
         [0212]      FIGS. 25A-25C  illustrate a third preferred embodiment of this invention. In this embodiment, unlike the prior two, the ferrule stripping element does not traverse the gap in the distal tip  98 . Rather, in this embodiment, the stripper wedge  131 , which can be a semi-flexible material, such as memory metal, Nitinol, or the like, passes through a channel in the bridge that traverses behind the gap in the jaw. This ferrule stripping embodiment can also be advanced towards the ferrule using a mechanism similar to the already described thumb slide mechanism  41  ( FIG. 3 ).  FIG. 25A  shows needle  34  after being retracted back and stripped off ferrule  103  held in its ferrule compartment  107  by the flexible integrated stripper  135 .  FIG. 25B  is a partial sectional view of needle  34  engaging ferrule  103  in its ferrule compartment  107 . The flexible integrated stripper  135  is shown retracted into the bridge channel  134  to permit the needle  34  to pull the ferrule  103  out of its ferrule compartment  107 .  FIG. 25C  illustrates a partially retracted needle after its ferrule  103  is stripped by the flexible integrated stripper  135 .  
         [0213]      FIGS. 26-30J  describe a fourth preferred embodiment of this invention. Unlike the previous three embodiments, this fourth version does not require an additional manual mechanism, like the thumb slide mechanism, to enable ferrule stripping. Instead of pushing a button to activate a stripper, this instrument is more automated to enable stripping the ferrule  103  imply squeezing the lever  36   a  a second time.  
         [0214]      FIG. 26  shows this instrument in a perspective view illustrating window  136  in the right handle half; a comparable window (not shown) is located in the opposite location on the left handle half. These windows permit an instrument user to view from either handle an asymmetric rotating disc  138   a  that indicates whether the cam needle  139  is in the stripper or non-stripper orientation. Also, note rod  137  mounts into the right handle half to engage the slots in the rotating cam  138 . When lever  36   a  rotates back, cam  138  drives forward, lifts towards the mid stroke, then lowers and rotates about rod  137 , as seen in  FIGS. 27A-27C .  
         [0215]      FIG. 27A  shows the rod  137  engaging the distal slot in cam  138 . The rotating indicator disc  138   a  is vertically oriented indicating a non-faceted edge of the cam needle  139  faces the ferrule latch  140  ( FIG. 27A ; also see  FIGS. 28-31J ). Release of the lever  36   a  permits the cam needle  139  and its rotational cam  138  to travel back and elevates slightly at mid stroke, where rod  137  enters an obliquely oriented slot, to begin rotating the rotational cam  138  and its attached cam needle  139  ( FIG. 27E ). By completion of the lever  36   a,  the full rotation of the rotational cam  138  ( FIG. 27A ), the needle facet  139   b  ( FIG. 27F ) is now oriented towards the ferrule latch  140 , which permits ferrule stripping.  
         [0216]      FIG. 28  shows the partially retracted cam needle  139  having its ferrule  103  held by ferrule latch  140 . Note this illustration shows a pocket  142  recessed in the distal tip  98  for holding the ferrule latch  140 .  
         [0217]      FIG. 29A  shows cam needle  139  oriented with a non-faceted shoulder  139   c  engaging and lifting the ferrule engaging surface  140   g  of the ferrule latch  140 . The ferrule  103  is not held by the ferrule latch  140 , because the ferrule  103  latch  140  is compressed by the non-faceted shoulder  139   c  pushing against timing surface  140   b.  The ferrule  103  is able to be pulled from its ferrule compartment  107  by cam needle  139 .  FIG. 29B  shows the distal end of the fourth preferred embodiment with cam needle  139  retracting back through the gap and the ferrule latch  140  engaging into the proximal edge of ferrule  103 .  FIG. 29B  highlights cam needle  139  oriented to have a facet  139   b  towards the ferrule latch  140 , to not engage timing surface  140   b  so that the ferrule engagement surface  140   g  contacts the proximal edge of ferrule  103 . Surfaces  140   f  and  140   e  provide contacts to help maintain latch placement in its pocket  142 .  
         [0218]      FIGS. 30A-30J  show one complete cycle of the cam needle  139  traversing the jaw  104 , picking up a ferrule  103 , the ferrule  103  being returned to its ferrule compartment  107  and the ferrule  103  being stripped by the ferrule latch  140 . This cycle reloads the ferrule  103  for another stitch placement.  FIG. 30  shows the retracted cam needle  139  oriented with a non-faceted shoulder  139   c  facing the ferrule latch  140 , which secures the ferrule  103  with its suture  105  in its ferrule compartment  107  in the distal tip  98 .  FIG. 30B  shows cam needle  139  fully advanced into ferrule  103 , with its non-faceted shoulder  139   c  compressing ferrule latch  140 .  FIG. 30C  shows cam needle  139  pulling ferrule  107  and suture  105  back beyond the compressed ferrule latch  140 . At approximately the midpoint of the cam needle  139  retraction, cam needle  139  begins its rotation with ferrule  103  and suture  105  rotating with cam needle  139 .  FIG. 30E  shows cam needle  139  along with its ferrule  103  and suture  105  fully retracted back with its  900  rotation completed.  FIG. 30F  shows cam needle  139 , ferrule  103  and suture  105  advancing back into ferrule compartment  107 . A faceted shoulder  139   a  of cam needle  139  now faces the ferrule latch  140 .  FIG. 30G  shows the cam needle  139 , ferrule  103  and suture  105  fully placed back into its ferrule compartment  107 . The faceted shoulder  139   a  of cam needle  139  does not cause ferrule latch  140  to compress up or deflect away from the proximal edge of ferrule  103 .  FIG. 30H  shows the retraction of ferrule  103  stopped by ferrule latch  140 , stripping ferrule  103  from its partially retracted cam needle  139 .  FIG. 30J  shows the cam needle  139  now fully retracted back and rotated back 180° so that the opposite side of the non-faceted shoulder  139   c  is oriented towards the ferrule latch. The ferrule  103  is reloaded back into its ferrule compartment  107  and cam needle  139  is ready to advance through more tissue  120 , picking up ferrule  103  and pulling it along with its suture  105  back through another bite of tissue  120 .  
         [0219]     An additional embodiment of the invention, suturing instrument  16 , is represented in  FIGS. 31-50J . Referring to  FIGS. 31-33 , show the suturing instrument  16 , which represents the SEW-RIGHT® SR·5® manufactured by LSI SOLUTIONS, Inc. (formerly LaserSurge, Inc.) of Victor, N.Y., that has been modified to provide a means for both selecting a left needle  144  or right needle  145  via a selector mechanism  146  and selectably stripping a ferrule  103  from the left needle  144  or right needle  145  at its tissue engaging end  16   a.    
         [0220]     A shaft  147  offers a suture loading window  147   a  through which a suture  105  loaded at the tissue engaging end  16   a  may be passed into a suture channel  150   a  of a guide member  150  and subsequently through the instrument  16  and out of a valve controller  19   b.    
         [0221]     The housing  143  has a body shaped like a pistol having a handle portion  143   a,  and may be made of a two-piece construction of molded plastic. A left needle  144  and right needle  145  extend from housing  143  through the shaft opening  143   c  into the shaft  147  and proceeds into the tissue engaging end  16   a.  Left needle  144  and right needle  145  have a non-tissue engaging end  144   a  and  145   a,  respectively, in the housing  143  having a spherical member  148 , such as a ball or bearing, attached thereto. The left needle  144 , right needle  145 , and spherical member  148  may be made of metal, such as surgical stainless steel. The spherical member  148  may have a bore into which the non-tissue engaging end  144   a  or  145   a  of the left needle  144  or right needle  145 , respectively, extends and joins thereto, such as by welding or brazing.  
         [0222]     The suturing instrument  16  includes an actuating member  149  representing a lever  149   a  having two pins  149   b  extending into holes  143   b  in the sides of housing  143  upon which the actuating member  149  is pivotally mounted. The lever  149   a  of actuating member  149  extends through a lever opening  143   d  ( FIG. 32 ) in housing  143  to enable pivotal movement about pins  149   b.  An extension spring  38  is provided which hooks at one end in a notch  149   c  of actuating member  149  and is wound at the other end around a pin  40  located in holes  143   d  in the sides of housing  143 , such that the actuating member  149  is spring biased to retain actuating member  149  normally in a forward position, fully advanced, as shown for example in  FIG. 32 . The body of housing  143  has a front pivot stop  143   e  ( FIG. 32  and  33 ) providing a stop that limits the pivotal movement of the actuating member  149 . Grooves  149   d  are provided in the actuating member  149  which are shaped to retain the non-tissue engaging ends  144   a  and  145   a  of the left needle  144  and right needle  145 , respectively accompanied by a channel  149   e  shaped to accept a shuttle  151  that shaped to accommodate the spherical member  148  to be driven forward by an operator pulling the actuating member  149  to pivot actuating member  149  towards handle portion  143   a.    
         [0223]     An adapter  154  is fixedly attached to the inside of the housing  143  by means of opposing flanges  154   d.  Through the adapter  154 , the remainder of the components of the instrument  16  are assembled. The selector mechanism  146  is stationed on the post  154  through the post hole  146   c  ( FIG. 35 ).  
         [0224]     A suture routing tube  47  is provided for the unobstructed passage of suture  105  in housing  143 . Suture routing tube  47  has one end received in valve assembly  19  at the bottom of handle portion  143   a  of housing  143  and extends through the suture routing tube notch  143   h  ( FIG. 33 ) along the interior of the left side of the housing  143 , through a routing tube passageway  154   e  along the left side of the adapter  154  ( FIG. 40B ). The other end of the suture routing tube  47  is then mounted in a suture routing tube hole  51   a  in gasket member  51 . Gasket member  51  further has two needle holes  51   b  and  51   c  through which right needle  145  and left needle  144  respectively extend. The gasket  51  may be made of medical grade rubber, such as Santoprene®.  
         [0225]     A longitudinal guide member  150  provides multiple tracks along its length, including a suture channel  150   a  for unhindered passage of suture  105  extending from opening  51   a  of gasket  51 , a left needle channel  150   b  to aid in guidance of the left needle  144  as it extends towards the distal tip  16   a  of instrument  16 , and a right needle track  150   c  to aid in the guidance of the right needle  145  as it extends towards the distal tip  16   a  of instrument  16 . The guide member  150  may be made of an extruded flexible material such as Tecoflex®. A shaft  147  is provided in which a D-shaped end  147   b  is registered into a corresponding shaped opening in adapter  154 , and a threaded nut  54  having an opening which extends over shaft  147 , screws onto the end of the adapter  154  to secure the shaft  147  to the adapter  154 . With the gasket member  51  loaded first into the shaft  147 , guide member  150  inserted into the shaft  147  through a distal opening  147   c  extends from the gasket member  51  through the shaft  147 . In this manner, channels  150   a,    150   b,  and  150   c  each form a passage with the interior surface of shaft  147 . The left needle channel  150   b  and right needle channel  150   c  serve as guides to direct the passage of the left needle  144  and right needle  145 , respectively, as well to prevent loss of motion that may be encountered if the needles  144  and  145  meet resistance and the build up of stress causes the needles  144  and  145  to undulate. The suture channel provides a smooth bore through which suture  105  can pass freely on its path through gasket member  51 , suture routing tube  47  and out of instrument  16  through the valve controller  19   b.  The shaft  147  may be made of stainless steel, or other rigid material, and has for example an outside diameter of 0.203 inches. (Note for other applications, such as flexible endoscopy, this tube could be flexible.) Inside shaft  147 , gasket member  51  has a ring  51   d,  which frictionally engages the interior surface of shaft  147 . Suture routing tube hole  51   a  of the gasket member  51  is of a diameter such that the suture routing tube  47  fits tightly therein and provides a seal around suture routing tube  47 . The suture routing tube  47  may be held in place in the suture routing tube hole  51   a  by friction alone, but an adhesive may also be used. Left needle hole  51   c  and right needle hole  51   b  are of a larger diameter than the left and right needles  144  and  145 , respectively, except for a small section of holes  51   c  and  51   b  where the diameter reduces to form flaps of gasket material which seal around the left and right needles  144  and  145 , respectively. This enables movement of the left and right needle  144  and  145 , respectively back and forth while maintaining a seal about the left needle  144  and right needle  145 . One feature of the gasket member  51  is that it enables sealing of the shaft  147  as well.  
         [0226]     The guide member  150  is received into the shaft  147  such that the guide member  150  abuts the gasket member  51  and engages a distal tip  152 . The distal tip  152  is fixedly attached into the distal opening  147   c  of the shaft  147  by a mechanical means such a metal deformation in which small dents  147   d  are formed and the metal displaced in the shaft  147  is forced into the four recessed pockets  152   b  ( FIG. 33 ), i.e., two on each side of the distal tip  152 .An optional valve assembly  19  can be provided at the bottom of the handle portion  143   a  of housing  143 , as shown in  FIG. 33 , having a valve seat  19   a  and a valve controller  19   b.  Valve seat  19   a  is composed of a medical grade rubber, such as Santoprene®, and has a through hole  76  extending into an interior chamber. A valve controller  19   b  composed of molded plastic, or other rigid material, has a circular section through an opening and a surface forming a cam that can be turned to select a valve fully open to intermediate partially open to a fully closed position. The suture routing tube  47  is received in hole  76  of valve seat  19   a,  as shown in  FIG. 33 , such that suture  105  material can pass through openings of the valve seat  19   a  and then through the valve controller  19   b.    
         [0227]     Referring to  FIGS. 32 and 33 , the tissue engaging end  16   a  of the suturing instrument  16  is shown having the distal tip  152  which is mounted in a shaft  147 , such that the front section  152   a  of the distal tip  152  extends from the shaft  147 . Where  FIG. 32A  is an enlarged partial side view of the distal tip  152  showing the front section  152   a,  the jaw opening  152   f,  and the ferrule latch pocket  152   g,  all of the distal tip  152 , along with a ferrule latch  153  showing the tissue engaging end  16   a  of instrument  16  as it is fixed to the shaft  147 .  
         [0228]     As shown in  FIGS. 34A and 34B , an actuating member  149  is pivotally mounted in holes  143   b  of housing  143  via two pins  149   b.  The actuating member can be constructed of a molded plastic. A pair of grooves  149   d  accepts and contain the non-tissue engaging ends  144   a  and  145   a  of the left needle  144  and right needle  145 , respectively, guiding the spherical members  148  into the channel  149   e  which accommodates a shuttle  151 . By maneuvering the shuttle  151  across the channel  149   e,  either the left needle  144  or right needle  145  can be selected to advance. For instance, if the shuttle  151  is positioned to the left side of the actuating member  149 , the left needle  144  will advance upon the retracting action of the actuating member  149 . The right needle  145  will remain stationary throughout the pivotal range of the actuating member  149  due to the clearance profile  149   f.  This embodiment includes a mechanism to prevent selection of the left needle  144  or right needle  145  during a sequence of operation that could damage the instrument. It is preferred to select the left needle  144  or right needle  145  only before actuating the lever  149   a.  The actuating member  149  has a left advancing track  149   g,  a right advancing track  149   h,  and a selection track  149   j  located along the surface of the clearance profile  149   f.  While a follower pin  146   c  of a selector mechanism  146  ( FIG. 35 ) engages in the left advancing track  149   g  of the actuating member  149 , the selector mechanism  146  cannot be manipulated until the actuating member  149  is returned to its full advanced state. At this point, and only this point, the follower pin  146   c  of the selector mechanism  146  can traverse the selection track  149   j  so that a shuttle  151  can be manipulated to capture a spherical member  148  of the left needle  144  or right needle  145  to allow advancement.  
         [0229]      FIG. 35  represents a selector mechanism  146  of  FIG. 33 . The arm  146   a  is attached through a post hole  146   c  to the post  154   c  of the adapter  154  ( FIG. 33 ) such that the selector mechanism  146  can only be manipulated in a back and forth motion. The arm  146   a  extends out of the selector slot  143   g  in the housing  143  to allow an operator to manipulate the selector mechanism  146  to select the left needle  144  or the right needle  145 . The selection of the left or right needle  144  or  145 , respectively, is accomplished by a shuttle actuator  146   b  incorporated into the arm  146   a  of the selector mechanism  146 . A shuttle groove  146   e  envelopes a tongue  151   a  protruding from a shuttle  151 . The movement of the selector mechanism  146  thus causes the shuttle  151  to the change position and shroud a spherical member  148  of either the left needle  144  or the right needle  145  to allow for either the left needle  144  or the right needle  145  to advance. A spherical member channel  146   g  of selector mechanism  146  provides clearance for the spherical members  148  so that the shuttle  151  can travel freely across the channel  149   e  of the actuating member  149  ( FIG. 33 ). A needle clearance  146   f  is provided to allow the left needle  144  or right needle  145  (whichever is not being advanced) to remain free of contact with moving components and subsequently remain stationary. A follower pin  146   d  of selector mechanism  146  is provided to engage in the left advancing track  149   g,  right advancing track  149   h,  and the selector track  149   j  to prevent selection operations at inappropriate stages of the instrument  16  cycle of operation. The selector mechanism  146  can be made of molded plastic or other rigid material  
         [0230]      FIG. 36  illustrates a shuttle  151  that, through a ball pocket  151   b,  encompasses a spherical member  148  to allow for either left needle  144  or right needle  145  advancement. The shuttle  151 , and its rail  151   c,  sits in a channel  149   e  of the actuating member  149  such that it allows free lateral movement while preventing component disassembly similar to a ball-and-socket joint.  
         [0231]      FIGS. 37A-38B  depict the instrument  16  in a partial right perspective view with the housing  143  removed. The illustrations clarify the deployment of the selector mechanism  146 , the actuation of the actuating member  149 , and the subsequent retraction of the left needle  144  and the right needle  145 .  
         [0232]      FIG. 37A  is a partial right perspective view of the instrument  16  with the housing  143  removed. The arm  146   a  of selector mechanism  146  is positioned over the left needle  144  thus locating the shuttle actuator  146   b  and shuttle  151  onto the left needle  144 . The actuating member  149  is fully advanced and both the left needle  144  and the right needle  145  are fully retracted.  
         [0233]      FIG. 37B  is a partial right perspective view of the instrument  16  with housing  143  removed. The arm  146   a  of selector mechanism  146  is positioned over the left needle  144 . The actuating member  149  is fully retracted as evidenced by the rearward motion of the lever  149   a  rotating about pins  149   b.  The shuttle  151  in channel  149   e  exits the shuttle actuator  146   b  and fully advances the left needle  144  while the non-tissue engaging end  145   a  of the right needle  145  is unobstructed by the needle clearance  146   f  of the shuttle actuator  146   b  of the selector mechanism  146  allowing the right needle  145  to remain fully retracted.  
         [0234]      FIG. 38A  is a partial right perspective view of the instrument  16  with the housing  143  removed and the actuating member  149  in its fully advanced position. The arm  146   a  of selector mechanism  146  is positioned over the right needle  145  thus locating the shuttle actuator  146   b  and shuttle  151  onto the right needle  145 . With the actuating member  149  fully advanced, both the left needle  144  and the right needle  145  are fully retracted.  
         [0235]      FIG. 38B  is a partial right perspective view of the instrument  16  with housing  143  removed. The arm  146   a  of selector mechanism  146  is positioned over the right needle  145 . The actuating member  149  is fully retracted as evidenced by the rearward motion of the lever  149   a  rotating about pins  149   b.  The shuttle  151  in channel  149   e  exits the shuttle actuator  146   b  and fully advances the right needle  145  while the non-tissue engaging end  144   a  of the left needle  144  is unobstructed by the needle clearance  146   f  of the shuttle actuator  146   b  of the selector mechanism  146  allowing the left needle  144  to remain fully retracted.  
         [0236]      FIGS. 39A-39F  detail one complete cycle of an actuation sequence of instrument  16 . The views depict the instrument  16  in a proximal partial right perspective view with the housing  143  removed. The views highlight the function of the selector mechanism  146  and its interface with an actuating member  149  as the actuating member  149  pivots through its range of motion about pins  149   b.    
         [0237]      FIG. 39A  shows the actuating member  149  fully advanced. The selector mechanism  146  is positioned over the left needle  144  where the shuttle actuator  146   b  maneuvers the shuttle  151  through the channel  149   e  of the actuating member  149  onto the left needle  144  and the follower pin  146   d  is engaged in the left advancing track  149   g  of the actuating member  149 .  
         [0238]      FIG. 39B  shows the selector mechanism  146  in position over the left needle  144  and the actuating member  149  fully retracted as evidenced by the rearward motion of the lever  149   a  about pins  149   b.  As the follower pin  146   d  travels in the left advancing track  149   g  of the actuating member  149 , the shuttle  151  exits the shuttle actuator  146   b  of the selector mechanism  146  and fully advances the left needle  144  while the right needle  145  remains fully retracted.  
         [0239]      FIG. 39C  shows the selector mechanism  146  in position over the left needle  144  and the actuating member  149  returned to its fully advanced state as indicated by the forward motion of the lever  149   a  about pins  149   b.  The follower pin  146   d  remains in the left advancing track  149   g  of the actuating member  149  while the shuttle  151  returns to the shuttle actuator  146   b  thus retracting the left needle  144 .  
         [0240]      FIG. 39D  shows the actuating member  149  fully advanced. The selector mechanism  146  is positioned over the right needle  145  where the shuttle actuator  146   b  maneuvers the shuttle  151  through the channel  149   e  of the actuating member  149  onto the right needle  145  and the follower pin  146   d  traverses the selection track  149   j  of the actuating member  149 . With the actuating member  149  in its fully advanced state, the selector mechanism  146  can only now be activated precluding the selection process during advancement of the left needle  144  or right needle  145  as selection of the left needle  144  or right needle  145  is only desired while both the left needle  144  or right needle  145  are fully retracted.  
         [0241]      FIG. 39E  shows the selector mechanism  146  in position over the right needle  145  and the actuating member  149  fully retracted as evidenced by the rearward motion of the lever  149   a  about pins  149   b.  As the follower pin  146   d  travels in the right advancing track  149   h  of the actuating member  149 , the shuttle  151  exits the shuttle actuator  146   b  of the selector mechanism  146  and fully advances the right needle  145  while the left needle  144  remains fully retracted.  
         [0242]      FIG. 39F  shows the selector mechanism  146  in position over the right needle  145  and the actuating member  149  returned to its fully advanced state as indicated by the forward motion of the lever  149   a  about pins  149   b.  The follower pin  146   d  remains in the right advancing track  149   h  of the actuating member  149  while the shuttle  151  returns to the shuttle actuator  146   b  thus retracting the right needle  145 .  
         [0243]      FIG. 40A  is a perspective view of the adapter  154  and spring arms  156 . The adapter  154  is fixedly attached to the housing  143  via two flanges  154   d  and coupled to the selector mechanism  146  by way of the post  154   c.  The mounting end  156   a  of spring arms  156  attach to the adapter  154  at the mounting holes  154   a.  The mounting holes  154   a  are of a diameter that allows a secure fit of the mounting ends  156   a  of the spring arms  156  such that the spring arms  156  cannot freely move. The followers  156   b  of the spring arms  156  then locate into the follower holes  154   b  of the adapter  154 . The follower holes  154   b  are of a diameter that is slightly larger than the followers  156   b  of the spring arms  156  to allow for free vertical movement of the followers  156   b.  This feature permits the spring arm  156  to engage the rotation cam  155  at all times under a light pressure. The adapter  154  can be manufactured via plastic injection molding and the spring arms  156  are comprised of rigidly formed stainless steel wire.  
         [0244]      FIG. 40B  is a proximal perspective view of the adapter  154  showing the rotation cam bores  154   f  through which the rotation cams  155  pass. It is through the rotation cam bores  154   f  that the rotation cams  155  are installed in order to engage the followers  156   b  of the spring arms  156 . Also visible from this vantage point is the suture routing tube passage  154   e  that allows for the routing of the suture routing tube  47  while maintaining its position safely away from the path of the rotation cams  155 .  
         [0245]      FIGS. 41A-41E  detail the operational aspects of the rotation cam  155  through a variety of views. The rotation cam  155  allows for the rotation of the left needle  144  or right needle  145  upon initiation of the actuating member  149 . The rotation cam  155  incorporates features that allow for straight advancing of the left needle  144  or right needle  145  while also allowing for the 90 degree rotation of each during retraction. Other aspects of the rotation cam  155  prevent undesired operation during the operation of suturing instrument  16  via various interlocks engaged by the follower  156   b  of the spring arm  156 . The rotation cam can be precision manufactured of stainless steel or other medical-grade rigid material via a machining process, metal injection molding process, or even a selective laser sintering process.  
         [0246]      FIG. 41A  is a side view of the rotation cam  155  showing an advancing track  155   b  and a rotation track  155   c.  Each advancing track  155   b  and rotation track  155   c  are represented every 90 degrees along the circumference of the rotation cam  155 . This permits the advancing and subsequent rotation upon retraction of the left needle  144  or right needle  145  when the actuating member  149  is employed. At the end of each advancing track  155   b  there is an advancing stop  155   d  which is, in essence, a fall-off for the follower  156   b  of spring arm  156  so that the follower  156   b  cannot travel backward in the advancing track  155   b.  The same fall-off feature, a rotation stop  155   e,  is incorporated at the end of the rotation track  155   c  so that once the follower  156   b  of the spring arm  156  falls off the rotation stop  155   e  end of the rotation track  155   c,  the follower  156   b  cannot travel in retrospect through the rotation track  155   c  of rotation cam  155 . This series of stops sanctions the continuous 360 degree rotation of the left needle  144  or right needle  145  in 90 degree increments in only direction.  
         [0247]      FIG. 41B  is a cross-sectional view of the rotation cam  155  of  FIG. 41A  showing the needle bore  155   a  through which the left needle  144  or right needle  145  can pass through and affix via a shrink fit process, welding, or by the use of adhesives. In this view, the four advancing tracks  155   b  are visible. Each advancing track  155   b  consists of an advancing ramp  155   f  that the follower  156   b  of spring arm  156  must follow, rising until it eventually falls off at the advancing stop  155   d.    
         [0248]      FIG. 41C  is a side view of a flat pattern of the rotation cam  155  cam profile. Note the orientation of the advancing tracks  155   b  and rotation tracks  155   c  every 90 degrees. Readily visible are the advancing stop  155   d  and the rotation stop  155   e.    
         [0249]      FIG. 41D  is a perspective view of the rotation cam  155  along with the needle bore  155   a.  The advancing track  155   b  and rotation track  155   c  are visible. Also evident is an advancing stop  155   d  created by the intersection of the advancing ramp  155   f  and rotation track  155   b  and a rotation stop  155   e  formed at the intersection of the rotation ramp  155   g  and the advancing track  155   b.    
         [0250]      FIG. 41E  is a cross-sectional view of the rotation cam  155  of  FIG. 41D  detailing the needle bore  155   a  through which the left needle  14  or right needle  145  can pass and be fastened unto and also showing the advancing track  155   b  along with its advancing ramp  155   f  and its consequent advancing stop  155   d.  The rotation stop  155   e  is shown intersecting with the advancing track  155   b  after falling off abruptly from the rotation ramp  155   g  ( FIG. 41D ).  
         [0251]      FIG. 42  is a perspective view of a typical left needle  144  showing the spherical member  148  attached to the non-tissue engaging end  144   a.  Note that the same features do apply to the right needle  145 .  
         [0252]      FIG. 42A  is a detail view of the tissue-engaging end  144   b  of the needle  144  of  FIG. 42  showing the engaging latch surface  144   d,  which when oriented towards the ferrule latch  153  extends down radially to push down upon the ferrule latch  153 , thereby moving the ferrule contact edge  153   f  out of the path of the ferrule  103 . It is this feature that allows the suture  105  and its attached ferrule  103  to be removed from its ferrule compartment  152   h  of the distal tip  152 . As the needle  144  advances into the ferrule  103  the ferrule latch  153  is engaged by one of the engaging latch surfaces  144   d,  thus the ferrule latch  153  will be forced down allowing withdrawal of the ferrule  103  and its attached suture  105 .  
         [0253]      FIG. 42B  is a detail view of the tissue-engaging end  144   b  of the needle  144  of  FIG. 42  showing the non-engaging latch surface  144   c.  It is this feature that allows the suture  105  and its attached ferrule  103  to be reset into its ferrule compartment  152   h  of the distal tip  152 . As the needle  144  returns the ferrule  103  to its compartment  152   h,  the ferrule latch  153  is not engaged because this surface is faceted or has a shorter radial length, thus the ferrule latch  153  will remain extended engaging and retaining the ferrule  103  with its ferrule contact edge  153   f  upon needle  144  retraction.  
         [0254]      FIGS. 43-47B  detail the sequence of operation induced by the actuation of the actuating member  149 , advancing and subsequent retraction of the left needle  144  (note that the same sequence applies to the right needle  145  which is not shown in this sequence to better illustrate the complete cycling of the left needle  144 ), and the function of the rotation cam  155 .  
         [0255]      FIG. 43  is a partial right perspective view of the instrument  16  with housing  143  removed showing a partial cross-section of the adapter  154 . The actuating member  149  is fully advanced and the ball pocket  151   b  of the shuttle  151  is retaining the spherical member  148  of the needle  144  in its fully retracted position. The rotation cam  155  is fully retracted, and the follower  156   b  of the spring arm  156  is engaged in the trough of the advancing track  155   b  of the rotation cam  155 .  
         [0256]      FIG. 43A  is an enlarged view of the adapter  154 , rotation cam  155 , and spring arm  156  of  FIG. 43 . Note that the follower  156   b  of the spring arm  156  is fully engaged in the advancing track  155   b  of the fully retracted rotation cam  155 .  
         [0257]      FIG. 43B  is an enlarged view of the tissue engaging end  144   b  of the needle  144  showing its orientation with respect to the sequence shown in  FIG. 43 . The engaging latch surfaces  144   d  are oriented vertically to engage the ferrule latch  153 .  
         [0258]      FIG. 44  is a partial right perspective view of the instrument  16  with housing  143  removed showing a partial cross-section of the adapter  154 . The actuating member  149  is partially retracted as evidenced by the rearward movement of the lever  149   a  pivoting about pins  149   b.  The spherical member  148  retained in the ball pocket  151   b  of the shuttle  151  is partially advanced thus partially advancing the left needle  144 . The rotation cam  155  begins it advance and the follower  156   b  of the spring arm  156  rises as it follows the advancing ramp  155   f  of the advancing track  155   b  of the rotation cam  155 .  
         [0259]      FIG. 44A  is an enlarged view of the adapter  154 , rotation cam  155 , and spring arm  156  of  FIG. 44 . Note that the follower  156   b  of the spring arm  156  is beginning to rise as it rides up the advancing ramp in the advancing track  155   b  of the partially advanced rotation cam  155 .  
         [0260]      FIG. 45  is a partial right perspective view of the instrument  16  with housing  143  removed showing a partial cross-section of the adapter  154 . The actuating member  149  is fully retracted as evidenced by the rearward movement of the lever  149   a  pivoting about pins  149   b.  The spherical member  148  retained in the ball pocket  151   b  of the shuttle  151  is fully advanced thus completely advancing the needle  144 . The rotation cam  155  is fully advanced and the follower  156   b  of the spring arm  156  falls off the advancing stop  155   d  at the end of the advancing ramp  155   f  and continues to the end of the advancing track  155   b  of the rotation cam  155 . FIG. 45A  is an enlarged view of the adapter  154 , rotation cam  155 , and spring arm  156  of  FIG. 45 . Note that the follower  156   b  of the spring arm  156  falls as it passes the advancing stop  155   d  precluding it from traversing back through the advancing track  155   b  of the fully advanced rotation cam  155 .  
         [0261]      FIG. 45B  is an enlarged view of the tissue engaging end  144   b  of the needle  144  showing its orientation with respect to the sequence shown in  FIG. 45 . The engaging latch surfaces  144   d  are oriented vertically to engage the ferrule latch  153 .  
         [0262]      FIG. 46  is a partial right perspective view of the instrument  16  with housing  143  removed showing a partial cross-section of the adapter  154 . The actuating member  149  is partially advanced as evidenced by the forward movement of the lever  149   a  pivoting about pins  149   b.  The spherical member  148  retained in the ball pocket  151   b  of the shuttle  151  begins retracting thus retracting the needle  144 . The rotation cam  155  begins its retraction and partial rotation as the follower  156   b  of the spring arm  156  travels through the rotation track  155   c  and rises as it progress up the rotation ramp  155   g  of the rotation cam  155 .  
         [0263]      FIG. 46A  is an enlarged view of the adapter  154 , rotation cam  155 , and spring arm  156  of  FIG. 46 . Note that the follower  156   b  of the spring arm  156  rises as it passes the advancing stop  155   d  (which is rotated out of view) into to the rotation track  155   c  and up the rotation ramp  155   g  of the partially retracted rotation cam  155 .  
         [0264]      FIG. 46B  is an enlarged view of the tissue engaging end  144   b  of the needle  144  showing its orientation with respect to the sequence shown in  FIG. 46 . The engaging latch surfaces  144   d  are rotated slightly, bringing the non-engaging latch surfaces  144   c  closer to vertical.  
         [0265]      FIG. 47  is a partial right perspective view of the instrument  16  with housing  143  removed showing a partial cross-section of the adapter  154 . The actuating member  149  is fully advanced as evidenced by the forward movement of the lever  149   a  pivoting about pins  149   b.  The spherical member  148  retained in the ball pocket  151   b  of the shuttle  151  is fully retracted thus completely retracting the needle  144 . The rotation cam  155  completes its retraction and full 90 degree rotation as the follower  156   b  of the spring arm  156  travels through the rotation track  155   c,  falls off the rotation stop  155   e  at the end of the rotation ramp  155   g  (which have rotated out of view) and continues into the next advancing track  155   b  of rotation cam  155 .  
         [0266]      FIG. 47A  is an enlarged view of the adapter  154 , rotation cam  155 , and spring arm  156  of  FIG. 47 . Note that the follower  156   b  of the spring arm  156  falls as it passes the rotation stop precluding it from traversing back into the rotation track  155   c  of the fully retracted rotation cam  155 .  
         [0267]      FIG. 47B  is an enlarged view of the tissue engaging end  144   b  of the needle  144  showing its orientation with respect to the sequence shown in  FIG. 47 . The needle  144  has completed its 90 degree rotation and the non-engaging latch surfaces  144   c  are oriented vertically so as to not engage the ferrule latch  153 .  
         [0268]      FIG. 48  is a partial perspective view of the underside of the distal end  16   a  of instrument  16 . The ferrule latch  153  is inserted into the latch pocket  152   g  of the distal tip  152 . The ferrule latch  153  can be retained via force fit, adhesive, or welding and can be made from medical grade stainless steel or materials with a high elasticity.  
         [0269]      FIG. 49A  is a perspective view of the ferrule latch  153  of  FIG. 48 . Detailed is the functioning of the ferrule latch  153  when engaged by the left needle  144 . The engaging latch surface  144   d  of the left needle  144  advances past a needle ramp  153   g  and onto the left needle relief  153   d  forcing the ferrule latch  153  on its rigid base  153   a  to flex at the upper spring section  153   b  pushing the ferrule contact edge down and consequently releasing the ferrule  103  from its ferrule compartment  152   h  in the distal tip  152 .  
         [0270]      FIG. 49B  is a perspective view of the ferrule latch  153  of  FIG. 48 . Detailed is the functioning of the ferrule latch  153  when engaged by the right needle  145 . The engaging latch surface  145   d  of the right needle  145  advances past a needle ramp  153   g  and onto the right needle relief  153   e  forcing the ferrule latch  153  on its rigid base  153   a  to flex at the lower spring section  153   c  pushing the ferrule contact edge down and consequently releasing the ferrule  103  from its ferrule compartment  152   h  in the distal tip  152 .  
         [0271]      FIG. 50A-50J  are perspective views of the underside of the distal end  16   a  of the instrument  16  exhibiting the sequence of events transpiring as the left needle  144  is actuated by the employment of the actuating member  149  as applied to the ferrule latch  153  and the ferrule  103  and its attached suture  105 . Note that in addition to the left needle  144 , the following operations can be utilized to describe the right needle  145 .  
         [0272]      FIG. 50A  represents the instrument  16  with the actuating member  149  fully advanced. Both the left needle  144  and right needle  145  are fully retracted inside the distal tip  152 . The ferrule latch  153  rests, fully extended, inside the latch pocket  152   g  of the distal tip  152 . Both ferrules  103  and attached sutures  105  are retained in their respective ferrule compartments  152   h  by the ferrule latch  153  and is best described by the actuating member  149  and rotation cam  155  operation illustrated in  FIG. 43  and  43 A.  
         [0273]      FIG. 50B  represents the instrument  16  with the actuating member  149  partially retracted. The left needle  144  begins to advance across the jaw  152   f  of the distal tip  152 . The ferrule latch  153  rests, fully extended, inside the latch pocket  152   g  of the distal tip  152 . Both ferrules  103  and attached sutures  105  are retained in their respective ferrule compartments  152   h  by the ferrule latch  153  and is best described by the actuating member  149  and rotation cam  155  operation illustrated in  FIG. 44  and  44 A.  
         [0274]      FIG. 50C  represents the instrument  16  with the actuating member  149  fully retracted. The left needle  144  has fully traversed the jaw  152   f  of the distal tip  152 . The engaging latch surface  144   d  (most visible in  FIG. 50B ) of the left needle  144  contacts the left needle relief  153   d  (most visible in  FIG. 50B ) of the ferrule latch  153  and in turn forces the upper spring section  153   b  of the ferrule latch  153  to flex downward and release the ferrule  103  from its ferrule compartment  152   h  and is best described by the actuating member  149  and rotation cam  155  operation illustrated in  FIG. 45  and  45 A.  FIG. 50D  represents the instrument  16  with the actuating member  149  partially advanced. The left needle  144  begins to retract back across the jaw  152   f  of the distal tip  152  and start its 90 degree rotation so as to return the ferrule  103  to its compartment  152   h  on the next actuating member  149  employment sequence. The ferrule latch  153  free of the engaging latch surface  144   d  of the left needle  144  fully extends inside the latch pocket  152   g  of the distal tip  152 . The left ferrule  103 , now affixed to the left needle  144  and free from its ferrule compartment  152   h  also traverses the jaw  152   f  of the distal tip  152  and is best described by the actuating member  149  and rotation cam  155  operation illustrated in  FIG. 46  and  46 A.  
         [0275]      FIG. 50E  represents the instrument  16  with the actuating member  149  fully advanced. The left needle  144  fully retracts across the jaw  152   f  and into the distal tip  152  and completes its 90 degree rotation to return the ferrule  103  to its compartment  152  on the next actuating member  149  employment sequence and is best described by the actuating member  149  and rotation cam  155  operation illustrated in  FIG. 47  and  47 A.  
         [0276]      FIG. 50F  represents the instrument  16  with the actuating member  149  partially retracted. The left needle  144  with the non-engaging latch surface  144   c  now vertical partially advances across the jaw  152   f  as to return the ferrule  103  to its compartment  152   h  and is best described by the actuating member  149  and rotation cam  155  operation illustrated in  FIG. 44  and  44 A.  
         [0277]      FIG. 50G  represents the instrument  16  with the actuating member  149  fully retracted. The left needle  144  is fully advanced across the jaw  152   f  returning the ferrule  103  to its compartment  152   h  with the non-engaging latch surface  144   c  now vertical, the left needle  144  does not engage the left needle relief  153   d  (best viewed in  FIG. 50H ), and consequently the ferrule latch  153  does not flex and remains in position to retain the ferrule  103  and is best described by the actuating member  149  and rotation cam  155  operation illustrated in  FIG. 45  and  45 A.  
         [0278]      FIG. 50H  represents the instrument  16  with the actuating member  149  partially advanced. The left needle  144  begins to retract back across the jaw  152   f  of the distal tip  152  and start another 90 degree rotation so as to remove the ferrule  103  from its compartment  152   h  on the next actuating member  149  employment sequence. The ferrule latch  153  free of the engaging latch surface  144   d  of the left needle  144  is fully extended and inside the latch pocket  152   g  of the distal tip  152  and retains the ferrules  103  and is best described by the actuating member  149  and rotation cam  155  operation illustrated in  FIG. 46  and  46 A.  
         [0279]      FIG. 50J  represents the instrument  16  with the actuating member  149  fully advanced. Both the left needle  144  and right needle  145  are fully retracted inside the distal tip  152 . The ferrule latch  153  rests, fully extended, inside the latch pocket  152   g  of the distal tip  152 . Both ferrules  103  and attached sutures  105  are retained in their respective ferrule compartments  152   h  by the ferrule latch  153  and is best described by the actuating member  149  and rotation cam  155  operation illustrated in  FIG. 47  and  47 A.  
         [0280]      FIG. 51A  depicts the first step in tying a novel knot with the instrument  16  of  FIG. 31 . This step is known as a “surgeon&#39;s” knot and is used for apposing the tissue  159 . The suture  105  having been passed through opposing tissue  159  is arranged such that the ferrule end  158   b  of the suture  105  is passed over the free end  158   a  of the suture  105 , then under the free end  158   a  of the suture  105 , then finally through the closed loop created by the free end  158   a  and ferrule end  158   b  of the suture  105 . This process is conducted a total of two times to produce two throws  158   c  of the ferrule end  158   b  of suture  105  around the free end  158   a  of the suture  105 .  
         [0281]      FIG. 51B  shows the correct procedure for sliding the two throws  158   c  produced in  FIG. 51A  towards the wound closure site of the tissue  159 . The instrument  16  of  FIG. 31  is maneuvered such that the ferrule end  158   b  of the suture  105  is pulled taut and straight while the free end  158   a  of the suture  105  forms the two throws  158   c  created in  FIG. 51A  and can be advanced towards the closure site of the tissue  159 .  
         [0282]      FIG. 51C  depicts the second step in tying the knot with the instrument  16  of  FIG. 31 . This step is referred to as an “end-point” knot and is used to stabilize the suture  105  and help to secure the surgeon&#39;s knot performed in  FIGS. 51A and 51B . The suture  105  is again arranged such that the ferrule end  158   b  of the suture  105  is passed over the free end  158   a  of the suture  105 , then under the free end  158   a  of the suture  105 , then finally through the closed loop created by the free end  158   a  and ferrule end  158   b  of the suture  105 . This process creates one throw  158   c  about the free end  158   a  of the suture  105 .  
         [0283]      FIG. 51D  shows the procedure for sliding the throw  158   c  produced in  FIG. 53C  towards the wound closure site of the tissue  159 . The instrument  16  of  FIG. 31  is maneuvered such that the ferrule end  158   b  of the suture  105  is pulled taut and the free end  158   a  of the suture  105  forms the throw  158   c  created in  FIG. 51C  and can be advanced towards the closure site of the tissue  159  onto the surgeon&#39;s knot created in  FIGS. 51A and 51B .  
         [0284]      FIG. 51E  depicts the third step in tying knot with the instrument  16  of  FIG. 31 . This step is referred to as “locking” and is used to secure the suture  105  and lock over the end-point knot performed in  FIGS. 51C and 51D . The suture  105  is again arranged such that the ferrule end  158   b  of the suture  105  is passed over the free end  158   a  of the suture  105 , then under the free end  158   a  of the suture  105 , then finally through the closed loop created by the free end  158   a  and ferrule end  158   b  of the suture  105 . This process creates one throw  158   c  about the free end  158   a  of the suture  105 .  
         [0285]      FIG. 51F  shows the procedure for advancing the throw  158   c  produced in  FIG. 51E  towards the wound closure site of the tissue  159 . At this point, the free end  158   a  of the suture  105  is pulled taut and the throw  158   c  created in  FIG. 51E  now formed from the ferrule end  158   b  of the suture  105  can be advanced towards the closure site of the tissue  159  and onto the end-point knot created in  FIGS. 51C and 51D . By producing the closed loop throw  158   c  in the ferrule end  158   b  of the suture  105  instead of the free end  158   a  of the suture  105  as shown in  FIGS. 51A and 51B , both the free end  158   a  of suture  105  and the ferrule end  158   b  of the suture  105  will have tight bends and will effectively lock the knot.  
         [0286]      FIG. 51G  depicts the fourth step in tying this knot with the instrument  16  of  FIG. 31 . This step is referred to as a “finishing” knot and is used to secure the suture  105  over the locking knot performed in  FIGS. 51E and 51F , providing sufficient holding forces to maintain the locking knot and conclude the knot tying process, but more throws  158   c  can be placed if desired by the operator. The suture  105  is again arranged such that the ferrule end  158   b  of the suture  105  is passed over the free end  158   a  of the suture  105 , then under the free end  158   a  of the suture  105 , then finally through the closed loop created by the free end  158   a  and ferrule end  158   b  of the suture  105 . This process creates one throw  158   c  about the free end  158   a  of the suture  105 .  
         [0287]      FIG. 51H  shows the procedure for sliding the throw  158   c  produced in  FIG. 51G  towards the wound closure site of the tissue  159 . The instrument  16  of  FIG. 31  is maneuvered such that the ferrule end  158   b  of the suture  105  is taut and the free end  158   a  of the suture  105  and the throw  158   c  created in  FIG. 51C  can be advanced towards the closure site of the tissue  159  and onto the locking knot created in  FIGS. 51E and 51F .  
         [0288]     The foregoing examples of specific compositions, processes, articles and/or apparatus employed in the practice of the present invention are, of course, intended to be illustrative rather than limiting, and it will be apparent the numerous variations and modification of these specific embodiments may be practiced within the scope of the appended claims.