Patent Publication Number: US-11039909-B2

Title: Implants, tools, and methods for treatments of pelvic conditions

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a Continuation of, and claims priority to, U.S. patent application Ser. No. 14/946,068, filed on Nov. 19, 2015, entitled “IMPLANTS, TOOLS, AND METHODS FOR TREATMENTS OF PELVIC CONDITIONS”, which is a divisional of, and claims priority to, U.S. patent application Ser. No. 13/763,296, filed on Feb. 8, 2013, entitled “IMPLANTS, TOOLS, AND METHODS FOR TREATMENTS OF PELVIC CONDITIONS”, which claims priority to U.S. Provisional Patent Application No. 61/596,803, filed on Feb. 9, 2012, entitled “IMPLANTS, TOOLS, AND METHODS FOR TREATMENTS OF PELVIC CONDITIONS”, the disclosures of which are incorporated by reference herein in their entirety. 
    
    
     TECHNICAL FIELD 
     The present invention relates generally to implants, tools, devices, systems, apparatus, and related methods for treating pelvic conditions including but not limited to incontinence and prolapse conditions in men and women. 
     BACKGROUND 
     Pelvic health for men and women is a medical area of increasing importance, at least in part due to an aging population. Examples of common pelvic ailments include incontinence (e.g., urinary or fecal), pelvic tissue prolapse (e.g., female vaginal prolapse), and conditions of the pelvic floor. Urinary incontinence can further be classified as including different types, such as stress urinary incontinence (SUI), urge urinary incontinence, mixed urinary incontinence, among others. Urinary incontinence can be characterized by the loss or diminution in the ability to maintain the urethral sphincter closed as the bladder fills with urine. Male or female stress urinary incontinence (SUI) generally occurs when the patient is physically stressed. Other pelvic floor disorders include cystocele, rectocele, enterocele, and prolapse such as anal, uterine and vaginal vault prolapse. Pelvic disorders such as these can result from weakness or damage to normal pelvic support systems. 
     In its severest forms, vaginal vault prolapse can result in the distension of the vaginal apex outside of the vagina, and is often associated with a rectocele, cystocele or enterocele. An enterocele is a vaginal hernia in which the peritoneal sac containing a portion of the small bowel extends into the rectovaginal space. Vaginal vault prolapse and enterocele represent challenging forms of pelvic disorders for surgeons. One known method of repairing vaginal vault prolapse is by suturing to the supraspinous ligament or attaching the vaginal vault through mesh or fascia to the sacrum Many patients suffering from vaginal vault prolapse also require a surgical procedure to correct stress urinary incontinence that is either symptomatic or latent. Many of these procedures often involve lengthy surgical procedure times. 
     There is therefore a desire to provide minimally invasive yet highly effective implantable systems that can be used to treat incontinence, and/or pelvic organ prolapse and other conditions. It is further desirable that such systems can be delivered via minimally invasive (e.g., transvaginal, laparoscopic, transabdominal) surgical procedures. 
     SUMMARY 
     Devices, systems, and methods as described can be used to treat pelvic conditions such as incontinence (various forms such as fecal incontinence, stress urinary incontinence, urge incontinence, mixed incontinence, etc.), vaginal prolapse (including various forms such as enterocele, cystocele, rectocele, apical or vault prolapse, uterine descent, etc.), levator defects, and other conditions caused by muscle and ligament weakness, hysterectomies and the like. While many of the surgical procedures and devices described herein are directed to transvaginal surgical procedures, it is understood that the procedures can instead be performed using laparoscopic and/or transabdominal approaches. 
     One procedure that can be used to treat vaginal prolapse conditions is sacral colpopexy. An aspect of certain sacral colpopexy procedures is to place a fixation element (e.g., an anchor such as a bone anchor or soft tissue anchor) into tissue of a posterior pelvic region to secure an implant to the tissue. This aspect of the procedure requires a surgeon to place a tissue anchor at a location deep inside a posterior pelvic region, such as through a transvaginal incision (when using certain current methods). 
     Surgical tools and procedural improvements are disclosed herein. Certain embodiments of tools and methods are used for attaching sutures, mesh, or other devices to the anatomy, such as for treating incontinence and/or prolapse. Embodiments of the tools can be used for deploying sutures through a retractor and into the peritoneum, for example. This can be useful for a number of different procedures that require suturing in the peritoneal space, such as sacral colpopexy (e.g., for attaching mesh material to the sacral promontory and for closing the peritoneal membrane over the mesh), high uterosacral suspension procedures (e.g., for passing suture through a tissue structure and fixating the suture to that tissue structure), McCall culdoplasty (i.e., a method of supporting the vaginal cuff by attaching the uterosacral and cardinal ligaments to the peritoneal surface with suture material that can be drawn toward the midline to help close off the cul-de-sac), uterosacral suspension procedures, and the like. 
     Various surgical tools, implants, and procedural improvements are disclosed herein. Certain embodiments of methods and implants involve reperitonealization or covering sacral mesh during a transvaginal sacrocolpopexy procedure using a curved trocar and retractor system. Certain embodiments of methods and implants described herein involve placing a fixation element at the sacrum and then attaching mesh to the fixation elements via a snapping or other positive engagement system. Other methods, devices, and systems provided herein include a suture knot pusher, a clip-on light tube for use with a surgical transvaginal sacrocolpopexy retractor, a method of moving the bowel out of the retractor and the physician&#39;s view, a vaginal mesh suture pad and instrument, suction tip features at the end of a retractor, and a retractor with flexible fingers at one end. Embodiments of implants and methods can involve placement of an implant to support pelvic tissue, by way of one or more incisions of minimum size, for example. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The invention will be further explained with reference to the appended Figures, wherein like structure is referred to by like numerals throughout the several views, and wherein: 
         FIG. 1  is a schematic perspective view of a surgical procedure for reperitonealizing sacral mesh; 
         FIG. 2  is a schematic front view of a trocar tunneling under the peritoneum in the area of the vaginal cuff and to the sacral promontory of a patient; 
         FIG. 3  is another schematic view of the arrangement of  FIG. 2 , and further illustrating a mesh member connected via a suture; 
         FIG. 4  is a schematic view of a manner of connecting a mesh member to a sacral promontory; 
         FIG. 5  is a front view of an exemplary embodiment of a fixation kit or system; 
         FIG. 6  is a front view of another exemplary embodiment of a fixation kit or system; 
         FIG. 7  is a front view of another exemplary embodiment of a fixation kit or system; 
         FIG. 8  is a perspective view of a suture knot pusher device; 
         FIG. 9  is a perspective view of a system for attaching a light cable to a retractor; 
         FIG. 10  is a perspective view of the system of  FIG. 9  as it can be attached to a retractor tube; 
         FIGS. 11 a -11 c    are schematic views of a retractor apparatus for use in a sacrocolpopexy or related procedure; 
         FIGS. 12 a  and 12 b    are front views of a retractor tube with a sleeve; 
         FIG. 13  is a top view of a surgical tool for use during suturing processes; 
         FIG. 14  is a front view of the surgical tool of  FIG. 13 ; 
         FIG. 15  is a perspective view of the surgical tool of  FIGS. 13 and 14 ; 
         FIG. 16  is a perspective end view of a retractor that includes a plurality of suction holes; 
         FIG. 17  is a perspective view of an exemplary embodiment of a retractor; and 
         FIG. 18  is another perspective view of the retractor of  FIG. 17 , wherein the end portion is in an expanded condition. 
     
    
    
     DETAILED DESCRIPTION 
     Pelvic floor disorders include cystocele, rectocele, enterocele, and uterine and vaginal vault prolapse, levator defects, among others, in male and female patients. These disorders typically result from weakness or damage to normal pelvic support systems. The most common etiologies include childbearing, removal of the uterus, connective tissue defects, prolonged heavy physical labor and postmenopausal atrophy. 
     Vaginal vault prolapse is the distension of the vaginal apex, in some cases to an orientation outside of the vagina. Vaginal vault prolapse is often associated with a rectocele, cystocele or enterocele. It is known to repair vaginal vault prolapse by suturing the vaginal vault (e.g., by stitches) to the supraspinous ligament or by attaching the vaginal vault through mesh or fascia to the sacrum Many patients suffering from vaginal vault prolapse also require a concurrent or subsequent surgical procedure to correct stress urinary incontinence that is either symptomatic or latent. 
     In order to place a sling to stabilize or support the bladder neck or urethra, such as for the treatment of incontinence, surgical procedures and devices are often used. There are a variety of different sling procedures, where the slings used for pubovaginal procedures vary widely in the types of material and anchoring methods. In some cases, the sling is placed under the bladder neck and secured via suspension sutures to a point of attachment (e.g., bone) through an abdominal and/or vaginal incision. Examples of sling procedures are disclosed, for example, in U.S. Pat. Nos. 5,112,344; 5,611,515; 5,842,478; 5,860,425; 5,899,909; 6,039,686; 6,042,534; and 6,110,101. 
     A sacral colpopexy (otherwise known as “sacrocolpopexy”) is one procedure used for providing vaginal vault suspension. It may be performed through an abdominal incision, a vaginal incision, or laparoscopically. A sacral colpopexy entails suspension (by use of an implant such as a strip of mesh) of the vaginal cuff to a region of sacral anatomy such as the sacrum (such as may be accomplished using bone screws that are implanted into the sacrum), a nearby sacrospinous ligament, uterosacral ligament, or anterior longitudinal ligament at the sacral promontory. An implant such as a synthetic mesh can be carefully customized or assembled into a special shape by the surgeon. In some sacral colpopexy procedures that also involve a hysterectomy, an implant can alternatively be attached to posterior vaginal tissue that remains after removal of the uterus and cervix, and also to anatomy to support the vaginal tissue at or around the sacrum, such as to uterosacral ligaments or to the sacrum itself (i.e., to a component of the sacral anatomy). 
     As used herein, the term “anchor” refers non-specifically to any structure that can connect an implant to tissue of a pelvic region. The tissue may be bone, or a soft tissue such as a muscle, fascia, ligament, tendon, or the like. The anchor may be any known or future-developed structure, or a structure described herein, useful to connect an implant to such tissue, including but not limited to a clamp, a suture, a soft tissue anchor such as a self-fixating tip, a bone anchor, any of the structures described herein to be useful to connect an implant to soft tissue or bone of a pelvic region, or the like. 
     The suturing instruments described herein are directed to the surgical treatment of a pelvic condition including prolapse (e.g., any form of vaginal prolapse), urinary and fecal incontinence, levator defects, etc., in a male or female patient. To treat such conditions, one or more implants can be implanted in a male or a female to treat a condition such as urge incontinence, mixed incontinence, overflow incontinence, functional incontinence, and the like. To treat any of such conditions, one or more implants can be implanted in a male or a female, which implants can include a tissue support portion that can be used to support a urethra or other pelvic tissue, along with one or more extension portions (otherwise known as an end portion or arm) attached or attachable to the tissue support portion. An implant may include portions, pieces, or sections that are synthetic or made of biologic material (e.g., porcine, cadaveric, etc.). Extension portions of an implant may be a synthetic mesh, for example, such as a polypropylene mesh, a suture, a biodegradable suture, etc. The tissue support portion may be synthetic (e.g., a polypropylene mesh) or biologic. Examples of implant products that may be similar to those useful according to the present description, include those sold commercially by American Medical Systems, Inc., of Minnetonka Minn., under the trade names “Apogee”, “Perigee”, and “Elevate” for use in treating pelvic prolapse (including vaginal vault prolapse, cystocele, enterocele, etc.), and under the trade names “Spare”, “Bioarc”, “Monarc”, “MiniArc”, “InVance”, and “AdVance” for treating urinary incontinence. 
     In exemplary uses, extension portions of an implant can extend from the 10 location of attachment with the tissue support portion, through pelvic tissue, and optionally be attached to supportive tissue within the pelvic region. For certain procedures, the supportive tissue can be tissue adjacent to the urethra such as pelvic fascia; tissue between the urethra and an obturator foramen such as pelvic fascia; or tissue of an obturator foramen such as obturator fascia, obturator internus muscle, obturator membrane, obturator externus muscle, etc. For alternate procedures an extension portion can be sized to extend from the tissue support portion, through an obturator foramen, around a pubic ramus bone, and threaded (subcutaneously) back to a medial location such as near a medial incision. 
     Implants as described can include a tissue fastener at a distal end or a distal portion of an extension portion, which is the end or portion not attached to a tissue support portion. As used herein, the term “distal” generally refers to a direction toward a patient and away from a surgeon installing a device. A tissue fastener at a distal end or portion of an extension portion can be any of various types, including: a self-fixating tip that is inserted into soft tissue and frictionally retained; soft tissue anchors; biologic adhesive; a soft tissue clamp that can generally include opposing, optionally biased, jaws that close to grab tissue; and opposing male and female connector elements that engage to secure an end of an extension portion to tissue. (See International Patent Application No. PCT/US2007/014120; U.S. patent application Ser. Nos. 12/223,846 and 12/669,099; and WO 2009/075800, the entireties of which are all incorporated herein by reference). An implant may also have one or more extension portions that do not include a tissue fastener, such as may be used if the distal end is designed to be secured to tissue by other methods (e.g., suturing), or is intended to pass through an obturator foramen and a tissue path around a pubic ramus bone, in which case the extension portion may optionally include a connector, dilator, or dilating connector, which connects to an elongate tool that can be used to either push or pull the connector, dilator, or dilating connector through a tissue path (e.g., to a medial incision). 
     One embodiment of a tissue fastener is a self-fixating tip. In general, a self-fixating tip can be a structure (sometimes referred to as a soft tissue anchor) connected at a distal end of an extension portion (or extension portion piece) that can be implanted into soft tissue (e.g., muscle, fascia, ligament, etc.) in a manner that will maintain the position of the self-fixating tip and support the attached implant. Exemplary self-fixating tips can also be designed to engage an end of an insertion tool (e.g., elongate needle, elongate tube, etc.) so the insertion tool can be used to push the self-fixating tip through and into tissue for implantation, preferably also through a medial incision to reach the interior of the pelvic region, e.g., at a location of an obturator foramen. 
     According to various systems, one or more instruments, insertion tools, adjusting tools, or the like, may be incorporated or used with an implant or method as described. Examples of useful tools include those that generally include one or more (stationary or moveable) thin elongate, relatively rigid shafts or needles that extend from a handle. The shaft can be a single elongate shaft or multiple separate elongate shafts extending from the handle, or one or more primary shafts that extend from the handle and that contain multiple branch or “tine” shafts that separate at the end of the primary shaft. The handle is located at a proximal end of the device and attaches to one end (a proximal end) of a shaft. According to some embodiments, a distal end of one or more shafts can be adapted to engage a portion of an implant, such as a tissue fastener (e.g., a self-fixating tip), in a manner that allows the insertion tool to engage and push the tissue fastener through a tissue passage and connect the tissue fastener to supportive tissue of the pelvic region. Examples of this type of tool can be used with a self-fixating tip that includes an internal channel designed to be engaged by a distal end of an insertion tool to allow the self-fixating tip to be pushed into tissue. Other general types of insertion tools will also be useful, but may engage a self-fixating tip or other tissue fastener in an alternate manner, e.g., that does not involve an internal channel. 
     Exemplary insertion tools for treatment of incontinence and vaginal prolapse are described, e.g., in U.S. patent application Ser. Nos. 10/834,943; 10/306,179; 11/347,553; 11/398,368; and 10/840,646; PCT Application Nos. 2006/028828 and 2006/0260618; WO 2010/093421; and U.S. Patent Publication No. US 2010/0256442, wherein the entirety of these documents are incorporated herein by reference. A tool that can be used for embodiments of the invention can optionally include a mechanism by which a tissue fastener (e.g., a self-fixating tip) can be securely and releasable engaged with a distal end of an insertion tool such that the tissue fastener can be selectively secured to the distal end mechanically, then selectively released. With a releasable engagement, a tissue fastener (e.g., self-fixating tip) can be released from the distal end by releasing the engagement (e.g., mechanical engagement) by movement of an actuator at the proximal end of the insertion tool, such as at the handle. Optionally, an implant can include a tissue fastener at a location of a tissue support portion, or at a location along a length of an extension portion. This form of tissue fastener can be in the form of reinforced (e.g., by coating, heat treating, or a reinforcing weave or strip) edge extensions, multiple layers of mesh and edge extensions in an extension portion, etc., as described, for example, at Applicant&#39;s co-pending U.S. Pat. No. 7,422,557, and Applicant&#39;s co-pending United States Patent Publication Nos. US 2006/0195011, US 2006/0195007, and US 2006/0195010, all of which are incorporated herein by reference. 
     Referring now to the Figures, and initially to  FIGS. 1 through 3 , a method and device are illustrated for reperitonealizing sacral mesh as part of a sacrocolpopexy procedure. Reperitonealization or covering of the mesh inside the peritoneal cavity can be important for avoiding complications such as bowel obstruction, infection, bowel adhesions, and the like. In many known surgical methods, reperitonealization has been accomplished by cutting the peritoneal membrane and suturing it back over the mesh, which approach can be relatively difficult to accomplish when using a transvaginal approach. The method of the present invention, however, provides an alternative approach to reperitonealization by tunneling under the peritoneal membrane in order to separate the sacral mesh from the bowel. 
     In accordance with the invention, a curved trocar  10  is provided with a retractor system. The trocar  10  is introduced through a small pocket  12  that is created at the open vaginal cuff  14  between the vaginal musosa and the peritoneal membrane. The trocar  10  is advanced under the peritoneal membrane and toward the sacral promontory  16  along the right pelvic sidewall of the patient. The movement or advancement of the trocar  10  can be monitored using a retractor, which is used to clear the small bowel off the peritoneum and gain direct visual access to the peritoneal membrane and a tip of the trocar  10 . This advancement or tunneling of the trocar  10  can be continued all the way to the sacral promontory  16  where an incision has been made through the peritoneal membrane. When the trocar  10  reaches the sacral promontory  16  and can be seen through the peritoneal incision, a suture  18  can be loaded onto the tip of the trocar  10 , and the trocar  10  can be pulled out with the suture  18 . The suture  18  can be of a sufficient length that it will extend from the introitus through the peritoneal tunnel and back to the introitus, as is illustrated in  FIG. 3  (e.g., with a suture loop). The tunnel under the peritoneal membrane can be used for pulling a sacral mesh  20  though the patient until it reaches the sacrum, to which it can be attached. In particular, one end of the suture  18  can be tied to the sacral mesh  20  and pulled through the peritoneal tunnel. In one exemplary embodiment, two fixation elements (not shown) will have been fixated at the sacral promontory  16  so that the sacral mesh  20  can be snapped or otherwise connected to these fixation elements. When this is done, the reperitonealization aspect of the transvaginal colpopexy procedure can be considered to be complete. 
     In at least one currently used surgical method, a fixating element and a mesh are both loaded on a fixation driver that is used for placing the fixation element at the sacral promontory. Due to the presence of mesh at the tip of the driver, this method can be cumbersome and can therefore cause difficulty in achieving accurate placement of the fixation element at the sacral promontory. Because accurate placement of the fixation element is important for avoiding critical structures at the sacrum, there is a need to provide different methods and/or instruments for these surgical methods.  FIG. 4  illustrates one such exemplary method of attaching a mesh member  30  to a sacral promontory  32 , such as during a transvaginal sacrocolpopexy procedure. With this method, one or more fixation elements  34  are implanted separately from the mesh member  30  during fixation delivery by first attaching the fixation element(s)  34  at desired locations at the sacral promontory  32 , such as by screwing the fixation elements  34  into the sacrum, for example. The mesh member  30  can then be attached or “snapped” the onto the fixation element(s)  34 . For one example, a fixation element  34  can be connected to the sacral promontory  32  in the area of the anterior ligament, while the mesh member  30  is provided with an end portion having one or more eyelet-type elements  36  that are designed for engaging with this fixation element  34 . In one embodiment, the attachment of an eyelet  36  to a fixation element  34  is accomplished by pressing an eyelet element  36  onto one of the fixation elements  34  until the eyelet element  36  snaps or otherwise attaches to the fixation element  34 . The mesh member  30  can alternatively or additionally be provided with a different type of attachment element than the eyelet-type element, wherein such an attachment element can be designed or selected for secure attachment to a structure or portion of a fixation element. With this method, it is contemplated that two or more fixation elements can be snapped or otherwise attached to a single mesh member, if desired. 
     In accordance with another aspect of the invention, which is generally illustrated in  FIGS. 5 through 7 , for example, a kit is provided that can be used in sacrospinous ligament suspension procedures. In other words, such a fixation kit is provided for the sacrospinous ligament/uterosacral/soft tissue. This fixation kit leverages the prolapse repair and cystocele treatment system recognized under the trade name “Elevate”, which is commercially available from American Medical Systems of Minneapolis, Minn. The kit includes a fixation element similar to that used with the “Elevate” system, along with two suture threads that are securely attached to the fixation element. The attachment of the suture threads to the fixation element can be accomplished in a number of different ways, such as through a molding process, by looping suture thread(s) through an eyelet on the fixation element, or by tying the suture thread(s) to an eyelet on the fixation element. The kit also includes an instrument that can be used for delivering the fixation element and sutures or thread into the ligament. This kit may include an element that is similar to the apical needle used for the “Elevate” system, with or without modifications to accommodate the sutures. 
     With particular reference to  FIG. 5 , an exemplary fixation kit or system  40  is provided, which includes a fixation element  42  into which two sutures  44 ,  46  are molded or otherwise attached. The sutures  44 ,  46  may be made from a variety of materials, such as permanent or reabsorbable polymers, for example. The sutures  44 ,  46  can be positioned within the fixation element  42  by any desired distance and/or configuration that will securely attach the components to each other so that the sutures will not become prematurely disengaged from the fixation element. The kit or system  40  may further include a needle  48  at an end of one or both of the sutures  44 ,  46  that is opposite the end that is attached to the fixation element  42 . These needle(s)  48  can help with passing through vaginal tissue. 
       FIG. 6  illustrates another exemplary fixation kit or system  50  that includes a fixation element  52  having an eyelet  58  at one end to which one or more sutures or suture segments  54 ,  56  are attached. In one embodiment, a single suture is looped through the eyelet  58 , and in another embodiment, two sutures are attached to the eyelet  58  or to another area of a base of the fixation element  52 , such as by tying each of the sutures to the eyelet  58 . If a single suture is looped through the eyelet  58 , the suture may be inserted into the eyelet so that it is free to move along its length relative to the eyelet, which can be advantageous for certain surgical procedures, or the suture can instead be secured to the eyelet itself so that it cannot be moved relative to the eyelet along its length. 
     Another exemplary fixation kit  60  is illustrated in  FIG. 7 . Fixation kit  60  includes an apical needle assembly of the type that can be used for the Elevate system discussed above. This system further includes a sheath  62  that can have provisions for facilitating management of sutures and/or needles. 
       FIG. 8  illustrates an exemplary suture knot pusher  70  that can be used in accordance with a number of the methods and systems described herein, along with other surgical procedures. Suture knot pusher  70  includes an elongated member  72  and a distal end portion  74  that extends from a distal end of the elongated member  72 . The distal end portion  74  is shown as having a width that is larger than the width or diameter of the elongated member  72 , and can have a wide variety of shapes and sizes. In this illustrated embodiment, the distal end portion  74  includes a tapered shape with a width that increases from the point where it extends from the elongated member  72 . The distal end portion  74  includes a saddle shaped end with an embedded groove  76 . The groove  76  is designed to hold one or more sutures or suture segments so that the suture(s) can be pushed along a pathway that would otherwise be difficult to access with the hands, such as through a retractor, for example. The saddle shape of the groove  76  allows the suture lines to be pulled at a number of angles, including at approximately right angles to the direction that the suture and pusher  70  are being translated or “pushed”. Pulling on the opposing lines can cause the knot to advance in the direction that the pusher  70  is being moved or translated. 
       FIGS. 9 and 10  illustrate a system that can be used for attaching a light cable to a retractor in order to direct light to a specific surgical site at the end of a retractor. In this exemplary embodiment, a clip-on light tube or light pipe  80  is illustrated that includes a frame  82 , which may be made of plastic or another relatively rigid material, for example, although the frame  82  may have at least a small amount of flexibility. The frame  82  supports an optical fiber  84  that extends along at least a portion of its length. Alternatively, a frame and optical fiber may be integrated and molded as a one-piece component, which may be transparent, translucent, or opaque. 
     One end of the frame  82  may include a bayonet-type fitting, for example, which can be used for connection of a light cable and a light source. Alternatives to the bayonet-type fitting can alternatively be used, such as a threaded connector, friction connection, and the like. The light pipe  80  can further include a tapered dovetail insert  86  at an end of the frame  82  opposite that end that can include the bayonet-type fitting. This insert  86  can include an extending tab  88  that slides into a dovetail slot that is provided on the inner surface of a retractor tube  90 , a portion of which is illustrated in  FIG. 10 . The dovetail attachment can provide a light interference fit between components, with the light pipe  80  being positioned so that it is partially within the retractor tube  90  and partially extending from the retractor tube  90 . Alternative attachments are also possible, such as can be provided via components of the light pipe  80  and retractor tube  90  that can be snap-fit, frictionally fit, interference fit, or otherwise attached to each other, for example. With regard to the illustrated tapered dovetail type of connection between components, such a connection method can also be used to attach other devices to the retractor, such as fiber scopes, laparoscopic instruments, irrigation tubes, suction tubes, and the like. 
     In a sacrocolpopexy procedure, it can be desirable to provide a relatively easy method of accessing the sacral promontory in a minimally traumatic or non-traumatic manner. Exemplary methods of the invention, along with associated devices, are illustrated in  FIGS. 11 a -11 c  and 12 a - b   , which provide for methods of moving the bowel out of the area of a retractor so that it does not block a physician&#39;s view of the area. Also contemplated are methods to provide direct visualization of the sacral promontory in order to eliminate blind or partially blocked visual access and confirmation. Other advantages that can be provided by these methods include safe and easy device manipulation, along with a relatively low insertion force for the device. 
     A first exemplary embodiment of an access procedure and device is illustrated and described relative to  FIGS. 11 a -11 c   . As illustrated, a retractor tube  100  is provided, which can be provided with an anchor  102  having perforated or “tear away” features, such as the tear away line  104  illustrated best in  FIG. 11 b   . The tube  100  can further be provided with one or more associated pull rings  106  that extend from an elongated member (e.g., a pull cord), wherein four of such rings are shown in  FIG. 11 c   , although it is understood that more or less than four rings may be used. At least some portions of the tube and/or its associated tear away portion(s) and elongated member(s) can be made of can be made of a relatively soft and/or flexible material, such as a mesh, cloth, or plastic material, for example. In operation, the retractor tube  100  is placed in a patient, and if the bowel  108  is in view at the end of an obturator, a corresponding pull ring  106  can be pulled outwardly until the perforated or tear away line  104  breaks. A corresponding movement of the cloth or mesh will move the bowel out of view. 
     A second exemplary embodiment of an access procedure and device is described relative to  FIGS. 12 a - b   , which is generally configured as an “inverted sock” type of device and procedure. As illustrated in  FIG. 12 a   , a retractor tube  110  is surrounded by a cover  112  that has a first end  114  and a second end  116 . As shown, the first end  114  of the cover  112  is adjacent to a first end  118  of the tube  110 , and the second end  116  of the cover  112  is inverted over a second end  120  of the tube  110  so that it is positioned within the interior area of the retractor tube  110 . The tube  110  with the cover  112  are placed in a patient in this configuration and advanced as far as possible without moving the cover  112 . A physician can then look through the tube  110  while pulling on the cover  112  and pushing the tube  110  into the patient, thereby navigating toward the sacral promontory. Once the sacral promontory is reached, the cover  112  is pulled until its second end  116  is no longer within the inner area of the tube  110 , but can be adjacent to the second end  120  of the retractor  110 , as is illustrated in  FIG. 12 b   . It is noted that pulling of the cover  112  to advance the tube  110  can reduce the required insertion force as compared to a tube  110  that does not have such a cover  112 . In addition, the cover  112  can be made of a relatively soft outer material that can help to move and manage the bowel in a relatively atraumatic manner. 
     In some cases, attachment of mesh to the vagina in a sacrocolpopexy procedure can be difficult and time consuming. To address this issue an exemplary tool of the invention is illustrated in  FIGS. 13-15 , which provides a structure to which a mesh and vagina can be clamped during suturing. In particular, a tool  130  is illustrated that includes a curved flat surface  132  to which the vaginal wall and mesh can be secured, such as with clamps (e.g., Kelly clamps). That is, the mesh and vaginal wall are clamped to a suture pad  136  at the area of the curved flat surface  132 , and then the physician can suture the two together while controlling depth and mesh flatness. The tool  130  further includes a handle  134  that can be used to support and manipulate the vaginal wall while suturing. With this tool  130 , more controlled suture depth can be achieved to prevent puncturing or capturing unwanted tissue when suturing. In addition, the use of this tool  130  can provide more assurance that the mesh is appropriately sized and that it lies flat during the suturing process. 
       FIG. 16  illustrates an end of an exemplary retractor  140  that includes at least one suction hole  142  that terminates at one of the ends of the retractor  140  (e.g., at a front rim or distal end of the retractor  140 ). The number, placement, size, shape, and other features of the suction holes  142 , and their associated channels that extend through the walls of the retractor  140 , can vary widely, and are generally provided to affix the tip of the retractor  140  to the peritoneum over the sacrum In some cases, this can help to keep the peritoneum taut across the opening of the retractor. In addition, this can help to keep the retractor positioned in a desired location within the patient. A suction device or mechanism can be provided at a proximal end of the retractor for communication with the channels and suction holes  142 , wherein such a suction device or mechanism can provide for adjustable suction so that the physician can achieve a desired amount of force between the distal end of the retractor and the peritoneum or other tissue of the patient. 
       FIGS. 17 and 18  illustrate an end portion of a retractor  150  that includes a plurality of fingers or flanges  152  extending from a solid length of tubing to an end of the retractor. The fingers or flanges  152  can be formed or created around the perimeter of the retractor by cutting the tube along slit lines in multiple locations, or can alternatively be created by removing thin slots of material from between the fingers  152 . The number, length, width and other features of the fingers or flanges  152  can vary widely, and are generally provided to achieve a certain amount of expansion without compromising the capabilities of the retractor during surgery. In surgery, the retractor can be used to move the bowel away from the sacral promontory, where the retractor  150  can be inserted into a patient with the fingers  152  in a non-expanded condition, as is illustrated in  FIG. 17 , and when it is desired to move structures from each other, the fingers  152  can be expanded or bent outwardly, as is illustrated in  FIG. 18 . This expansion provides a larger working area for the surgeon. 
     Suturing instruments described herein can be used for supporting pelvic tissue, and can therefore be useful in conjunction with other methods of treating pelvic conditions, such as treating a levator hiatus, anal incontinence, etc. The implants and tools described herein can be made of conventional materials. For example, the various mesh members and portions can be constructed of polymer materials, such as a thin film or sheet material of polypropylene, polyethylene, fluoropolymers or like compatible materials, both permanent and absorbable, and the suturing instrument components can be made of standard surgical-grade materials, such as polymeric materials, stainless steel, and the like. 
     The disclosed systems, their various components, structures, features, materials and methods may have a number of suitable configurations as shown and described in the previously-incorporated references. Various methods and tools for introducing, deploying, anchoring and manipulate device, implants, and the like as disclosed in the references incorporated herein are envisioned for use with the present invention as well. All patents, patent applications, and publications cited herein are hereby incorporated by reference in their entirety as if individually incorporated, and include those references incorporated within the identified patents, patent applications and publications.