Abstract:
A method for suturing a perforation formed in a hollow organ comprises the steps of:
       causing plural end portions of the suture thread to puncture a tissue around the perforation in the same direction as each other;   connecting the end portions of the suture thread to each other; and   tightening up the suture thread after connecting the end portions of the suture thread with each other.

Description:
BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     This invention relates to a suturing method using an endoscope and a suture instrument used for suturing. For example, this invention relates to a method for suturing a perforation formed in a wall of a hollow organ and a suture instrument used therefore. 
     2. Description of Related Art 
     In the case of performing treatment in a body of a patient, the treatment can be performed by incising the body of the patient by surgical operation, or by oral endoscopic treatment or transanal endoscopic treatment. In the case of using an endoscope, the treatment can be performed by passing through a channel of the endoscope a forceps, high-frequency treatment instrument, incision instrument, suture instrument, or the like. In the case of using an endoscope inserted in the lumen from natural opening of a living body such as, for example, the mouth or anus to perform a medical treatment in the abdominal cavity, tissue is removed from the abdominal cavity or incised to form a hole, and then the medical treatment is carried out by approaching the abdominal cavity from the lumen through this hole. After the end of the medical treatment, the formed hole is sutured by using a suture instrument. 
     As a method for suturing a perforation formed in a hollow organ, a suturing method is disclosed in FIGS. 12 to 15 of U.S. Pat. No. 6,290,674. In this suturing method, a catheter for closing the interatrial septum is used. At the tip of the catheter, an anchor supporting member containing an anchor is provided. The anchor supporting member projects through a perforation from the inside to the outside of the tissue. From the anchor supporting member, two anchors are respectively made to perforate the tissue from the outside to the inside thereof. After that, the anchor supporting member is drawn out from the perforation. Since a suture thread is fixed to the anchor, the suture thread penetrates the tissue from the inside to the outside thereof. The suture thread is drawn from the outside into the inside of the tissue through the perforation. When the suture thread is tightened up, the tissue around the perforation is pulled together, and thereby the perforation is closed. 
     SUMMARY OF THE INVENTION 
     A method for suturing a perforation of the present invention comprises the steps of: 
     causing plural end portions of the suture thread to puncture a tissue around the perforation in the same direction as each other; 
     connecting the end portions of the suture thread to each other; and 
     tightening up the suture thread after connecting the end portions of the suture thread with each other. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a view showing a schematic constitution of an endoscope and a suture unit. 
         FIG. 2  is a cross-sectional view of a suture unit and an end portion of an endoscope. 
         FIG. 3  is a perspective view of a suture unit and an end portion of an endoscope. 
         FIG. 4  is a view showing a constitution of a suture instrument. 
         FIG. 5  is a view showing a step of inserting an endoscope into the stomach of a patient to observe a proposed incision position from the inside of the stomach. 
         FIG. 6  is a view showing a step of inserting an endoscope insertion part from a perforation into the abdominal cavity to carry out treatment. 
         FIG. 7  is a view showing a step of thrusting a needle to extrude an anchor into an abdominal cavity side. 
         FIG. 8  is a view indicating the state as viewed from an abdominal cavity side, in which an anchor is placed. 
         FIG. 9  is a view in which anchors are made to attach to each other. 
         FIG. 10  is a view in which a suture thread of a suture instrument is gripped by a forceps. 
         FIG. 11  is a view in which a suture instrument is tightened up by an outer sheath of a forceps. 
         FIG. 12  is a view showing a suture instrument placed inside of the body. 
         FIG. 13  is a view indicating the suture instrument of  FIG. 12  as viewed from an abdominal cavity side. 
         FIG. 14  is a view in which anchors are serially engaged. 
         FIG. 15  is a view showing another embodiment of a suture instrument. 
         FIG. 16  is a view showing another embodiment of a suture instrument. 
         FIG. 17  is a view showing another embodiment of a suture instrument. 
         FIG. 18  is a view showing another embodiment of a suture instrument. 
         FIG. 19  is a view showing a step of thrusting a needle to extrude an anchor into an abdominal cavity side. 
         FIG. 20  is a view showing a step of engaging anchors with each other. 
         FIG. 21  is a view in which anchors are engaged with each other. 
         FIG. 22  is a view showing another embodiment of a suture instrument. 
         FIG. 23  is a view in which anchors are engaged with each other. 
         FIG. 24  is a view in which two suture units are passed through an endoscope. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     (First Embodiment) 
     In  FIG. 1 , an endoscope and a suture unit used in this embodiment are shown. An endoscope  1  (flexible endoscope) has an endoscope operation unit  2  which is operated by an operator. The endoscope operation unit  2  is connected to a control device via a universal cable  3  and equipped with various switches  4  and angle knobs  5 . At the tip of the endoscope operation unit  2 , an endoscope insertion part  6  that is flexible and long is extendedly formed. At the tip of the endoscope insertion part  6 , an observation device  7  for obtaining an image of the internal body, a lighting unit  8 , and a tip opening of a channel  9  are provided. As the observation device  7 , an imaging device having a CCD (Charge Coupled Device) or an optical fiber can be used. The lighting unit  8  has an optical fiber that conducts light from a light source. The channel  9  opens at a lateral part  2   a  of the endoscope operation unit  2  through the endoscope insertion part  6 . At an opening of the lateral part  2   a , a cap  10  is provided. In the cap  10 , an insertion hole is formed, and a treatment instrument such as a suture unit  11  is inserted into the channel  9  through this insertion hole. 
     As shown in  FIGS. 1 to 3 , in the suture unit  11 , a flexible inner sheath  13  is passed through the inside of a flexible outer sheath  12  so as to be able to freely move. To the tip of the inner sheath  13 , a needle  14  is fixed. The needle  14  has a slit  15  formed in a longitudinal direction from the tip thereof. A suture instrument  16  is contained inside of the needle  14 . Each of the lengths of the outer sheath  12  and the inner sheath  13  is longer than that of the channel  9  of the endoscope  1 . At a proximal end of the inner sheath  13 , an operation unit  17  is provided. The operation unit  17  has a handle  19  which can freely slide with respect to a main body  18  of the operation unit. To the handle  19 , a proximal end of a pusher  20  is fixed. The pusher  20  extends through the inside of the inner sheath  13  to the inside of the needle  14 . A distal end portion  21  of the pusher  20  is pressed against the suture instrument  16 . 
     As shown in  FIG. 4 , the suture instrument  16  has a suture thread  25 . The suture thread  25  is folded approximately in two and a knot  31  is formed in the vicinity of its turn-around point. Moreover, the suture thread  25  is bundled at both end portions (a first end portion and a second end portion) thereof and passed through a stopper  26  that is substantially triangular. To each of the first end portion and the second end portion of the suture thread  25 , an anchor  27  is fixed. The anchor  27  has a cylindrical shape and the suture thread  25  is fixed at an approximately center portion in a longitudinal direction of the anchor  27 . Both end portions of two anchors  27  in their longitudinal direction are respectively polarized. One end portion  27 A of the anchor  27  becomes a south pole of a magnet, and the other end portion  27 B becomes a north pole of the magnet. In  FIG. 4 , the end portion  27 A of the south pole and the end portion  27 B of the north pole are distinguished by using different colors so as to allow visual distinction. However, the end portions  27 A and  27 B and other portions may not be distinguished by using different colors. 
     The stopper  26  includes a long, thin plate member in which a hole  28  is formed at the center portion in a longitudinal direction thereof, through which the suture thread  25  is passed. Both end portions  29  in a longitudinal direction of the stopper  26  are diagonally folded back to hold the suture thread  25  therebetween. Both end portions  29  in a longitudinal direction of the stopper  26  are cut to form triangular sections  30 . Both end portions  29  of the stopper  26  are diagonally folded back so that the sections  30  intersect with each other to hold the suture thread  25  therebetween. As a result, the suture thread  25  is prevented from passing through a space formed between end portions  29 . When the knot  31  of the suture thread  25  is pulled in a direction away from the stopper  26 , both end portions  29  of the stopper  26  are slightly opened. Accordingly, the stopper  26  allows the suture thread  26  to move in the same direction. On the other hand, when end portions of the suture thread  25  at the side of the anchors  27  are pulled, the suture thread  25  is ready to move in a direction shown by an arrow in  FIG. 4 . At this time, however, the suture thread  25  does not move, since both end portions  29  of the stopper  26  are closed and secure the suture thread  25 . 
     As shown in  FIG. 3 , the suture instrument  16  sequentially holds two anchors  27  in an inner hole of the needle  14 . The suture thread  25  is drawn out from the slit  15  of the needle  14 . As shown in  FIG. 2 , the stopper  26  is held at a more distal end portion than the needle  14  in the outer sheath  12 . The number of the anchors  27  and the shape of the stopper  26  are not limited to the embodiment shown in the figures. 
     Next, a suturing method of this embodiment will be explained mainly with reference to  FIGS. 5 to 14 .  FIGS. 5 to 12  are pattern diagrams illustrating manipulation and show the stomach as an example of a hollow organ. 
     As shown in  FIG. 5 , the endoscope insertion part  6  is inserted from the mouth (a natural opening of a living body, such as the anus, nose, or ear) of a patient  41  prepared with a mouthpiece  40 . The tip of the endoscope insertion part  6  is bent by the angle knob  5 . A needle-like knife that is a high-frequency incision tool is passed through the channel  9  of the endoscope insertion part  6 , and a perforation is formed by incising the tissue of the wall of the stomach  43 . As shown in  FIG. 6 , the endoscope insertion part  6  is directed to the abdominal cavity  53  through the perforation  52  formed in the stomach  43 . A forceps  54  is passed through the channel  9 , and the treatment in the abdominal cavity  53  is carried out by using the forceps  54 . After finishing the treatment, the endoscope insertion part  6  is drawn back to the inside of the stomach  43 . 
     When the perforation  52  is sutured, the suture unit  11  is passed through the channel  9  of the endoscope insertion part  6 , and the needle  14  of the suture unit  11  is projected from the outer sheath  12 . At this time, the stopper  26  falls to the stomach  43 . When the suture unit  11  is moved forward, the needle  14  is thrust into the tissue around the perforation  52  (inside of the stomach  43 ). When the tip portion of the needle  14  penetrates the tissue and projects to the abdominal cavity  53  side, the forward movement of the suture unit  11  is stopped. The handle  19  (see  FIG. 1 ) of the operation unit  17  is manipulated to move the pusher  20  forward. As shown in  FIG. 7 , the first anchor  27  (the first connection member) is pushed out to the abdominal cavity  53 . When the needle  14  is pulled out from the tissue, the anchor  27  is placed in the abdominal cavity  53 . The suture thread  25  penetrates the tissue in the wall of the stomach  43 . Next, the needle  14  is thrust again in the same direction (direction toward the abdominal cavity  43  from the inside of the stomach  43 ) at an approximately symmetrical position across the perforation  52  with respect to the position at which the needle  14  is thrust to place the first anchor  27 . When the tip of the needle  14  penetrates the tissue and projects to the abdominal cavity  53  side, the second anchor  27  the second connection member) is pushed out. As shown in  FIG. 8 , the second anchor  27  (the second connection member) is placed at an approximately symmetrical position across the perforation  52  with respect to the position at which the first anchor  27  is placed. 
     Since the two anchors  27  have the end portions  27 A and  27 B which are polarized, one end portion  27 A of the first anchor  27  and the other end portion  27 B of the second anchor  27  attract each other. In the same way, one end portion  27 B of the first anchor  27  and the other end portion  27 A of the second anchor  27  attract each other. Accordingly, as shown in  FIG. 9 , the two anchors  27  attach to each other before closing the perforation  52 . Since the thrust positions are near, the two anchors  27  adhere parallel to each other. By attachment of the two anchors  27 , both end portions of the suture thread  25  are connected via these anchors  27 . 
     After the suture instrument  16  is mounted on the wall so as to cross the perforation  52 , the suture instrument  16  is tightened up. In order to tighten up the suture instrument  16 , a forceps  62  shown in  FIG. 10 , for example, is used. The forceps  60  includes an outer sheath  61  having an external diameter larger than the anchor  27  and an inner sheath  62  passing through the inside of the outer sheath  61  so as to be able to freely move forward or backward. At the tip of the inner sheath  62 , a supporting member  63  is provided, and a pair of grip segments  64  are supported on the supporting member  63  so as to be able to freely open or close. 
     After the knot  31  of the suture thread  25  of the suture instrument  16  is gripped by the grip segments  64 , the outer sheath  61  is moved forward to press the tip of the outer sheath  61  against the stopper  26 . As shown in  FIG. 11 , when the outer sheath  61  is moved further forward, the stopper  26  is pushed into the wall of the stomach  43 . Since the stopper  26  is constructed to be able to move in this direction, the stopper  26  moves toward the wall. Since the position of the pair of the grip segments  64  does not change, the stopper  26  moves relatively forward with respect to the suture thread  25 . As a result, the distance between the stopper  26  and the anchor  27  decreases, and the suture thread  25  is gathered. This pulls together the tissue around the perforation  52  as shown in  FIGS. 12 and 13 , and the perforation  52  is sutured by the suture thread  25 . 
     After the perforation  52  is sutured by the suture instrument  16 , the outer sheath  61  is moved backward, and then the grip segments  64  are opened to release the suture thread  25 . Although the tip of the stopper  26  can move in a direction in which the tissue is tightened up by the suture thread  25 , it acts to tighten up the suture thread  25  in a direction for loosening the suture thread  25 . As a result, the suture thread  25  is not loosened, even if the suture instrument  16  is placed inside of the stomach  43 . 
     As shown in  FIG. 12 , when the two anchors  27  attach parallel to each other, the tissue around the perforation  52  is collapsed, and the diameter of a loop of the suture thread  25  decreases. On the contrary, as shown in  FIG. 14 , when one end portion  27 A of the first anchor  27  and the other end portion  27 B of the second anchor  27  serially and attach to each other, the distance between the suture thread  25  penetrating the tissue increases. The diameter of the loop of the suture thread  25  formed via the anchor  27  increases. 
     In this embodiment, since a pair of the anchors  27  of the suture instrument  16  are polarized so as to pull together, the anchors  27  approach each other, and attach to each other when suturing the perforation  52 . Since anchors of a suture instrument of the prior art are completely independent and attitude or position thereof cannot be controlled, the tissue around the perforation is unevenly pulled and tends to leave a gap. According to this embodiment, since the anchors  27  attach to each other, the unevenness of the tissue is prevented and the tissue around the perforation formed in the stomach  43  can close neatly. Thus, the perforation  52  is properly closed. When the anchors  27  attach parallel to each other, the attached area is large, and thereby a high engagement strength can be achieved. Moreover, since the anchors  27  are parallel to a line of closure formed due to the close contact with the inner edges of the perforation  52 , the perforation  52  can be more properly closed. 
     Since the suture thread  25  forms a closed loop via the anchors  27  that attach to each other due to a magnetic force, it is possible to bring the inside and the outside of both sides of the tissue across the perforation  52  closely. Accordingly, as in the case of surgical suturing, suturing can be properly carried out. The diameter of the loop of the suture thread  25  can be controlled in accordance with a way of attaching the anchors  27 . When the diameter of the loop is desired to be enlarged, the anchors  27  may be attached parallel to each other. When the diameter of the loop of the suture thread  25  is desired to be diminished, the anchors  27  may be closely and linearly attached to each other. 
     Another aspect of the anchor  27  is shown in  FIGS. 15 to 17 . 
     Anchors  70  as shown in  FIG. 15  are connection members respectively provided at the first and the second end portions of the suture thread  25  and divided in two perpendicularly in a longitudinal direction. One portion  70 A of the connection member divided in two becomes a south pole and the other portion  70 B becomes a north pole. Since the attached area due to a magnetic force is large, it becomes easy for the anchors to attach to each other. 
     The anchors  71  as shown in  FIG. 16  are connection members respectively provided at the first and the second end portions of the suture thread  25  and divided in two parallel to a longitudinal direction. One portion  71 A of the connection member divided in two becomes a south pole and the other portion  71 B becomes a north pole. 
     As shown in  FIG. 17 , a first anchor  72  is a first connection member provided at the first end portion of the suture thread  25  and produced from a magnet. A second anchor  73  is a second connection member provided at the second end portion of the suture thread  25  and produced from a ferromagnet. As the ferromagnet, pure iron, Permalloy, or the like is used. The anchor  73  attaches to the anchor  72  due to the magnetic force of the anchor  72 , and both end portions of the suture thread  25  are connected via these anchors  72  and  73 . When only the anchor  72  is a magnet, the same effect as described above can be achieved. 
     These anchors  27 ,  70 ,  71 ,  72 , and  73  may have a cross section of which the shape is a circle or an oval, or a cross section of which the shape is a polygon such as a tetragon. 
     (Second Embodiment) 
     In this embodiment, the same endoscope  1  and suture unit  11  as in the first embodiment are used. Descriptions that overlap with the first embodiment will be omitted. 
     As shown in  FIG. 18 , a suture instrument  80  is equipped with a ring  81  at the first end portion of the suture thread  25 . The ring  81  is a first connection member having a hole. At the second end portion of the suture thread  25 , a tag  82  that is a second connection member is provided. The thickness of the tag  82  is of a size which allows it to be inserted into the inside of the ring  81 . The length of the tag  82  is larger than the external diameter of the ring  81 . The ring  81  and the tag  82  can be contained inside of the needle  14 . For this reason, the ring  81  and the tag  82  are made from a material having flexibility and are held in the needle  14  in a folded form. The ring  81  and the tag  82  may be produced so as to be in a size smaller than the inner diameter of the needle  14 . 
     A suturing method of this embodiment will be explained. 
     As shown in  FIG. 5 , the endoscope I is directed to the stomach  43 . As shown in  FIG. 6 , the endoscope insertion part  6  enters the abdominal cavity  53  through the perforation  52 . By using the forceps  54  passed through the endoscope insertion part  6 , the treatment is carried out in the abdominal cavity  53 . When the perforation  52  is sutured, the suture unit  11  is used. As shown in  FIG. 19 , after the needle  14  of the suture unit  11  penetrates the tissue around the perforation  52  from the inside of the stomach  43  toward the abdominal cavity  53 , the pusher  20  is moved forward, and the ring  81  is pushed out from the needle  14 . When the ring  82  is pushed out, the needle  14  is drawn back to be pulled out from the tissue. Moreover, the needle  14  penetrates at an approximately symmetrical position across the perforation  52  in the same direction as for placing the ring  81 , that is, from the inside of the stomach  43  toward the abdominal cavity  53 . The pusher  20  is moved further forward. From the needle  14 , the tag  82  is pushed out to the abdominal cavity  53  side. When the tag  82  is pushed out, the needle  14  is pulled out from the wall. 
     As shown in  FIG. 20 , the forceps  54  is passed through the channel  9  of the endoscope  1 . The forceps  54  is directed through the perforation  52  to the abdominal cavity  53 , and grips the tag  82  in the abdominal cavity  53 . This tag  82  is inserted inside of the ring  81 . As shown in  FIG. 21 , the ring  81  is engaged with the tag  82 , and both end portions of the suture thread  25  are connected to each other via the ring  81  and the tag  82 . 
     After the forceps  54  is pulled back from the perforation  52  to the stomach  43 , the suture instrument  80  is tightened up. The tightening method is the same as in the first embodiment. A loop of the suture thread  25  is formed to close the perforation  52 . 
     According to this embodiment, since the ring  81  and the tag  82  are respectively provided at the end portion of the suture thread  25 , the loop of the suture thread  25  can be properly formed by engaging the ring  81  with the tag  82 , and thereby the perforation can be properly sutured. 
     Next, another embodiment of the suture instrument is shown in  FIG. 22 . A suture instrument  85  is equipped with the ring  81  at the first end portion of the suture thread  25 . At the second end portion of the suture thread  25 , a hook  86  is provided as a second connection member. The hook  86  is thinner than the internal diameter of the ring  81  and the tip portion thereof is folded back so as to be able to be engaged with the ring  81 . As shown in  FIG. 23 , the ring  81  and the hook  86  of the suture instrument  85  are engaged with each other at the abdominal cavity  53  side. By the ring  81  and the hook  86 , the end portions of the suture thread  25  are connected with each other to form a loop. By this suture instrument  85 , the perforation  52  can be closed in the same manner as with the suture instrument  80  shown in  FIG. 21 . 
     Moreover, this invention can be widely applied without being limited to the above-mentioned embodiments. 
     The form of the end portion of the suture thread  25  is not limited to a magnet, ring, tag, hook, or the like. After bundling the end portions of the suture thread  25 , the end portions may be engaged with each other by a treatment tool such as a clip, high-frequency forceps, or the like, followed by tightening up the suture thread  25 . The suture thread  25  may be tightened up after the end portions of the suture thread  25  are adhered to each other by using an adhesive agent. 
     The anchors  27  of the first embodiment may be gripped by a treatment tool to force them to attach to each other, followed by tightening up the suture thread  25 . 
     As shown in  FIG. 24 , when the endoscope insertion part  6  has two channels  9 , the suture units  11  may be passed individually through respective channels  9 . In this case, the anchors  27  of the suture instrument  16  are individually held in the needle  14  of the respective suture unit  11 . The same can be applied to other types of the anchor.