Abstract:
An automatic suturing device including: a body for insertion into an opening in tissue; a plurality of hooks movably disposed in the body between retracted and extended positions; a suture holder having sutures disposed therein, the suture holder having a mechanism for engaging a portion of the hooks when in the retracted position and for attaching the sutures to a portion of the plurality of hooks; and an actuator for actuating the plurality of hooks from the retracted position to the extended position and for embedding the exposed plurality of hooks with the attached sutures into the tissue surrounding the opening.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
   This application is a Continuation-In-Part of U.S. application Ser. No. 10/261,429, filed Sep. 30, 2002, the entire contents of which is incorporated herein by reference. 

   BACKGROUND OF THE INVENTION 
   1. Field of the Invention 
   The present invention relates generally to a device for providing automatic-stitching of an incision, and more particularly, to a device for providing access to a hollow organ as well as automatic stitching on an incision in the hollow organ. 
   2. Prior Art 
   Surgery may be performed using open-chest techniques while the heart is under cardioplegic arrest and circulation is maintained by cardiopulmonary bypass. Using such techniques, a gross thoracotomy is created in order to gain access to the heart and great vessels, facilitating clamping and cannulation of the aorta for inducing cardioplegic arrest, and allowing instruments to be introduced into the chest cavity and into the heart to perform a surgical repair. The necessity of stopping the heart significantly heightens the risks attendant such procedures, particularly the risks of causing ischemic damage to the heart muscle, and of causing stroke or other injury due to circulatory emboli produced by aortic clamping and vascular cannulation. 
   A number of endovascular approaches for use in procedures in which the heart is arrested have been developed in the prior art. These approaches attempt to allow intracardiac access using catheters introduced transluminally from peripheral vessels into the heart. However, these devices suffer from many problems including a lack of control and precise positionability from the proximal ends of the highly flexible and elongated devices, the significant size constraints of peripheral vessels, and the inability to position the devices in all potentially diseased sites within the heart. 
   A number of minimally invasive or endoscopic access devices for use in beating heart procedures have also been developed in the prior art. These endoscopic devices are used to gain intracardiac access to the heart. Such devices are disclosed in U.S. Pat. Nos. 6,079,414 to Roth and 5,829,447 to Stevens et al., which are hereby incorporated by reference. However, such devices generally have a substantially long axial bore into which instruments are passed. The long length of the bore restricts the manipulative capability of the instruments passed through the bore into an interior of the heart. For example, a distal end of the instrument mainly moves in an axial direction and cannot stray very much from a central axis in the axial direction. Furthermore, the instruments must be very straight in order to traverse the long length of the bore, thus, curved instruments cannot be utilized with the endoscopic access devices of the prior art. Lastly, because such endoscopic access devices are directed to the heart wall under observation of a viewing device, they cannot be directly secured to the heart wall to maintain a tight seal against blood flow from the heart. 
   Furthermore, stitching of the incision made to provide access to hollow organs (as well as stitching of wounds and stitching to repair damaged portions of tissue) often require special skills on the part of the surgeon, are not uniform or reliable, and can be time consuming and therefore costly. 
   SUMMARY OF THE INVENTION 
   Therefore it is an object of the present invention to provide an access device that overcomes the disadvantages of the prior art. 
   Accordingly, an automatic suturing device is provided. The automatic suturing device comprising: a body for insertion into an opening in tissue; a plurality of hooks movably disposed in the body between retracted and extended positions; a suture holder having sutures disposed therein, the suture holder having means for engaging a portion of the hooks when in the retracted position and for attaching the sutures to a portion of the plurality of hooks; and actuation means for actuating the plurality of hooks from the retracted position to the extended position and for embedding the exposed plurality of hooks into the tissue surrounding the opening. 
   Preferably, the device further comprises means for providing access into a hollow organ through the opening. The means for providing access preferably comprises: the body having a bore for passage of at least a distal portion of an instrument into an interior of the hollow organ; and a valve disposed in the bore for allowing passage of the instrument and substantially preventing a fluid in the interior of the hollow organ from leaking outside the hollow organ. 
   The body preferably comprises first and second body portions movable relative to each other, wherein the actuation means comprises: rotatable actuation means for exposing the plurality of hooks upon rotation of one of the first and second body portions relative to the other of the first or second body portions; and translatable actuation means for embedding the exposed plurality of hooks into the wall upon translation of one of the first and second body portions relative to the other of the first or second body portions. In which case, the automatic suturing device preferably further comprises a fluid seal between the first and second body portions. 
   Preferably, the suture holder is separately formed from the body and inserted on a distal portion of the body. 
   In a first version, the means for engaging a portion of the hooks when in the retracted position and for attaching the sutures to a portion of the plurality of hooks comprises an adhering means for adhering the sutures to a portion of the plurality of hooks. Preferably, the adhering means comprises: the suture holder having a longitudinal channel for holding the sutures therein; and the suture holder having two or more collet assemblies each of which correspond to a frayed end of the sutures, each of the collet assemblies having a collapsible collet having a glue chamber containing a dose of glue disposed in an internal channel and means for collapsing the collapsible collet radially into the internal channel; wherein the at least a portion of the plurality of hooks and the frayed ends of the sutures are disposed in the interior channel and wherein each of the collapsible collets are collapsed to compress the frayed ends of the sutures and dose of glue against a portion of the hooks disposed in the interior channel to adhere the sutures to the hooks. 
   In a second version, the means for engaging a portion of the hooks when in the retracted position and for attaching the sutures to a portion of the plurality of hooks comprises a fastening means for mechanically fastening the sutures to a portion of the plurality of hooks. Preferably, the fastening means comprises: the suture holder having a longitudinal channel for holding the sutures therein; at least a portion of the plurality of hooks having one or more projections; and the suture holder having two or more collet assemblies each of which correspond to a frayed end of the sutures, each of the collet assemblies having a collapsible collet having an internal channel and means for collapsing the collapsible collet radially into the internal channel; wherein the at least a portion of the plurality of hooks and the frayed ends of the sutures are disposed in the interior channel and wherein each of the collapsible collets are collapsed to compress the projections against a corresponding hook to capture the frayed ends of the sutures against a portion of the hooks disposed in the interior channel to fasten the sutures to the hooks. 
   Also provided is an automatic suturing device comprising: an access device for providing access into a hollow organ during an open surgical procedure, the access device comprising: a body having a distal portion for insertion into an opening in a wall of the hollow organ, the body further having a bore for passage of at least a distal portion of an instrument into an interior of the hollow organ; a valve disposed in the bore for allowing passage of the instrument and substantially preventing a fluid in the interior of the hollow organ from leaking outside the hollow organ; a plurality of hooks movably disposed in the body between retracted and extended positions; and actuation means for actuating the plurality of pins from the retracted position to an extended position and for embedding the exposed plurality of hooks into the wall to secure the body to the wall; and the automatic suturing device further comprises a suture holder having an internal bore disposed on the distal portion of the body, the suture holder having sutures disposed therein and means for engaging a portion of the plurality of hooks when in the retracted position and for attaching the sutures to a portion of the plurality of hooks. 
   Preferably, the body comprises first and second body portions movable relative to each other and wherein the actuation means comprises: rotatable actuation means for exposing the plurality of hooks upon rotation of one of the first and second body portions relative to the other of the first or second body portions; and translatable actuation means for embedding the exposed plurality of hooks into the wall upon translation of one of the first and second body portions relative to the other of the first or second body portions. In which case, the automatic suturing device preferably further comprises a fluid seal between the first and second body portions. 
   Preferably, the body has a low-profile length in an axial direction of the bore to increase a manipulative capability of the instrument through the bore. Preferably, the length of the body in the axial direction of the bore is substantially within a range of 1.5 T to 5 T, where T is a thickness of the wall. 
   In a first version, the means for engaging a portion of the hooks when in the retracted position and for attaching the sutures to a portion of the plurality of hooks comprises an adhering means for adhering the sutures to a portion of the plurality of hooks. Preferably, the adhering means comprises: the suture holder having a first longitudinal channel for holding the sutures therein; the suture holder having a second longitudinal channel for holding a glue therein; and a linking channel for linking at least a portion of the first and second longitudinal channels and corresponding to at least a portion of the plurality of hooks when in the retracted position; wherein the at least a portion of the plurality of hooks are disposed in the linking channel and in communication with both the sutures and glue in the respective first and second longitudinal channels when in the retracted position to adhere at least a portion of a suture to at least a portion of each of the plurality of hooks. Preferably, the suture holder has an internal bore and the first and second longitudinal channels are disposed on an inner surface of the internal bore. Furthermore, the linking channel is preferably disposed on a distal surface of the suture holder. 
   In a second version, the means for engaging a portion of the hooks when in the retracted position and for attaching the sutures to a portion of the plurality of hooks comprises a fastening means for mechanically fastening the sutures to a portion of the plurality of hooks. Preferably, the fastening means comprises: the suture holder having a longitudinal channel for holding the sutures therein; at least a portion of the plurality of hooks having one or more projections; and the suture holder having two or more collet assemblies each of which correspond to a frayed end of the sutures, each of the collet assemblies having a collapsible collet having an internal channel and means for collapsing the collapsible collet radially into the internal channel; wherein the at least a portion of the plurality of hooks and the frayed ends of the sutures are disposed in the interior channel and wherein each of the collapsible collets are collapsed to compress the projections against a corresponding hook to capture the frayed ends of the sutures against a portion of the hooks disposed in the interior channel to fasten the sutures to the hooks. 
   Still provided is a method for automatically stitching an opening in tissue. The method comprising: inserting a portion of a device into the opening; extending a plurality of hooks from the device and through the tissue surrounding the opening; inserting at least a portion of each of the plurality of hooks back into the device; attaching the at least a portion of each of the plurality of hooks to a suture; withdrawing the plurality of hooks and attached suture from the tissue surrounding the opening and through the opening; severing the sutures from the at least portion of each of the plurality of hooks; and pulling the sutures to close the opening. The method preferably further comprises tying the sutures together after closing the opening. 
   The attaching preferably comprises adhering the at least a portion of each of the plurality of hooks to the sutures. Alternatively, the attaching comprises mechanically fastening the at least a portion of each of the plurality of hooks to the sutures. 
   Still yet provided is a method for providing access into an interior of a hollow organ for manipulation of an instrument therein. The method comprising: providing access to the hollow organ; making an opening in a wall of the hollow organ; inserting a body of an access device in the opening; securing the body to the wall; passing at least a distal portion of an instrument through a bore in the access device to an interior of the hollow organ; substantially preventing a fluid in the interior of the hollow organ from leaking outside the hollow organ; removing the access device from the opening; and automatically closing the hole in the wall of the internal organ upon removal of the access device from the opening. 
   Preferably, the automatically closing comprises: inserting a portion of the access device into the opening; extending a plurality of hooks from the access device and through the tissue surrounding the opening; inserting at least a portion of each of the plurality of hooks back into the access device; attaching the at least a portion of each of the plurality of hooks to a suture; withdrawing the plurality of hooks and attached suture from the tissue surrounding the opening and through the opening; severing the sutures from the at least portion of each of the plurality of hooks; and pulling the sutures to close the opening. Preferably, the method further comprises tying the sutures together after closing the opening. 

   
     BRIEF DESCRIPTION OF THE DRAWINGS 
     These and other features, aspects, and advantages of the apparatus and methods of the present invention will become better understood with regard to the following description, appended claims, and accompanying drawings where: 
       FIG. 1  illustrates an isometric view of a first preferred implementation of an intracardiac access device having an expandable balloon. 
       FIG. 2A  illustrates a sectional view of the intracardiac access device of  FIG. 1  as taken along line  2 - 2  therein in which the access device is inserted into an opening in a heart wall and the expandable balloon is in a relaxed state. 
       FIG. 2B  illustrates the sectional view of  FIG. 2A  in which the expandable balloon is in an expanded state. 
       FIG. 3A  illustrates the sectional view of  FIG. 2B  having a straight instrument passed therethrough. 
       FIG. 3B  illustrates the sectional view of  FIG. 2B  having a curved instrument passed therethrough. 
       FIG. 4  illustrates an isometric view of a second preferred implementation of an intracardiac access device having a plurality of hooks, the hooks being shown in an exposed position. 
       FIG. 5  illustrates a sectional view of the access device of  FIG. 4  as taken along line  5 - 5  in  FIG. 4 . 
       FIG. 6  illustrates an isometric view of the access device of  FIG. 6  with the plurality of hooks being rotated while in an extended position. 
       FIG. 7  illustrates a sectional view of the access device of  FIG. 4  with the plurality of hooks being in an extended position. 
       FIG. 8  illustrates an isometric view of the access device of  FIG. 7  with the plurality of hooks in the unexposed position. 
       FIG. 9  illustrates an isometric view of a spacer for use with the access device to lock the same with the hooks in the exposed position. 
       FIG. 10  illustrates a side view of a preferred implementation of one of the plurality of hooks for use with the access device of  FIG. 4 . 
       FIG. 11  illustrates a preferred implementation of a valve for use with the access device of  FIG. 4 . 
       FIG. 12  illustrates a perspective exploded view of the access device substantially similar to that of  FIG. 4  used together with a suture holder to provide an automatic stitching of an incision. 
       FIG. 13  is a sectional view of the exploded view of the access device and suture holder of  FIG. 12 . 
       FIG. 14  is a perspective view of the access device and suture holder of  FIG. 12  with the suture holder being loaded onto the access device. 
       FIG. 15  is a perspective view of the access device and suture holder of  FIG. 14  having a distal portion being inserted into an incision in tissue. 
       FIG. 16  is a sectional view of the access device and suture holder of  FIG. 15  with the hooks in an extended position. 
       FIG. 17  is a sectional view of the access device and suture holder of  FIG. 15  with the hooks retracted into the tissue surrounding the incision and with the sharp pointed ends of the hooks being engaged with the suture holder. 
       FIG. 18  is a sectional view of the access device and suture holder of  FIG. 15  with each of the hooks being in an extended position and having a suture retained thereon. 
       FIG. 19  is a perspective view from the distal end of the access device in which the upturned portions of the hooks having the thread retained thereon are entering their respective second longitudinal channels. 
       FIG. 20  is a perspective view of the access device and suture holder with the upturned portions of the hooks being entered into the second longitudinal channels. 
       FIG. 21  is a perspective view of the access device and suture holder being removed from the incision. 
       FIG. 22  is a sectional view of the access device and suture holder of  FIG. 21 . 
       FIG. 23  is a sectional view of the access device and suture holder after the suture holder is separated from the access device and the sutures are separated from the sharp pointed ends of the hooks. 
       FIG. 24  illustrates a top view of an alternative suture holder of the present invention. 
       FIG. 25  illustrates a sectional view of  FIG. 24  as taken along line  25 - 25  of  FIG. 24 , showing the collet assemblies in an open position. 
       FIG. 26  illustrates the sectional view of  FIG. 25  with the collet assemblies in a closed position. 
       FIGS. 27   a  and  27   b  illustrate alternative hooks for use with the alternative suture holder of  FIG. 24 . 
   

   DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
   Although this invention is applicable to numerous and various types of procedures and providing access to various hollow organs, it has been found particularly useful in the environment of providing intracardiac access in a beating heart open chest procedure. Therefore, without limiting the applicability of the invention to providing intracardiac access in a beating heart open chest procedure, the invention will be described in such environment. 
   Referring now to  FIGS. 1 ,  2 A, and  2 B there is shown a first preferred implementation of an intracardiac access device having an expandable balloon, the first preferred implementation of the access device being generally referred to by reference numeral  100 . The access device  100  provides access into a hollow organ  102 , such as the heart, during an open surgical procedure. The access device has a body  104  that is inserted into an opening or incision  106  in a wall  108  of the hollow organ  102 . The body  104  is preferably cylindrical in shape and is typically fabricated from a medical grade thermoplastic and can be fabricated from any methods known in the art, such as conventional machining or injection molding. The body  104  has a bore  110  sized to permit at least a distal portion of an instrument (not shown) to pass through the bore  110  and into an interior of the hollow organ  102 . The bore extends in an axial direction A from an exterior of the hollow organ  102  to an interior of the hollow organ  102 . 
   A valve  112  is disposed in the bore  110  of the body  104  for allowing passage of the instrument while substantially preventing a fluid in the interior of the hollow organ  102  from leaking outside the hollow organ  102  Preferably, the valve  112  is what is commonly referred to in the art as a duckbill valve. The duckbill valve  112  is fabricated from an elastomer, such as silicone, and has a cylindrical portion  116  and a tapered portion  118 . The tapered portion  118  terminates in a slit  120 . The slit  120  is normally closed to provide a seal and is configured to conform to a shape of an instrument passed through the slit  120  to provide a seal around the instrument. The duckbill valve  112  further has a stepped portion  122  that rests on a corresponding shoulder  124  of the body  104 . The duckbill valve  112  can be press fit into the body or retained therein by way of a medical grade adhesive. Alternatively, a flange (not shown) can be used to capture a portion of the duckbill valve  112 . Although, duckbill valves are preferred, other types of valves known in the art can be used without limiting the scope or spirit of the present invention, such as a flexible membrane (not shown) having a small expandable aperture. 
   The access device  100  also has securing means for securing the body  104  to the wall  108  of the hollow organ  102 . The securing means fixes the body  104  to the wall  108  such that it is not in danger of coming off or falling into the interior of the internal organ  102 . Preferably, the securing means also provides a seal between the opening  106  and the body  104  of the access device  100 . In a first preferred implementation, the securing means comprises a balloon configuration. In such a configuration, a lip  126 , which is preferably cylindrical, is disposed on a proximal portion  104   a  of the body  104 . The lip  126  is preferably integrally formed with the body  104 , but may also be formed separately and attached to the body  104  by any means known in the art, such as by ultrasonic welding, thermal welding, or with a medical grade adhesive. 
   A balloon  128  is disposed on a distal portion  104   b  of the body  104 . The balloon is shown in a deflated or relaxed position in  FIG. 2A . The relaxed position of the balloon  128  may be due to the lack of a fluid, such as saline or air, therein, or by applying a vacuum to the balloon. A conduit  130  is preferably formed in the body for supplying the fluid from a fluid source (not shown) or applying a vacuum from a vacuum source (not shown) to the balloon for expansion or contraction, respectively, thereof. A port  132  is preferably provided in fluid communication with the conduit  130  to facilitate connection of the fluid or vacuum source to the conduit  130 . Preferably, the fluid and vacuum source comprise a syringe (not shown) and the port  132  comprises a self-sealing needle port as is known in the art.  FIG. 2B  shows the balloon  128  in an expanded position in which the wall  108  of the hollow organ  102  is captured between the lip  126  and the balloon  128 . Although not shown, it is preferred that the wall  108  be compressed slightly upon the expansion of the balloon  128 . 
   Referring now to  FIGS. 3A and 3B , the body  104  has a low-profile length L in the axial direction A of the bore  110  to increase a manipulative capability of the instrument  134  through the bore  110 . Preferably, the length L of the body  104  in the axial direction A of the bore  110  is substantially within a range of 1.5 T to 5 T, where T is a thickness of the wall  108 . For example, the thickness for a typical heat wall varies between approximately 3-7 mm and the length L of the body  104  is in the range of 4.5 mm to 35 mm, most preferably about 10-15 mm. 
   As clearly seen in  FIG. 3A , the low-profile length L of the body  104  as compared to the thickness T of the wall  108  allows an instrument  134  to be manipulated at a greater angle α with respect to a central axis of the bore than the endoscopic access devices of the prior art. Furthermore, as clearly shown in  FIG. 3B , the low-profile length L of the body  104  as compared to the thickness T of the wall  108  allows insertion of a curved instrument having a radius R, which is not possible with the endoscopic access devices of the prior art. 
   Referring now to  FIGS. 4 and 5 , there is illustrated a second preferred implementation of an access device of the present invention, the second preferred access device being generally referred to by reference numeral  200 . Access device  200  also preferably has a low-profile shape as discussed above with regard to the first preferred implementation and has the same advantages as discussed above with regard to  FIGS. 3A and 3B . Access device  200  includes a body  202  having first and second body portions  204 ,  206 , respectively. The first and second body portions  204 ,  206  are fabricated from any medical grade material, such as stainless steel or a polymer. The first body portion  204  includes a flange  208  and a cylinder portion  210 . The first body portion  204  further has a bore  212  that accommodates a valve  214 . Referring now to  FIG. 11 , the valve  214  is preferably a duckbill or slit valve fabricated from a medically approved elastomer, such as silicone. The valve  214  has a flange  216  which fits within a corresponding stepped groove  218  in the bore  212  of the first body portion  204 . The valve  214  also has a cylindrical body portion  220  that fits within the bore  212  of the first body portion  204 . The valve  214  has a slit  222  on a conical nose  224  thereof to sealingly accommodate an instrument inserted through the access device  200 . The valve  214  is retained in the bore  212  by any means known in the art such as by adhesive or press-fit. The valve  214 , although shown disposed in the first body portion  204  may also be disposed in the second body portion  206  and although shown and described as a discrete part may be integrally formed with either of the first and second body portions  204 ,  206 . 
   Referring back to  FIGS. 4 and 5 , the second body portion  206  has a bore  226 , at least a portion of which accommodates the cylinder portion  210  of the first body portion  204  such that it is free to both rotate and translate within the bore  226  of the second body portion  206 . The second body portion  206  further has at least one shoulder or flange  228  on an exterior surface thereof. A seal, such as an o-ring  230  is provided to seal a fluid path between the first and second body portions  204 ,  206 . The second body portion  206  further has a plurality of first longitudinal channels  232  corresponding to each of a plurality of hooks  234  disposed circumferentially about the second body portion  206 . Each of the plurality of hooks  234  have at least a portion thereof which is slidingly disposed in a corresponding first longitudinal channel  232 . The second body portion also includes a plurality of second longitudinal channels  236  for housing an upturned portion  238  of the hooks  234  when the hooks  234  are in an unexposed position. 
   Referring now to  FIG. 10 , one of the plurality of hooks  234  is shown therein. The hooks  234  are fabricated from a medically approved metallic material, such as stainless steel and have a sharp pointed end  240  at the end of the upturned portion  238 . At a proximal end of the hook is a tuned-in portion  242  that engages with and is retained in portions of the first body portion  204 , such as in corresponding circumferential slots  244  in the bore  212  of the cylinder portion  210 . At the distal end of the hooks  234  is the upturned portion  238 . A straight portion  246  connects the in-turned  242  and upturned  238  portions with a curved portion  248  at a transition between the straight portion  246  and the upturned portion  238 . At least a portion of the straight portion  246  is slidingly disposed in a corresponding first longitudinal channel  232 . 
   Referring now to  FIGS. 5-8 , an operation of the access device  200  of the second preferred implementation will be described. The access device  200  is securely positioned in an incision  106  in a wall  108  of a hollow organ  102 , such as the heart. The incision is made by any methods known in the art and may be a slit or a punched hole after access is provided to the hollow organ, such as by a gross thoracotomy. The wall  108  is shown in  FIG. 5 , but omitted from  FIGS. 6-8  for the sake of clarity. Referring first to  FIG. 8 , the upturned portions  238  of the hooks  234  are disposed in corresponding second longitudinal channels  236  such that the sharp pointed ends  240  are unexposed. The access device is inserted into the incision  106  while the hooks  234  are in the unexposed position as shown in  FIG. 8 . While the upturned portions  238  are shown as being disposed in the second longitudinal channels  236  in the unexposed position, they can alternatively be disposed in corresponding cut-outs (not shown) on the exterior of the second body portion  206 . 
   Referring next to  FIG. 6 , the first body portion  204  is translated relative to the second body portion  206  in the direction of arrow A to extend the upturned portions  238  from the second longitudinal channels  236 . Referring now to  FIG. 7 , the first body portion  204  is then rotated in the direction of arrow B about a central axis C to turn the upturned portions  238  90 degrees and expose the sharp pointed ends  240 . When the first body portion  204  is rotated, the hooks  234  are rotated by an interference with the in-turned portions  242  of the hooks  234  and a wall of the corresponding slots  244 . Once the hooks  234  are both extended and exposed as shown in  FIG. 6 , the first body portion  204  is translated in the direction of arrow D (opposite to the direction of arrow A) to embed the upturned portions  238  into the wall  108  of the hollow organ  102  circumferentially about the incision  106 , as shown in  FIG. 5 . The access device  200  is then secured to the wall  108  by sandwiching the wall  302  between the step or flange  228  and the curved portions  248  of the hooks  234 . Referring now to  FIGS. 5 and 9 , while the hooks  234  are embedded into the wall  108 , a locking clip  250  is disposed in a gap  252  between the flange  208  of the first body portion  204  and the second body portion  206  to prevent any translation of the first body portion  204  in the direction of arrow A. The thickness t of the locking clip  250  substantially conforms to a thickness t of the clip. The locking clip  250  is preferably fabricated from a medically approved polymer and has fingers  254  which elastically deform to fit within the gap  252 . The locking clip  250  further has a pull  256  for facilitating handling and inserting and removing the locking clip  250  into and from the gap  252 . Locking clip  250  may have a tether attached to it on one end and to a point outside the operative field on another end to prevent locking clip  250  from inadvertently being left within the patient when the procedure is complete. Alternatively, the locking clip  250  may be tethered to the access device  200  itself. While the access device  200  is secured and locked to the wall  108 , surgical instruments (not shown) are inserted through the valve such that the working ends thereof are inserted into an interior of the hollow organ for performing a necessary surgical procedure. 
   After completion of the surgical procedure, the access device  200  is removed and the incision  106  is closed. To remove the access device  200  from the incision  106 , the clip  250  is removed and the first body portion  204  is translated in the direction of arrow A to dislodge the upturned portions  238  of the hooks  234  from the wall  108 . The first body portion  204  is then rotated in a direction opposite to that of arrow B about the central axis C to rotate the hooks 90 degrees such that the sharp pointed ends  240  are aligned with the second longitudinal channels  236 . The first body portion  204  is then translated in the direction of arrow D to return the up-turned portions  238  of the hooks  234  to the unexposed positions in the second longitudinal channels  236 . The access device  200  is then removed from the incision  106  and the incision  106  is closed by any means known in the art, such as with sutures or surgical glue. 
   Referring now to  FIGS. 12 and 13  there is illustrated an automatic stitching device, referred to generally by reference numeral  300 . Preferably, the automatic stitching device  300  comprises the access device  200  substantially similar to that described above used in combination with a suture holder  302  to provide an automatic stitching capability to the access device  200  for automatically stitching the incision  106  of the hollow organ  102  after completion of a surgical procedure. Although the automatic stitching device  300  is described in combination with the access device  200 , those skilled in the art will appreciate that the same can be used without the features of the access device  200  that facilitate use therewith with surgical instruments. For example, the access device  200  can be configured without the bores  212 ,  226 , and/or valve  214 . Furthermore, although described as a separate piece, those skilled in the art will appreciate that the suture holder  302  may be integrally formed with the access device  200 . Additionally, the incision  106  is described by way of example only as being in the wall  108  of a hollow organ  102  as described above. Those skilled in the art will appreciate that the automatic stitching device can be used to automatically stitch any incision, wound, or damaged tissue, and can also be used to join two tissues together such as an anastomodic device or in a valve repair or replacement. Lastly, the access device  200  is described as having a cylindrical distal portion  304  for insertion into the incision  106 , however, those skilled in the art will further appreciate that the distal portion  304  can be provided in many different shapes for use with different shaped incisions. For example, the distal portion  304  may by oval shaped for use with a linear incision. 
   The suture holder  302  is preferably disk-shaped and has a bore  306  for acceptance of the distal portion  304  of the access device  200 . The suture holder  302  has a thickness T smaller than the length L 1  of the distal portion  304  of the access device such that when the suture holder  302  is inserted onto the distal portion  304  of the access device (as shown in  FIG. 14 ), a portion L 2  of the distal portion  304  protrudes from the suture holder  302 . The suture holder  302  has two internal grooves  308 ,  310  about a periphery of the bore  306 . A proximal one of the internal grooves  310  holds sutures (one each for each of the hooks  234 ). A distal one of the internal grooves  308  holds a glue for, as will be described below, gluing an end of the suture onto each of the sharp pointed ends  240  of the hooks  234 . The glue is preferably a two-part medically approved pressure sensitive high viscosity epoxy wherein each of the two parts are separated in the groove by a membrane. Examples of glues for use with the suture holder  302  are a medical cyanoacrylate glue or Vitralit medical grade adhesive. Alternatively, two grooves can be provided to hold the glue, one for each of the two parts of the epoxy. The suture holder  302  also has a linking groove  312  on a distal surface  314  of the suture holder  302  for accepting the upturned portions  238  of the hooks  234  and for linking the two internal groves  208 ,  210 . Alternatively, the linking groove  312  can be individual holes corresponding to each of the upturned portions  238  of the hooks  234 . The suture holder is preferably a disposable device where the glue and sutures are loaded into their respective internal grooves  210 ,  208  and once used, it is discarded. However, those skilled in the art will appreciate that it can also be reusable where the glue and sutures are loaded into their respective internal grooves  210 ,  208  prior to each procedure. 
   Referring now to  FIGS. 14-23 , the operation of the automatic stitching device  300  will be described. As discussed above, the operation of the automatic stitching device  300  will be described with regard to the access device  200  described above. Referring specifically to  FIG. 14 , the access device is operated to have the upturned portions  238  of the hooks  234  inserted into their corresponding second longitudinal channels  236 , as described above, by rotating the first body portion  204  relative to the second body portion  206  and translating the first body portion  204  relative to the second body portion  206  in the direction of arrow D. The distal portion  304  of the access device  200  is then inserted into the bore  306  of the suture holder  302  such that a portion  316  protrudes therefrom a distance L 2 . Referring now to  FIG. 15 , portion  316  is inserted into the incision  106 . 
   Referring now to  FIG. 16 , the hooks are then extended, as described above, by translating the first body portion  204  relative to the second body portion  206  in the direction of arrow A. The hooks  234  are further rotated  90  degrees, as described above, by rotating the first body portion  204  relative to the second body portion  206  in the direction of arrow B. As shown in  FIG. 17 , the hooks  234  are then retracted, as described above, to embed the upturned portions  238  of the hooks  234  in the tissue wall  108  to secure the access device  200  to the tissue wall  108 . The access device  200  can then be used, if necessary, in combination with the locking clip  250  to perform a surgical procedure, as described above, by inserting an manipulating surgical instruments through the valve  214  and bores  212 ,  226 . 
   When the hooks  234  are retracted, each of the sharp pointed ends  240  further enter the linking channel  312  to engage a portion of a suture  318  and glue  320  disposed in the internal grooves  308 ,  310 . If necessary, the sharp pointed ends  240  further puncture the membrane separating the two parts of the epoxy. Thus, while a procedure is being performed, the sutures in one of the internal channels  310  are adhered to each of the sharp pointed ends  240  of the hooks  234 . Preferably, a locating means, such as a key (not shown) in the bore  306  and a corresponding keyway (not shown) is provided to orient the suture holder  302  in a predetermined position with respect to the sharp pointed ends  240  of the hooks  234  such that an end of a suture can be located in the linking channel  312  at the location of the sharp pointed ends  240 . In this way, the sharp pointed ends  240  would pierce the membrane between parts of the epoxy glue  320  and then contact the suture  318  end to adhere the same to the sharp pointed ends  240  of the hooks  234 . Although, the suture holder  302  described above is preferred, those skilled in the art will appreciate that such is given by way of example only and not to limit the scope or spirit of the present invention. Many configurations of the suture holder are possible, such as a disk having sutures with looped ends, where the looped ends correspond to each of a hole or linking channel. In such a configuration, each of the upturned portions  238  of the hooks  234  would have a downwardly facing slit. In operation, on the upstroke through the linking channel, the hooks  234  would displace the loop ends from the hole and pass through the hole, however, on the down stroke, the loop end would be captured in the slit and be retained therein. 
   Referring now to  FIG. 18 , after the procedure has been completed and/or after the sutures  318  have been retained on each of the hooks  234 , the hooks  234  are again extended, as discussed above. As shown in  FIG. 18 , as the hooks  234  are extended, they withdrawn the suture  318  from the longitudinal channel  310  and pull the sutures  318  through the tissue wall  108  in an area surrounding the incision  106 . As shown in  FIG. 19 , the hooks  234  are rotated 90 degrees, as discussed above, to correspond with their respective second longitudinal channels  236 . As shown in  FIG. 20 , the upturned portions  238  of the hooks  234  are then retracted into the second longitudinal channels  236  along with a corresponding portion of suture  318 . It is preferred that the suture  318  be tightly retained in the second longitudinal channels  236 , and as such, the second longitudinal channels  236  are sized closely to that of the upturned portions  238 . 
   Referring now to  FIGS. 21 and 22 , the automatic stitching device  300  is then removed from the incision  106  which in turn continues to withdraw suture  318  from the longitudinal channel  310  and the suture holder  302  is removed from the distal portion  304  of the access device  200 . As shown in  FIG. 23 , the sutures  318  are then cut free of the suture holder  302  and/or the access device. At this point, the sutures  318  are looped through the tissue wall  108  surrounding the incision  106  and can be pulled tightly to close the incision  106  and tied. Furthermore, the sutures can alternatively be anchored in the device such that the removal of the device itself pulls the sutures and closes the incision. 
   Those skilled in the art will appreciate that the preferred implementation of the automatic stitching device  300  described above simplifies the stitching of incisions (or wounds or damaged portions of tissue) and results in a reliable, and uniform stitch that is quickly made and does not require special skills on the part of the surgeon. Furthermore, when used in combination with the access device  200 , it provides a single device that provides access, secures to an area surrounding an incision in the tissue, and automatically closes and stitches the incision upon withdrawal of the device. As discussed above, the automatic stitching device  300  can also be used to create an anastomosis between vessels or to repair a damaged heart valve. 
   Referring now to  FIGS. 24-26  there is illustrated an alternative embodiment of the suture holder of the present invention, the alternative suture holder being referred to by reference numeral  400 . Although shown separately for the sake of clarity, the alternative suture holder  400  is intended to be used with the access device  200  substantially as shown and described above with regard to suture holder  302 . That is, the distal portion  304  of the access device  300  is disposed in a bore  402  of the alternative suture holder  400  similarly to that described above with regard to suture holder  302 . As also discussed above, the access device  300  and suture holder  400  may be integrally formed. The alternative suture holder has a channel  404  for holding one or more sutures  406 . The sutures  406  preferably have frayed ends  408  corresponding to the hooks  234  of the access device  300 . As discussed above, the alternative suture holder  400  and the access device  300  have locating means, such as a key and corresponding keyway (not shown) for locating the frayed ends  408  of the sutures  406  disposed in the suture holder  400  with the hooks  234  of the access device  300 . 
   The alternative suture holder  400  has a main body portion  410  and an annular ring  412  rotatably disposed in a groove  414  in the main body  410 . Preferably the main body  410  has upper and lower halves  410   a,    410   b,  which when assembled, define the groove  414  and allow easy assembly of the ring  412  to the main body  410 . The annular ring  412  has a ring gear  416  on an inner surface of the annular ring  412 . 
   The alternative suture holder  400  has a plurality of collet assemblies  418  disposed in a circular pattern about the bore  402 . Although four such collet assemblies  418  are shown in  FIG. 24 , two or more are necessary to perform the auto-stitching of tissue as described above. Each of the collet assemblies  418  includes an inner collet  420  having three or more slits  422  and an internal channel  423  in which is disposed the frayed ends  408  of the sutures  406 . A lower portion of the inner collets  420  has a tapered surface  424 . The collet assemblies  418  further have an idler  426  having a geared surface  428  meshingly mating with the inner-geared surface of the ring gear  416  and an inner threaded surface  430 . A sliding nut  432  is disposed in each of the collet assemblies  418  and having an inner bore disposed over the tapered surface  424 . The sliding nut  432  has an outer threaded surface  434  in mating relationship with the inner threaded surface  430  of the idler  426 . Finally, each collet assembly  418  has a glue chamber  436  disposed in the internal channel  423 . The glue chambers  436  each have a dose of glue, as described above, disposed within a cavity in the chamber  436 . 
   Similarly to that described above with regard to the access device  300  and suture holder  302 , the access device  300  is disposed in the bore  402  of the alternative suture holder  400  and the distal portion  304  of the access device  300  is inserted into an incision or other opening in tissue to be sutured. The hooks  234  are deployed from the access device  300 , pierce the tissue, and are accommodated in the internal channels  423 . As discussed above, the locating means (not shown) preferably locates each of the hooks  234  to correspond with one of the collet assemblies  418 , although more hooks  234  can be provided which do not correspond to collet assemblies  418  or additional collet assemblies  418  can be provided for each of the additional hooks  234 . 
   As the hooks  234  penetrate the internal channels  423  of the collet assemblies  418 , the sharp pointed ends  240  of the hooks pierce the glue chambers  436  to coat the sharp pointed ends  240  of the hooks  234  with a dose of glue. At this point, the inner bore of the sliding nuts  432  are engaged with a lowered end of the tapered surface  424  of the inner collets  420  as is shown in  FIG. 25 . The annular ring  412  is then rotated which in turn rotates the idlers  426  meshingly mated thereto by way of the ring gear  416  and geared surface  428 . As the idlers  426  rotate, the sliding nuts  432  move upward such that their inner bores further engage and push a corresponding tapered surface  424  due to the engagement of the inner threaded surface  430  of the idler and the outer threaded surface  434  of the sliding nuts  432 . As the inner bores of the sliding nuts  432  engage the tapered surface  424  the inner collets  420  close about the slits  422  to compress the frayed ends  408  of the sutures  406  against the sharp pointed ends  240  of the hooks  234  and the glue disposed thereon as shown in  FIG. 26 . After the glue has dried, thus adhering the sutures  406  to the hooks  234 , the access device is removed and the tissue opening is sutured as described above. 
   Alternatively, the frayed ends  408  of the sutures  406  can be pre-coated with pressure sensitive glue, eliminating the need for a glue chamber  436 . In such an alternative configuration, the radial pressure from the collet assemblies  418  will serve to attach the suture  406  to the hook  234 . 
   Referring now to  FIGS. 27   a  and  27   b,  there are shown alternative hooks, referred to generally by reference numerals  500  and  550 , respectively. The alternative hooks  500 ,  550  are similarly configured to the hooks described above with the exception of the sharp pointed ends  502 ,  552  which are illustrated in  FIGS. 27   a  and  27   b,  respectively. The sharp pointed ends  502 ,  552  include means for mechanically capturing and swaging the suture  406  to the hook  500 ,  550 . The alternative hooks  500 ,  550  can be used together with the alternative suture holder  400  to swage the frayed ends  408  of the suture  406  to the sharp pointed ends  502 ,  552  of the hooks  500 ,  550 . 
   The alternative hooks  500 ,  550  replace the hooks  234  in the access device  300  and are used as described above to pierce the tissue surrounding a tissue opening and which are accommodated in the internal channels  423  of the collet assemblies  418 . However, as the annular ring  412  is rotated, the collet assemblies  418  act to mechanically compress the sharp pointed ends  502 ,  552  of the hooks  500 ,  550  to thereby capture the frayed ends  408  of the suture  406 . In the first alternative configuration, shown in  FIG. 27   a,  the sharp pointed end  502  includes at least one projection  504  forming an opening  506 . As the collet assemblies  418  compress the projection, the suture  406  or frayed ends  408  thereof, are captured between the projections  504  and the sharp pointed ends  502  of the hook  500  in the opening  506 , thereby swaging the suture  406  to the hook  500  to provide a mechanical bond between the sutures  406  and hook  500 . In the second alternative configuration, shown in  FIG. 27   b,  an opening  554  is formed in the sharp pointed end  552 , preferably in the shape of a diamond. As the collet assemblies  418  compress the diamond shaped sharp pointed end  552 , the suture  406  or frayed ends  408  thereof, are captured in the opening  554 , thereby swaging the suture  406  to the hook  550  to provide a mechanical bond between the sutures  406  and hook  550 . 
   The glue chamber  436  may also be used with the alternative hooks  500 ,  550  to both glue and swage the frayed ends  408  of the sutures  406  to the sharp pointed ends  502 ,  552  of the hooks  500 ,  550 . 
   While there has been shown and described what is considered to be preferred embodiments of the invention, it will, of course, be understood that various modifications and changes in form or detail could readily be made without departing from the spirit of the invention. It is therefore intended that the invention be not limited to the exact forms described and illustrated, but should be constructed to cover all modifications that may fall within the scope of the appended claims.