Patent Publication Number: US-2010130990-A1

Title: Methods of suturing and repairing tissue using a continuous suture passer device

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
     This patent application claims priority to U.S. Provisional Patent Application Ser. No. 61/115,330 titled “METHODS OF SUTURING AND REPAIRING TISSUE USING A CONTINUOUS SUTURE PASSER DEVICE” filed on Nov. 17, 2008. This application also claims priority as a continuation-in-part of U.S. patent application Ser. No. 12/291,159, titled “SUTURE PASSING INSTRUMENT AND METHOD” filed on Nov. 5, 2008, and also U.S. patent application Ser. No. 11/773,388, titled “METHODS AND DEVICES FOR CONTINUOUS SUTURE PASSING” filed on Jul. 3, 2007. Each of these patent applications is herein incorporated by reference in their entirety. 
     INCORPORATION BY REFERENCE 
     All publications and patent applications mentioned in this specification are herein incorporated by reference in their entirety to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     This invention relates to method of treating tissue using surgical stitching devices by which a stitch or continuous stitches may be made during surgery. In particular, described herein are method of suturing tissue using a continuous suture passer, particularly suture passers having jaws that open and close in parallel, and that are capable of passing a suture when the jaws are open in any position. These suturing methods may also involve techniques and manipulations of the suturing device. Furthermore, the continuous suturing devices referred to herein may be modified to perform, or to facilitate performance of, the suturing techniques described. 
     Suturing instruments for assisting a medical practitioner in placing stitches during surgical procedures are useful, particularly in surgical procedures requiring the placement of secure and accurate sutures in difficult to access regions of the body, including internal body regions. Instruments and methods for suturing remotely are especially important in minimally invasive surgical procedures such as laparoscopic and endoscopic procedures. In addition to helping to access remote regions of the body requiring suturing, suturing instruments may also allow the efficient manipulation of very small needles and the formation of small and precise sutures 
     Arthroscopic rotator cuff repair is one example of a technically challenging procedure that requires the placement of sutures in difficult to reach regions, as well requiring precise placement of sutures. The procedure may be performed with the patient under general anesthesia, and small (e.g., 5 mm) incisions may be created in the back, side, and front of the shoulder, and an arthroscope and instruments may be switched between each of these positions as necessary. The rotator cuff tear may be visualized, and the size and pattern of the tear is assessed. Thin or fragmented portions are removed and the area where the tendon will be reattached to the bone is lightly debrided to encourage new blood vessel ingrowth for healing. Sutures may be placed to close a tear. Depending on the size and location of the tear, multiple suture stitches may be required. In many situations, an arthroscopic stitch passer and grasper are used to pass a suture through the tendon. A stitch passer and grabber are typically only capable of making a single stitch, and must be withdrawn and reloaded in order to make multiple stitches. Similarly, a separate arthroscopic knot tying instrument is typically used to pass and tie knots in the suture to secure the repair. Furthermore, most currently available suturing instruments are limited in their ability to be maneuvered, particularly over thicker tissue regions, and may require additional space so that additional surgical instruments, including forceps or other graspers. 
     For example, the ArthroSew™ is a commercially available bi-directional suturing device with multiple-pass capability that has two jaws hinged to open V-like (from a common pivot). A suture is attached to the center of a double-ended needle and can be passed between the two jaws. At least one end of the needle protrudes from one or the other jaw at all times. The protruding needle may become caught in tissue, a problem that is exacerbated in difficult to access regions and regions offering limited maneuverability, such as the subacromial space of the shoulder. In addition, it is not possible to pass a stitch through thick (&gt;4 or 5 mm) tissue because if the needle is too long then the device cannot be inserted through a cannula and is not easily manipulated around or off of tissue when sewing. When attempts are made to pass a stitch through such thick tissues, the needle commonly is released free within the shoulder because it is not captured within the far jaw (the needle does not make it all the way through the tissue). Additionally, the ArthroSew™ and similar devices require the user to flip a toggle switch in the handle each time the user desires to alternate the needle between the jaws while sewing. This step has been shown to be difficult for surgeons to master. Similar devices are described in U.S. Pat. No. 5,814,054, U.S. Pat. No. 5,645,552, U.S. Pat. No. 5,389,103, U.S. Pat. No. 5,645,552, and U.S. Pat. No. 5,571,090. 
     Other continuous suture passers include rotating suture passers, in which a curved suture needle is driven about an axis through successive revolutions to pass through an adjacent tissue, forming a spiral stitch through the tissue. U.S. Pat. No. 5,540,705 to Meade et al., describes one such embodiment. 
     U.S. patent application Ser. No. 11/773,388, titled “METHODS AND DEVICES FOR CONTINUOUS SUTURE PASSING”, and herein incorporated by reference in its entirety, describes devices and methods for repairing various tissues using a continuous suture passer that is capable of grasping tissue and simultaneously (or selectively) suturing the tissue. In particular, these methods may be best performed by a suture passer in which the jaws move in parallel and/or in which the jaws are free of exposed needle when the jaw are in an open position. 
     SUMMARY OF THE INVENTION 
     Described herein are suturing techniques, methods, and suture patterns that may be useful for securing tissue. These techniques may, for the first time, be used to suture tissue using a suture passer device that may allow minimally or non-invasive suturing of extremely hard-to-reach areas, which would not otherwise be accessible. 
     For example, described herein are methods of forming a complex suture pattern in tissue using a continuous suture passer. In general, a complex suture pattern may comprise a suture pattern in which the suture is passed first in a first direction through the tissue, and then in a second position through the tissue; multiple such passes (in different directions, e.g., up then down, down, then up, etc.) through the tissue are typically made to form the suture pattern. Examples of such complex suture patterns are provided herein. In some variations, this method may include the steps of: accessing a tissue to be sutured with a continuous suture passer, wherein the continuous suture passer includes a first jaw and a second jaw, and a tissue penetrating member configured to extend from the first jaw to the second jaw through the tissue to pass a suture therebetween, grasping the tissue to be sutured between the first and second jaws while the tissue penetrating member is completely retracted within the first jaw, extending the tissue penetrating member from the first jaw to engage a predetermined position on the second jaw and thereby passing a suture through the tissue in a first direction, and then retracting the tissue penetrating member completely within the first jaw, repositioning the tissue between the first and second jaws, and, extending the tissue penetrating member from the first jaw to engage a predetermined position on the second jaw and retracting the tissue penetrating member completely within the first jaw, thereby passing a suture through the tissue in a second direction. 
     The step of accessing may comprises arthroscopically accessing the tissue to be sutured. For example the suture passer may be passes to the tissue through a cannula of appropriate size for performing an arthroscopic surgery. In particular, the surgery may be performed on a joint (e.g., knee, shoulder, etc.). 
     The method may also include the step of pre-anchoring a suture in or near the tissue to be sutured. The suture may be coupled to the suture after it has been anchored in the body. In other variations, the suture may be passed without first anchoring; the suture may be pre-loaded into the suture passer. 
     In some variations the methods described herein may include a knotless anchor. 
     The step of accessing the tissue to be sutured may include accessing the tissue with a continuous suture passer that is configured so that the first and second jaws open substantially parallel to each other. In general, any of the continuous suture passers described herein may be used, including those that open/close so that the tissue-contacting surfaces of the jaws (the primary or major tissue-contacting surfaces) open and close substantially in parallel. 
     The step of grasping the tissue may include closing the first and second jaws a non-predetermined amount. This may mean that the jaws may be closed to any intermediate degree, and may (in some cases) be locked in this position. Thus, if different tissues (or regions of tissue) have different thicknesses, the jaws of the continuous suture passer may be opened and closed to a greater or lesser degree, depending on the tissue thickness, rather than on any predetermined settings on the device. Further, as mentioned above, in some variations, the step of grasping the tissue may include locking the first jaw in a position relative to the second jaw. 
     The method may be used to form any complex suture pattern, by repositioning the continuous suture passer and repeating the steps of extending the tissue penetrating member to pass the suture first up and then down through the tissue one or multiple times. For example, the continuous suture passer may be used to form a complex suture pattern selected from the group consisting of: a medial row modified Mason-Allen repair; an interweave stitch; a medial row modified Mason-Allen double row repair; a baseball stitch; a baseball stitch incorporated into a double row repair; a modified Mason-Allen stitch; an inverted mattress stitch; a figure eight margin convergence stitch; a buried figure of eight margin convergence stitch; a medial row modified Mason-Allen double row repair; a baseball stitch double row repair; a modified Mason-Allen repair; a method of performing a basic tension setting repair; and an advanced tension-setting repair. 
     Also described herein are methods of forming a complex suture pattern in tissue using a continuous suture passer, the method including the steps of: accessing a tissue to be sutured with a continuous suture passer, wherein the continuous suture passer includes a first jaw, a second jaw, and a tissue penetrating member configured to extend from the first jaw to the second jaw through the tissue to pass a suture therebetween; positioning the tissue to be sutured between the first and second jaws while the tissue penetrating member is completely retracted into the first jaw; extending the tissue penetrating member from the first jaw to engage the second jaw and thereby passing a suture through the tissue in a first direction, and then retracting the tissue penetrating member completely within the first jaw; repositioning the tissue to be sutured between the first and second jaws, and; extending the tissue penetrating member from the first jaw to the second jaw and retracting the tissue penetrating member completely within the first jaw, thereby passing a suture through the tissue in a second direction. 
     Any of the steps described above may be included with this method as well. For example, the step of accessing may comprise arthroscopically accessing the tissue by passing the suture passer through a cannula to reach the target tissue. The step of accessing may comprise accessing the tissue with a continuous suture passer configured so that the first and second jaws open substantially parallel to each other. 
     The step of positioning the tissue may comprises grasping the tissue by closing the first and second jaws over the tissue a non-predetermined amount. In some variations, the step of positioning the tissue comprises grasping and locking the first jaw in a position relative to the second jaw. 
     Also described herein are methods of performing a complex suture pattern as part of an arthroscopic surgery using a continuous suture passer, the method comprising: accessing a tissue to be sutured by passing a continuous suture passer through a cannula, wherein the continuous suture passer includes a first jaw and a second jaw configured to open and close substantially in parallel relative to each other, and a tissue penetrating member configured to extend from the first jaw to the second jaw through the tissue to pass a suture therebetween; positioning the tissue to be sutured between the first and second jaws while the tissue penetrating member is completely retracted into the first jaw; extending the tissue penetrating member from the first jaw to engage the second jaw and thereby passing a suture through the tissue in a first direction, and then retracting the tissue penetrating member completely within the first jaw; repositioning the tissue to be sutured between the first and second jaws, and; extending the tissue penetrating member from the first jaw to the second jaw and retracting the tissue penetrating member completely within the first jaw, thereby passing a suture through the tissue in a second direction. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1A  is a perspective view of a first embodiment suture passer device. 
         FIG. 1B  illustrates a planar view of the suture passer device of  FIG. 1A . 
         FIG. 2  illustrates a cross-sectional view of one embodiment of the suture passer device. 
         FIG. 3  illustrates a cross-sectional view of the distal end of one embodiment of the suture passer device. 
         FIG. 4  illustrates a close-up, perspective view of the distal end of one embodiment of the suture passer device, wherein the upper jaw is transparent. 
         FIGS. 5A and 5B  illustrate one embodiment of a suture shuttle. 
         FIGS. 6A and 6B  illustrate another embodiment of the suture shuttle. 
         FIG. 7  illustrates yet another embodiment of the suture shuttle. 
         FIG. 8  illustrates one embodiment of a tissue penetrator. 
         FIGS. 9A-9D  illustrate one embodiment of the interaction between the suture shuttle and the tissue penetrator. 
         FIG. 10  illustrates a first embodiment of a suture clip. 
         FIGS. 11A-B  illustrate another embodiment of the suture clip, split into two pieces. 
         FIG. 12  illustrates the suture clip of  FIGS. 11A-B , but combined to form the complete suture clip. 
         FIG. 13A-13B  illustrates another embodiment of the suture clip. 
         FIG. 14  illustrates yet a further embodiment of the suture clip. 
         FIG. 15  illustrates the suture clip of  FIG. 14  in use with a suture and suture passer device. 
         FIG. 16  illustrates another embodiment of a suture linkage wherein the linkage forms a  FIG. 8 . 
         FIGS. 17A-17B  illustrates a first embodiment of the shuttle retainer seat. 
         FIG. 18  illustrates a second embodiment of the shuttle retainer seat. 
         FIG. 19  illustrates one embodiment of the interaction of the suture shuttle and shuttle retainer seat. 
         FIGS. 20A-20B  illustrate, in cross-section of a lower jaw, one embodiment of the interaction of the suture shuttle, shuttle retainer seat, and a retaining pin. 
         FIG. 21  illustrates, in cross-section of a lower jaw, one embodiment of the interaction of the suture shuttle, shuttle retaining seat, tissue penetrator, and retaining pin. 
         FIG. 22  illustrates a further embodiment of a shuttle retainer seat within the jaw. 
         FIG. 23  illustrates, in cross-section of a lower jaw, one embodiment of a retaining pin, including a spring. 
         FIG. 24  illustrates another embodiment of a suture shuttle. 
         FIG. 25  is a close-up cross-section illustrating the interaction of a retaining pin, shuttle retainer seat, tissue penetrator and lower jaw. 
         FIG. 26  is a top plan view of one embodiment of a lower jaw and shuttle retainer seat. 
         FIG. 27  is a perspective view of a further embodiment of a lower jaw. 
         FIG. 28  illustrates a top plan view of a lower jaw wherein one embodiment of the shuttle retainer seat and stiff member is positioned. 
         FIGS. 29A-29K  illustrate an embodiment of the interaction of the shuttle, shuttle retainer seat, retainer pin and tissue penetrator as the shuttle is passed between the shuttle retainer seat, the tissue penetrator, and back again. 
         FIGS. 30A-30B  illustrate one embodiment of a distal portion of a suture passer device including first and second jaws. 
         FIG. 31  illustrates another embodiment of a distal portion of a suture passer device. 
         FIGS. 32A-32C  show yet another embodiment of a distal portion of a suture passer device. 
         FIG. 33  illustrates a first embodiment of a jaw control mechanism. 
         FIGS. 34A-34C  illustrate another embodiment of a jaw control mechanism. 
         FIGS. 35A-35B  illustrate a first embodiment of a tissue penetrator control mechanism. 
         FIGS. 36A-36B  illustrate further features of the first embodiment tissue penetrator control mechanism of  FIGS. 34A-34B . 
         FIGS. 37A-37C  illustrate one embodiment of retainer pin control layer. 
         FIGS. 38A-38C  illustrate the interaction between one embodiment of the tissue penetrator control layer and one embodiment of the jaw control layer. 
         FIGS. 39A-39B  illustrate further detail of retainer pin control layer, specifically the communication from the actuator control to retainer pin. 
         FIGS. 40A-42B  illustrate the interaction of one embodiment of the tissue penetrator control layer and one embodiment of the retainer pin control layer. 
         FIGS. 43A-43D  illustrate further detail of one embodiment of the slide block of  FIGS. 40A-42B . 
         FIG. 44  illustrates one embodiment of a shuttleless suture passer device. 
         FIG. 45  illustrates a further embodiment of a tissue penetrator and at least one of a shuttle and a suture. 
         FIG. 46  illustrates a further embodiment of a shuttle retaining device on a tissue penetrator. 
         FIG. 47  illustrates one position in which the shuttle retaining device of  FIG. 46  may be placed on the tissue penetrator. 
         FIG. 48  illustrates the interaction of the suture shuttle, tissue penetrator and shuttle retaining device of  FIG. 45 . 
         FIG. 49  illustrates one example of meniscus surgery using the suture passer device of the present invention. 
         FIGS. 50A-50D  illustrate yet another embodiment of meniscus surgery, whereby suture is passed from an anteromedial or anterolateral, portal using the suture passer device of the present invention. 
         FIG. 51  illustrates one example of anterior cruciate ligament surgery using the suture passer device of the present invention. 
         FIG. 52  illustrates one example of Achilles tendon repair using the suture passer device of the present invention. 
         FIGS. 53A-53C  illustrates one example of a superior labrum anterior posterior repair using the suture passer device of the present invention. 
         FIG. 54  illustrates one example of labral repair using the suture passer device of the present invention. 
         FIGS. 55A-55E  illustrate a modified Masson-Allen Double Row suture knot for rotator cuff repair using the suture passer device of the present invention. 
         FIGS. 56A-56C  illustrate a further step, following  FIGS. 55A-55E , in which the remaining strands of suture are tied to at least one knotless suture anchor. 
         FIGS. 57A-57C  illustrate one example of a dural tear repair using the suture passer device of the present invention. 
         FIG. 58  illustrates one example of an annulus repair using the suture passer device of the present invention. 
         FIGS. 59A-59D  illustrate one method of suturing a tendon (e.g., during a repair procedure) using the methods and devices described herein. 
         FIGS. 60A-60R  illustrate one method of performing a complex suture technique involving a medial row modified Mason-Allen repair. 
         FIGS. 61A-61B  illustrate a method of passing an interweave stitch using a continuous suture passer, as described herein. 
         FIGS. 62A-62B  illustrate a method of performing a medial row modified Mason-Allen double row repair using a continuous suture passer. 
         FIGS. 63A-63B  illustrate a method of performing a “baseball stitch” using a continuous suture passer as described herein. 
         FIGS. 64A-64B  illustrate a method of performing a baseball stitch incorporated into a double row repair using a continuous suture passer as described herein. 
         FIGS. 65A-65B  illustrate a method of performing a modified Mason-Allen stitch using a continuous suture passer. 
         FIGS. 66A-66B  illustrate a method of performing an inverted mattress stitch using a continuous suture passer. 
         FIGS. 67A-67B  illustrate a method of making a figure eight margin convergence stitch using a continuous suture passer. 
         FIGS. 68A-68B  illustrate a method of making a buried figure of eight margin convergence stitch using a continuous suture passer. 
         FIGS. 69A-69B  illustrate a method of performing a medial row modified Mason-Allen double row repair using a continuous suture passer. 
         FIGS. 70A-70B  illustrate a method of performing a Baseball stitch double row repair using a continuous suture passer. 
         FIGS. 71A-71B  illustrate a modified Mason-Allen repair using two lateral double loaded anchors and a continuous suture passer. 
         FIGS. 72A-72C  illustrate a method of performing a basic tension setting repair using a continuous suture passer. 
         FIGS. 73A-73B  illustrate a method of performing an advanced tension-setting repair using a continuous suture passer. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     The methods described herein may be best performed with continuous suture passers having jaws that open and close while remaining in an approximately parallel orientation (e.g., relative to the upper and lower tissue-contacting surfaces of the jaws). In addition, the suture passer jaws may lock (e.g., so that tissue can be secured between them), and the suture passed by means of a tissue penetrator that carries the suture (e.g., attached to suture shuttle) between the two jaws. In particular, these methods may be performed using a device that is configured to pass the suture between the jaws regardless of the position of the jaws relative to each other (e.g., the jaws are not required to be in a particular position in order to pass the suture there between). Example of such suture passers are described below in  FIGS. 1 to 59D . 
     Suture Passers  
     Described herein are continuous suture passers for passing a suture through tissue, as well as systems including suture passers, and methods of passing sutures through tissue. In general, the suture passers described herein are continuous suture passers that are configured to pass a suture back and forth through a tissue without having to reload the device. Thus, these devices may be used for continuous stitching of tissue, and may allow method of stitching tissue that are otherwise not possible. 
     In general, the suture passers described herein are continuous suture passers that are configured to pass a suture back and forth through a tissue without having to reload the device.  FIG. 1A  illustrates a first embodiment of a continuous suture passer  10 , including some of the features described herein, which may include a tissue penetrator, shuttle, reciprocating parallel-opening first and second jaws  20  and  21 , jaw lock, and lower-jaw shuttle retainer seat  25 .  FIG. 1B  shows a planar view of the device  10 , including the parallel-opening jaws  20  and  21 , tissue penetrator  50 , and lower-jaw shuttle retainer seat  25 . 
       FIG. 2  illustrates a cross-sectional view of a first embodiment device  10 . An actuator portion  15  of device  10  may include the mechanical elements which operate the entire device  10 . For example, the actuator  15  includes mechanical elements for movement of at least one of the jaws  20  and  21 , movement of the tissue penetrator  50 , and retainer pin  30  (not shown), and associated equipment. Actuator  15  may be, in one embodiment, a handle. However, actuator  15  could also be any other type of mechanism to interface the device  10  with a user, such as, a keyboard or remote control for electronic embodiments of the device  10 . 
       FIGS. 3 and 4  show enlarged sectional views of the distal end of device  10 . In  FIG. 3 , one embodiment of the distal portion of device  10  is shown in cross-section. Tissue penetrator  50  is retracted within upper jaw  20 , and shuttle retainer seat  25  is positioned near the distal end of lower jaw  21 . Tissue penetrator  50  may move from a retracted position, as shown, to an extended position whereby tissue penetrator  50  may move out of the distal end of upper jaw  20  and towards lower jaw  21  and shuttle retainer seat  25 . 
       FIG. 4  illustrates another embodiment of the relationship of tissue penetrator  50  with a shuttle  70 . The upper jaw  20  is shown as translucent to uncover detail of tissue penetrator  50  and shuttle  70 . Shuttle  70  engages the tissue penetrator such that it can extend from upper jaw  20  along with tissue penetrator  50  towards lower jaw  21  and shuttle retainer seat  25 . In this variation, the tissue penetrator that passes the suture through the tissue is completely retracted into the upper jaw, as indicated. Thus, the jaws of the device may be opened and closed and used to grasp/manipulate tissue without engaging the tissue penetrator. 
       FIGS. 5A-7  illustrate various shuttle embodiments  70 ,  170  and  270 . Shuttle  70 ,  170  and  270  may be any shape such that it may be releasably attached to tissue penetrator  50 . While the shape of shuttle  70 ,  170  and  270  may correspond to the shape of at least a portion of the tissue penetrator  50  for attachment purposes, it may be of any suitable shape. In these illustrative examples, the shuttle is generally triangular in shape, which may correspond to a tissue penetrator  50  having a generally triangular cross-sectional shape. The illustrated examples of suture shuttles are “channel shuttles” which may engage a tissue penetrator  50 . For example, a triangular or cylindrical tissue penetrator  50  may be used, as illustrated in  FIGS. 8-9D , to which the suture shuttle  70 ,  170  and  270  is adapted to connect. Tissue penetrator  50  may be, for example, a needle or any like instrument capable of puncturing through tissue. Shuttle  70 ,  170  and  270  may be substantially hollow within the triangular shape, and may further have a channel  71 ,  171  and  271 , or opening, along a portion of the triangular body. This channel  71 ,  171  or  271  may serve as an entry way for tissue penetrator  50  to engage the shuttle  70 ,  170  and  270 . Thus, in these embodiments, the shuttle  70 ,  170  and  270  wraps around a portion of the tissue penetrator  50 , which is positioned within the body of the shuttle. The shuttle may “snap” onto the tissue penetrator, or it may be more actively engaged. For example, the shuttle may be sufficiently elastically deformable so that it can snap onto the tissue penetrator, e.g., by expanding the channel region temporarily when force is applied to snap the shuttle on/off of the tissue penetrator. 
     For example, in  FIGS. 5A-B , the channel  71  may be positioned on any portion of the shuttle  70 . In the illustrated examples, the channel is positioned along an apex of the triangular shape. However, a channel may also be placed along a side of triangular shape or in any other appropriate place. 
     Some embodiments of shuttle  170 ,  270  may also contain openings  74 ,  274  which may make the shuttle lighter, and may also facilitate flexing of the shuttle so that it can readily attach/detach from the tissue penetrator  50 . Further, opening  74 ,  274  may provide an area through which a retaining mechanism, such as a retainer pin  30 , may pass to secure shuttle  170 ,  270 . 
     Some embodiments of shuttle  70 ,  170 ,  270  of the present invention may include additional features which may provide controllable, positive, robust, repeatable, and manufacturable retaining structures. Such features may include, for example, protrusions, such as dimples  72 ,  172  or the like, and finger springs  175   a  and  b,  both of which may help to retain shuttle  170  on the tissue penetrator  50 . 
     The protruding dimples  72 ,  172  may interact with divots  52 ,  152  located within a cut-out  51 ,  151 , or recessed portion, of the tissue penetrator  50 . The dimples  72 ,  172  allow for controllable, repeatable retaining of the shuttle  70 ,  170  on the tissue penetrator  50 , whereby the shuttle may, in one embodiment, snap on and off the tissue penetrator repeatedly, as necessary. In one embodiment, the position of shuttle  70 ,  170  on the tissue penetrator  50  may be the same given an additional feature such as the dimples and divots. In an alternative embodiment, dimples  72 ,  172  may be located on the tissue penetrator  50 , while the divots  52 ,  152  may be located on the suture shuttle  70 ,  170 . 
     In a further embodiment, the tissue penetrator  50  may include a cut-out region  51 , shown in  FIGS. 8-9D , that may be configured to seat the shuttle against the outer surface of the tissue penetrator, thereby allowing the tissue penetrator to present a uniform outer surface as it penetrates the tissue; in this example, the shuttle does not “stick out” from the tissue penetrator, but is flush with the outer surface of the tissue penetrator. This helps keep the shuttle on the tissue penetrator as it extends from upper jaw  20  and penetrates tissue. 
     Additionally, in some variations, the upper edge  54  of tissue penetrator  50  may be sharpened to provide additional cutting surface on tissue penetrator. In this variation, the shuttle  70  should not interact with the upper edge  54  such that upper edge  54  is exposed to assist in the piercing action of tissue penetrator. In some embodiments, tissue penetrator  50  may include an additional cut-out  51 ′ along a portion of tissue penetrator  50  within cut-out  51 . Cut-out  51 ′ may allow additional room for a linkage  85  (see  FIG. 15 , for example). Cut-out  51 ′ may reduce the chance of damage to linkage  85  during tissue penetrator  50  insertion into shuttle  70 , since cut-out  51 ′ may provide additional clearance for linkage  85 . 
     In some embodiments, for example in  FIGS. 6A-B  and  9 A-D, finger springs  175   a  and  175   b  may interact with a ramp  153  within the cut-out  151  of the tissue penetrator  150 . The finger springs, and even the entire sides of the shuttle  170 , may be sloped inwardly towards one end of the shuttle. Thus, in this embodiment, the finger springs are located at the narrowest portion of the shuttle. This slope of the finger springs may interact with the slope of the ramp  153  of the cut-out portion  151 . The interaction of these two slopes may regulate the holding force of the shuttle  170  on the tissue penetrator  150  prior to the dimples  172  interacting with the divots  152  to firmly secure the shuttle to the tissue penetrator. Likewise, the holding force may be regulated as the shuttle is removed from the tissue penetrator in a similar manner. Thus, when a force is applied to shuttle  170  to pull shuttle  170  off tissue penetrator  150 , the finger springs may be forced along the ramp, towards the tip of tissue penetrator, to engage the ramp, causing the finger springs, and thus the sides of the shuttle, to flex apart from one another, and disengage the dimples from the divots. 
     Continuing with this embodiment, in  FIG. 9A , for example, the dimple  172  of the shuttle is shown engaged with the divot  152  on the tissue penetrator  150 . At this point, the finger springs may only be slightly engaged to the tissue penetrator.  FIG. 9B  illustrates the shuttle  170  beginning to be removed from tissue penetrator. The dimple is no longer in the divot and is instead moving along the surface of the tissue penetrator. The finger springs  175   a  are increasingly engaged onto the tissue penetrator as they move along ramp  153  within cut-out on tissue penetrator. In  FIG. 9C , the finger springs are shown as fully engaged with tissue penetrator, particularly at the point where the ramp ends (at the distal end of cut-out portion). This full engagement may, in one embodiment, cause the shuttle to flex, and as a result widen, such that the dimples are no longer in contact with the cut-out portion of the tissue penetrator.  FIG. 9D  illustrates the final step wherein the dimple and finger spring are no longer touching the tissue penetrator at all, and the tissue penetrator may be retracted, leaving the shuttle  170  free. 
     Thus, in various embodiments the tissue penetrator  50  may be adapted to mate with one or more elements on the suture shuttle, whether it is a dimple, or like protrusion, or finger springs, or the like, that can engage with a divot, depression, cut-out or ramp portion on the tissue penetrator. 
     Shuttle  70 ,  170  and  270  may be made of any material suitable for use in surgical applications. In one embodiment, the shuttle must have strength, yet also have sufficient flexibility and resiliency to be able to move on and off the tissue penetrator as described. Such movement may require the shuttle to flex during removal from and addition to the tissue penetrator. Thus, a suitable spring characteristic may be achieved with a high stiffness material, such as steel, by designing the spring such that it has a high preload characteristic when installed relative to the tolerances. For example, one shuttle design illustrated herein may include retention features that are lower spring stiffness &amp; high preload, which may help provide more consistent performance and decrease sensitivity to tolerances. Note that the intrinsic stiffness of the material (Young&#39;s modulus) and the spring constant of the shuttle may be related, but may not be equivalent. In addition, these shuttle designs may have significantly reduced tolerance sensitivity, wherein the tolerance is a small percentage of deflection, compared to other shuttle designs. One suitable material may be stainless steel. For example, the shuttle may be composed of 0.004 in. (0.01 mm) thick 17-7 PH stainless steel, Condition CH-900. In other variations, the shuttle does not have to snap onto the tissue penetrator, but may be retained (e.g., friction fit) on the tissue penetrator. In still other variations, the shuttle may be locked on the tissue penetrator by a lock mechanism (shuttle lock on the tissue penetrator) such as a spring element. In other variations the shuttle is retained within the tissue penetrator, as previously described. 
     Shuttle  70  may be made of material whose hardness is matched to the tissue penetrator  50 . Tissue penetrators of a material that is too hard relative to the shuttle may wear the shuttle out. In one example, the tissue penetrator is stainless steel, Rockwell 60C hardness. For example, the shuttle then may be precipitation hardened stainless steel, “17-4 PH”, which is also known as stainless steel grade 630. The shape of the shuttle is matched to the shape of the tissue penetrator, and the shuttle clips onto a portion of the tissue penetrator, and can be slipped on and off repeatedly. 
     The shuttle  70  may be made of a material having a hardness, stiffness and elasticity sufficient so that it may partially elastically deflect to clamp onto the tissue penetrator  50 , as mentioned. In particular, we have found that matching the hardness of the shuttle to the hardness of the tissue penetrator may be particularly useful for repeated use. For example, the shuttle may be made of Nitinol, beryllium copper, copper, stainless steel, and alloys of stainless steel (e.g., precipitation hardened stainless steel such as 17-7 PH stainless steel), cement (ceramic and metal), various polymers, or other biocompatible materials. The material chosen may be matched to the material of the tissue penetrator for various properties including, for example, hardness and the like. The shuttles may be formed in any appropriate manner, including punching, progressive die, CNC, photolithography, molding, etc. 
     In the above examples, a pull-out force, or the force required to remove the shuttle  70  from the tissue penetrator  50 , may be more than about 2 pounds of force. Preferably, the force may be about 2 to about 5 pounds. The force may be from, for example, the pulling of a suture, or suture clip or connector, attached through one of the bore holes  73  located on shuttle  70 . This force should be from the direction of about the tip of the tissue penetrator. 
     In one variation, illustrated in  FIGS. 5A-B , the bore holes  73  are located away from channel  71  and towards the base of the triangle, which may be in a fold in the shuttle, as shown in  FIG. 5B . In the other illustrated embodiments,  FIGS. 6A-7  for example, the bore holes  173  are adjacent the channel.  FIGS. 5A-B  illustrate a position of bore holes  73  which may reduce, or even eliminate, the bending forces on the sides of shuttle  70 , when suture, or the like, applies a force at bore holes  73 . Typically, when bore holes  73  are located adjacent channel, as in  FIG. 6A , the bending force on the side of the shuttle may peel the shuttle from the tissue penetrator  50  at a force lower than the desired removal force, due to the advantage of the force being applied to a corner of the shuttle  70 . However, bore holes  73  located as shown in  FIG. 5B  limits this bending force, or torque, and thus prevents removal of shuttle  70  from tissue penetrator  50  at a premature time and at a force less than is desired for removal of shuttle  70 . 
     In some embodiments, the shuttle  70  may be in the shape of a spiraled wire, or the like, such as a “finger torture” type device, whereby as the shuttle is pulled by the tissue penetrator  50 , the shuttle may tighten around, thereby securing itself to the tissue penetrator. The stronger the force of the pull, the tighter the spiraled wire secures to the tissue penetrator. When the shuttle is to be transferred from the tissue penetrator, for example, to the shuttle retainer seat  25 , the shuttle may be twisted, or the like, to “unlock” the shuttle from the tissue penetrator. 
     Other examples of shuttles  70 , which may be able to clamp onto the tissue penetrator to secure itself, may include torsion springs, snap rings, a portion of wire, elastically deformable shapes, conically tapered shapes, and the like. Elastically deformable shapes may be any shape desired, such that it can be deformed to wrap around at least a portion of the tissue penetrator. Useful shapes may include, but are not limited to, cylinders, triangles, overlapping rings, and any partial portion of a shape such as a semi-circle. Once the tissue penetrator is in position, the shape of the tissue penetrator receiving area allows the elastically deformable shape to return to its original configuration while being securely attached to the tissue penetrator. Of course, the cut-out  51 , or recess, or receiving area, on the tissue penetrator may in one embodiment be shaped such that it coincides with the shape of the shuttle. For example, if a conically tapered shuttle were used, the tissue penetrator may include a conically tapered cut-out on a portion of the surface. The conically tapered shuttle may be deformable, and may deform upon being moved into the cut-out region. Once completely within the cut-out region, the conically tapered shuttle may then return to its original shape and secure itself within the cut-out region. The cut-out region may include, for example, a lip, or the like, to assist in securing the shuttle, fully or partially, within the cut-out region. 
     In other embodiments, the shuttle may constitute the tip of the tissue penetrator  50  itself, such that the tip may be releasably coupled on the end of the tissue penetrator. Thus, the tip of the tissue penetrator may be passed between jaws of the suture passer device to pass the suture, which suture is attached to the tip, back and forth through the tissue. Suture  90  may, in one embodiment, be attached directly to shuttle  70  at bore hole  73 , or other like retention location. The suture need not be secured only by a bore hole. Instead, a suture may be secured to the shuttle by adhesive, a clamp, by being ties or engaged to a portion of the shuttle, or in any other suitable manner. 
     Additionally, suture  90  may be secured to shuttle  70  via an intermediary device, such as the various examples in  FIGS. 10-15 . One such intermediary device may be a suture clip, or suture retainer,  80 ,  180 ,  280 ,  380 . A suture clip allows for simple and efficient releasable connection of a suture to a shuttle. A suture clip may be used for continuous suture passing, or alternatively for single passing of a suture. 
     In operation, suture clips  80 ,  180 ,  280 ,  380 , some examples of which are illustrated in  FIGS. 10-15 , may be used as part of a system for suturing tissue, particularly when used with a continuous suture passer  10 . For example, a suture  90  may be passed from the first jaw  20  to the second jaw  21  and/or back from the second jaw to the first jaw of a suture passer. This may be accomplished using an extendable tissue penetrator  50  that is connected to the first jaw. The extendable tissue penetrator can pierce the tissue, and can also engage a suture shuttle  70 , to which a suture is attached through the suture clip  80 ,  180 ,  280 ,  380 . The suture may then be pulled through the passage that the tissue penetrator forms in the tissue. Extending the tissue penetrator forms a passage through the tissue, which may also pass the suture between the first and second jaws. For example, the tissue penetrator may include a suture shuttle engagement region which may be, for example, a cavity within the tissue penetrator, along the outside of the tissue penetrator, or the like, to which the suture shuttle can be releasably attached. The suture can be passed from the tissue penetrator in the first jaw to or from a suture shuttle retainer seat  25  connected to the second jaw. Thus, in some variations, both the tissue penetrator and the suture shuttle retainer seat are configured to releasably secure the suture, which may be attached to a suture shuttle. 
     In some variations, the suture clip  80 ,  180 ,  280 ,  380  described herein may include an attachment linkage  85  to a suture shuttle  70 , for example a tether, leash, lead wire, or the like, which may be configured to connect the suture clip to the shuttle. In some examples, the suture clip includes a bias, for example, a spring, for securing a linkage  85  within a snap-fit element. Alternatively, the suture clip may include a central opening through which a linkage may be threaded. This linkage can act as a spacer. In one embodiment, the linkage may be stiffly attached to the shuttle  70  such that it both spaces the shuttle from the suture and also controls the position of the shuttle based on a force exerted on the linkage. The linkage may also control the position of the suture as the shuttle is passed from one jaw to the other. Similarly, the linkage  85  may be a stiff metallic wire, a portion of suture, a flexible polymeric strand, or the like. In the example of a stiff metallic wire, the wire may be welded to the shuttle such that it may project from the shuttle in a predictable manner. 
     In one embodiment, illustrated in  FIG. 10 , the shuttle  70  may be connected to a suture clip  80  that may be a compressed loop, in which the compressed loop has an inner, generally “teardrop” shaped opening  86  that is wider in one end than the other. The suture  90  may then be threaded through the inner loop  86  such that it becomes wedged within the narrow portion of the teardrop shape. The suture may then be secured by any method known in the art such as by tying a knot or bringing the end outside of the body. The suture may also be secured solely by being wedged within the teardrop shape, which may be sufficient to secure the suture within the suture clip. 
     In an alternative embodiment, the suture clip may be a ring, which may have a circular outer shape and a circular inner opening. In this example, the suture would be passed through the circular inner opening and secured by any method known in the art such that the suture is not easily separable from the suture clip. In another embodiment, the suture clip  180 , illustrated in  FIGS. 11-12 , may be a two-piece assembly that snaps together. The first piece  181  may include a connector  186  for one of the suture  90  or linkage  85 , while the second piece  182  may include a connector for the other of the suture  90  or linkage  85 . For example, a suture may be formed onto the second piece  182 , or knotted onto the second piece, or the like. The first and second pieces are configured to be secured together. In some variations, the first and second pieces are configured to be releasably secured together. For example, the first and second piece may be snapped together, but may include a releasable securing element  183 , such as a button or the like, for separating them. 
     In  FIGS. 11A-B , the suture clip  180  is shown with the first and second pieces  181  and  182  forming the clip  180  when connected together. The clip  180  may be configured so that it may readily pass through tissue. For example, the shape may be smooth, and may be tapered along the axis of its length. The surface may be lubricious or otherwise coated. Other shapes are possible. This “snap-fit” example of a suture clip also may include a suture retaining location on either of the pieces, or, alternatively, in between the two pieces. A lead wire, or other extension, may be secured within the eyelet  186 , or alternatively on the tip of the second piece  182 , or also secure in between the two pieces. 
     The clip  180  may be separated into the first and second pieces by releasing the securing element  183  between the two pieces. The first and second pieces of the assembly may also be referred to as “male” and “female” components. In the example shown in  FIGS. 11A-B , the pieces may be separated by applying pressure through the window region  184 , releasing the securing element that holds the two pieces together. Snapping the first and second pieces together to from the assembly shown in  FIG. 12  causes the securing element to engage and hold the first and second pieces together. The securing element may be disengaged by applying pressure. For purposes of simplicity, in one embodiment, the first and second pieces do not include either a suture or an attachment linkage to the shuttle. It should be understood that these components may be included. 
     For example, the securing element  183 , and the clip  180  as a whole, may be made of a plastic polymeric material, a metal, or the like. Although the latch is shown extending from the first piece  181 , it may alternatively extend from the second piece  182 . More than one latch may be used. Also, alternative variations of the latch may also be used. The suture  90  and/or linkage  85  may be glued, heat-staked, or otherwise attached permanently or semi-permanently to the second piece  182 . In some variations the suture may be knotted. For example, the suture or linkage may be attached to the second piece  182  by first threading the end of the suture through the hollow second piece and then knotting the suture; the larger-diameter knot will be retained by the second piece since the suture knot cannot pass through the tapered or smaller-diameter opening or passage in the second piece. In some variations the second piece may be pre-threaded with a suture. 
     In use, a surgeon can easily snap the two pieces together, and the assembly may pass through the tissue with minimal drag. As mentioned, the assembly can be separated back into the first and second pieces by releasing the latch, if necessary. The latch may be released manually, or by using a special tool configured to disengage the latch. For example, a disengaging tool may be used to clamp on the assembly in the proper orientation and to apply pressure to release the latch. 
     In a further embodiment, illustrated in  FIG. 13A-B , the clip  280  may be a piece of tubing which has been laser cut to accommodate suture  90  and linkage  85  connections. In one embodiment, clip  280  may be crimped securely to suture at suture-attachment element  286 . Linkage  85  may be secured within the laser cut path  287 . Additionally, suture  90  may protrude into central region of clip  280  to interact with linkage  85 , which may also secure linkage  85  within laser cut path  287 . Epoxy, or the link, may also be used to secure linkage in clip  280 . The laser cut path  287  need not be formed by a laser, but may be machined in other ways known in the art. Alternative embodiments may exist where the linkage  85  is connected to position  286  and suture is connected to position  287 . Additionally, linkage  85  may include a second portion of a suture. 
     In yet another embodiment, the suture clip  380  may include a flexible planar structure that is looped back on itself. This type of clip may be attached to an end of the suture, as illustrated in  FIGS. 14-15 . One end of the clip, which may include a suture-attachment element  386 , may be secured to the end of the suture  90 . The suture-attachment element may be crimped to the suture and may be polymeric tubing, such as cyanoacrylate and polyester, for example. The opposite end of the clip may be folded over itself to form a latch  387  within which a suture, wire or the like may be placed. The clip is secured to the suture at the suture-attachment element, and is latched to a wire loop  85  which is attached to the shuttle. Of course, the clip may be reversed such that the clip engages the suture rather than the wire loop. Alternatively, of course, the wire may be replaced by an additional suture or the like. 
     In yet another embodiment, illustrated in  FIG. 16 , the linkage  85  may be a wire loop. The wire may include nitinol. For example,  FIG. 16  shows a wire loop linkage  85  bonded in the middle to form a double-loop construction, having at least two loops, or in one embodiment, a “Figure-8” shape. A double-loop or a Figure-8 shape may provide additional safety in that if any portion of the wire loop linkage  85  fails, the linkage remains fixed to at least one of the suture clip  80  or the shuttle  70 . Conversely, a wire loop linkage looped through both the clip  80  and shuttle  70 , as a mere loop of wire, may fall into the body upon failing. In arthroscopic applications, this may create a dangerous situation for the patient. 
     A suture passer may also include one or more seating regions for receiving the tissue penetrating member on the opposite jaw from the one from which the tissue penetrating member extends. The seating region may releaseably (and alternatingly) hold and release the shuttle in variations including a shuttle. Thus, a suture passer device  10  may include a seating region  25  into which the tissue penetrator engages. This region may be referred to as a seat, a tissue penetrating engagement region, or a shuttle retainer or shuttle retainer seat. For example, the suture passers described in the U.S. Ser. No. 11/773,338 patent application (previously incorporated by reference) as well as provisional patent application U.S. Ser. No. 60/985,543 (herein incorporated by reference in its entirety) may include a cavity or opening into which a tissue penetrator  50  can be inserted. In these devices a suture shuttle  70  may be passed between the tissue penetrator  50  and the seat  25 , although shuttleless variations (as described below) may also include a seat region for engaging the tissue penetrator and suture  90 . 
       FIGS. 17-19  illustrate various embodiments of the shuttle retainer seat  25 ,  125 . The shuttle retainer seat may be positioned with respect to the lower jaw  21 , and in one embodiment, within the lower jaw  21  as shown. Hole and pin  126 ,  26 , respectively, may be for the attachment of a stiff member  32 ′ which may rotate the shuttle retainer seat to substantially match the motion, or angle of approach, of the tissue penetrator  50 , such that the shuttle retainer seat is moved to substantially match the angle of penetration of the tissue penetrator into the shuttle retainer seat. The amount of motion required may be dependent upon the distance the jaws  20  and  21  are spread apart. Thus, no matter the distance between jaws  20  and  21 , the shuttle retainer seat may move complimentary to any direction from which the tissue penetrator  50  is extending from jaw  20  towards jaw  21  and shuttle retainer seat  25 ,  125 . Opening  28 ,  128  in the suture retaining seat provides a throughway for a set screw or a retaining pin, for example, which may secure the shuttle  70  within the suture retaining seat. 
       FIG. 19  illustrates, in one embodiment, an example of the interaction of the shuttle  70  and the shuttle retaining seat  125 . The shuttle is lodged within the central cavity of shuttle retaining seat. The tissue penetrator may then enter through the central bore of both shuttle and shuttle retainer seat to retrieve the shuttle. 
     In another embodiment, illustrated in  FIGS. 17A-B , the shuttle retainer seat  25  may include flexible seat portions  27 , which may contact two sides of shuttle  70 , while providing additional clearance for shuttle and tissue penetrator during insertion and removal. The flexible seat portions  27  may provide dynamic clearance for expanding shuttle sides, during release from tissue penetrator  50 , thus accommodating shuttle flexure. Further, the device  10  may be more reliable because the flexible seat portions may lessen any effects of high forces during the seating process. 
     When these devices are used with some tissues, particularly softer tissues, tissue may prolapse into the seat as the tissue is secured between the jaws. This prolapsed tissue may prevent complete penetration by the tissue penetrator, and may also interfere with the operation of the suture passer. In order to prevent the tissue from entering the inner portion of the seat, the shuttle retainer seat  25  may include prominent side walls against which the tissue may be pressed by the collapsing of jaws  20  and  21  around the tissue. The side walls may stretch the tissue, or assist is pulling it taught, to prevent the tissue from prolapsing into the seat where the shuttle is retained. Maintaining pressure on the tissue during puncturing with the tissue penetrator may also form a cleaner cut by the tissue penetrator. These anti-prolapse features may also be incorporated into the non-moving lower jaw component  21  or on the upper jaw  20 , rather than on the shuttle retainer seat  25 , with spreading features disposed on each side of the shuttle retainer seat. 
       FIGS. 20A-B  illustrate one embodiment of the mechanics within lower jaw  21  concerning the shuttle retainer seat  25  and retaining pin  30 . As the figures suggest, in one embodiment, shuttle retainer seat  25  may pivot within lower jaw  21 , and retaining pin  30  may remain in contact throughout the seat&#39;s range of motion. 
     Retaining pin  30  may be moveable in the forward and rearward direction along its longitudinal axis, and may further be spring loaded to provide a force in at least one of the distal or proximal directions, as required. 
     Shuttle retainer seat  25  may, in one embodiment, include a cam surface  29  on which retaining pin  30  may at least partially interact. The cam surface  29  may limit retainer pin  30  movement, or depth, into the central bore of seat  25 , thereby eliminating interference of retaining pin with tissue penetrator  50 . Additionally, cam surface  29  may provide spring loaded rotation of shuttle retainer seat to the position needed to interact with the tissue penetrator. For example, the retaining pin  30  may be adjusted dependent upon the distance the jaws  20 ;  21  are apart. The adjustment of retaining pin applies a force on the cam surface  29  of seat  25 , thereby rotating the seat to the desirable position. In one embodiment, the cam surface  29  may maintain a precise retaining pin protrusion distance into the seat for any seat rotation angle. This may prevent the tissue penetrator from adversely interacting with the pin, aside from any proximal deflection of the retainer pin caused by the tissue penetrator contacting the pin radius  31 , as the tissue penetrator enters the seat. Further, a second portion of cam surface  29  (labeled as seat radius  29 ′) may interact with tissue penetrator  50  as tissue penetrator  50  extends into shuttle retainer seat  25 . This interaction may provide further alignment of shuttle retainer seat  25  and tissue penetrator  50  for tissue penetrator  50 -shuttle  70  interaction. 
     Additionally, once tissue penetrator  50  exits from shuttle retainer seat  25 , seat may return to its original position. This may occur once tissue penetrator terminates contact with seat radius  29 ′, allowing seat to return to its starting position. Upon withdrawal of tissue penetrator, retainer pin  30  returns to its distal position. Retainer pin may then also interact with cam surface  29  to return the seat to its original position. 
     In a further embodiment, shown in  FIG. 21 , retainer pin  30  may be considered passive, wherein the spring, which pushes the pin distally, is not displaced dependent upon the other factors, such as the distance between jaws  20  and  21 . As such, passive retainer pin  30  is held in a distal position in lower jaw  21 , which also therefore holds shuttle retainer seat  25  in a distal position as well. In this embodiment, shuttle retainer seat  25  includes a seat radius  29 ′, which is the radius of a portion of cam surface  29 , and retainer pin includes a pin radius  31 . Seat radius and pin radius may interact with tissue penetrator  50  upon extension of tissue penetrator from upper jaw  20  towards lower jaw  21 . As tissue penetrator  50  comes into contact with shuttle retainer seat  25 , it may contact both seat radius  29 ′ and pin radius  31 , thereby rotating seat  25  to the desired position (which is dependent upon tissue penetrator angle of entry, which is dependent upon the distance between the jaws), for tissue penetrator entry and collection of shuttle  70 . Similarly, the entry of tissue penetrator, upon contact pin radius  31 , pushes against pin  30  and pushes pin, against its spring force, in the proximal direction. In this embodiment, the lower jaw  21  mechanics are passive, and are adjusted to proper angles and positions by the tissue penetrator contacting the pin and seat radii to create the adjustment necessary for proper tissue penetrator-seat alignment for precise collection of shuttle  70 . 
     In yet another embodiment,  FIG. 22  illustrates a shuttle retainer seat  25  which may include a further degree-of-freedom aside from the aforementioned rotational degree-of-freedom. In one example, seat  25  may have a translational movement in the distal-proximal direction through at least a portion of the longitudinal length of lower jaw  21 . Arrow A illustrates the translational motion in the proximal direction, from the initial distal position of seat  25 . This added degree-of-freedom may provide further optimal alignment of seat with respect to tissue penetrator  50 . Further, it may provide a more compliant landing area for tissue penetrator, accommodating any tissue penetrator targeting errors which may occur. As such, seat  25  is not constrained to its exact mounting location on lower jaw  21 . 
       FIG. 23  illustrates a first embodiment of the initial set-up of suture passer device  10 , prior to use. In this example, shuttle  70  may be initially positioned within shuttle retainer seat  25 . Shuttle retainer seat may include a stop within its core to regulate the depth to which shuttle  70  may be positioned. Also, since inner core of seat  25  may be tapered, the stop would prevent jamming of the shuttle  70  within the taper. Spring  32  of retainer pin  30  may be used to preload shuttle  70 . As shuttle is inserted into seat  25 , retainer pin  30  moves proximally as shuttle engages pin radius  31 . Once the shuttle is in place, retainer pin  30 , through a force from spring  32 , returns to its distal position. In this position, retainer pin  30  may pass through a U-shaped notch  76  on shuttle  70  (see  FIG. 24 ), thereby securing shuttle within seat  25 . Upon retainer pin  30  returning to its distal position, spring  32  illustrates its function in lower jaw  21 . For example, in one embodiment, the spring&#39;s  32  distal force has several functions including, but not limited to: pushing retainer pin  30  distally to capture shuttle, pushing the seat distally into a receptive position for tissue penetrator insertion, providing rotational torque to rotate seat into an optimal angle for tissue penetrator insertion based on the interaction of cam surface  29  and retainer pin  30 . 
       FIGS. 24 and 25  further illustrate the interaction of shuttle  70  and retaining pin  30  in this embodiment. The U-shaped notch  76  is similar to the oval slot, or opening,  174  and  274  of other shuttle embodiments (see  FIGS. 6B and 7 ). However, unlike the oval slot, the U-shaped notch, of one embodiment, provides easier access into the area by the tissue penetrator, as well as allowing tissue penetrator to rotate seat  25  without portions of shuttle  70  interfering with process. 
     Similarly, in one embodiment, when shuttle  70  is located on tissue penetrator  50 , and tissue penetrator  50  extends from upper jaw  20  towards lower jaw  21  and seat  25 , the tip of tissue penetrator acts on seat and retainer pin  30  in much the same way as when shuttle is located within seat  25 . Therefore, as tissue penetrator  50  moves into the central bore of seat  25 , the tip of tissue penetrator  50  engages the seat radius and pin radius  29 ′ and  31  which may properly align seat  25  with tissue penetrator  50 , as well as push retainer pin  30  proximally and away from seat  25 . Once tissue penetrator  50  is extended fully into seat  25 , shuttle  70  may be within seat as well, and may further be in the proper position within seat for securing itself therein. Thus, retainer pin  30  may move distally once the U-shaped notch  76  passes through the longitudinal path of retainer pin  30 . As retainer pin  30  moves distally, it may pass at least partially through U-shaped notch, thereby securing shuttle  70  within seat  25 . The tissue penetrator  50  may then be retracted, leaving shuttle  70  within seat  25 . Tissue penetrator  50  may then extend once again into seat  25  to collect shuttle  70 , in which the reverse occurs and tissue penetrator  50  pushes retainer pin  30  proximally and shuttle  70  may then be collected. 
     In one embodiment, shuttle retainer seat  25  may be press-fit into lower jaw  21 . In a first example, as shown in  FIG. 26 , lower jaw  21  may include flexible side members  22   a  and  b,  which flex as shuttle retainer seat  25  is inserted into place. Once in place, flexible side members  22   a  and  b  return to their original position, securing seat in between them. As such, flexible side members may include a groove on the inner surfaces, or the like, so that the inner width in between the flexible side members is wider than on the edges. In a second example, as in  FIG. 27 , the side members of lower jaw  21  may include a tapered lead-in element  23  such that seat may be wedged within the taper. Other similar features may also be used to secure seat within lower jaw member  21 . 
     In an alternative embodiment, in  FIG. 28 , shuttle retainer seat  25  may instead be controlled by a stiff member  32 ′. Stiff member  32 ′ may rotate shuttle retainer seat, as the upper and lower jaws  20  and  21  move relative to one another, to maintain the proper angle with the tissue penetrator. The stiff member  32 ′ is controlled via mechanisms in the actuator  15  of device  10  to ensure proper alignment. 
       FIGS. 29A-29K  illustrate cross-sectional views of one embodiment of the interaction of shuttle  70 , shuttle retainer seat  25 , retainer pin  30  and tissue penetrator  50  at lower jaw  21 . Many of the operations discussed above would be used in this illustrated series of actions. In  FIG. 29A , shuttle  70  may be secured within shuttle retainer seat  25  by retainer pin  30  in lower jaw  21 . Tissue penetrator  50  is shown to be above lower jaw  21 . In  FIG. 29B , tissue penetrator  50  may pass through shuttle retainer seat  25 , where shuttle  70  may be located, and may push retainer pin  30  proximally. As discussed earlier, the shuttle retainer seat  25  may be movable to accommodate the entry angle of tissue penetrator  50 . 
     In  FIG. 29C , tissue penetrator  50  may extend fully into shuttle retainer seat  25 , engaging the shuttle  70 . Retainer pin  30  may move distally again, back to its original position, and into groove on the back portion of the tissue penetrator (as well as through the U-shaped portion of the shuttle  70 , not shown), due to the spring force pushing the retainer pin distally. 
       FIG. 29D  illustrates the retainer pin  30  being manually retracted proximally, through use of the actuator  15  (discussed below), to disengage the retainer pin from the shuttle  70 . In  FIG. 29E , the tissue penetrator  50 , with shuttle  70  engaged, may be retracted out of the lower jaw  21  and back towards upper jaw  20 . The shuttle  70  may be removed from the shuttle retainer seat  25  when the retainer pin  30  is retracted proximally, as shown.  FIGS. 29A-29E  illustrates one example of the tissue penetrator  50  engaging shuttle  70 , located in the shuttle retainer seat  25 , and retracting shuttle  70  up to upper jaw  20 . 
     In  FIG. 29F , the tissue penetrator  50 , with engaged shuttle  70 , may be retracted back to upper jaw  20 , and actuator  15  is released such that retainer pin  30  may move back to its original, distally located, position. This may be considered to be one pass of the shuttle  70 , which may have suture and/or suture clip attached. 
     In  FIGS. 29G-29K , an example of a second pass is illustrated where the shuttle is passed from the tissue penetrator  50  to the shuttle retainer seat. In  FIG. 29G , the tissue penetrator is extended from upper jaw  20  towards lower jaw  21 . Shuttle  70  may be engaged on tissue penetrator  50 . Retainer pin  30  may be in a distal position. 
     In  FIG. 29H , the tissue penetrator  50  and engaged shuttle  70  enter into shuttle retainer seat  25 . Retainer pin  30  may be pushed proximally by the tissue penetrator  50  and/or engaged shuttle  70 . In  FIG. 29I , the tissue penetrator  50  may be extended completely such that retainer pin  30  may return to a distal position, thereby passing through, for example, the U-shaped opening (not shown) on shuttle  70  and the groove within tissue penetrator  50 . Shuttle  70  may now be secured within shuttle retainer seat  25 , and may even still be engaged on tissue penetrator  50 . 
       FIG. 29J  illustrates tissue penetrator  50  retracting from shuttle retainer seat  25  and lower jaw  21 . Retainer pin  30 , though pushed proximally, once again, by the movement of tissue penetrator  50 , the spring (not shown) within retainer pin  30  may still be sufficient to maintain the retainer pin  30  in a position as distal as possible such that shuttle  70  may still be retained within shuttle retainer seat  25  by retainer pin  30 . The force on the shuttle  70 , applied by retainer pin  30 , and against the movement of tissue penetrator  50 , may cause a retaining structure, such as the dimple/divot structures discussed above, to disengage such that tissue penetrator and shuttle disengage from each other. Shuttle  70  is thus retained within shuttle retainer seat  25 . 
     In  FIG. 29K , the tissue penetrator  50  may retract completely away from shuttle retainer seat  25 , and retainer pin  30  may then move distally to return to its original position. Shuttle  70  is therefore secured within shuttle retainer seat  25  by retaining pin  30 . Tissue penetrator  50  may retract completely back to upper jaw  20 . 
     Thus  FIGS. 29A-29K  illustrate one embodiment of the interaction of the tissue penetrator  50 , shuttle  70 , shuttle retainer seat  25  and retainer pin  30 . This interaction may include the various mechanisms, structures and operations discussed throughout. 
     The jaws  20  and  21  can be moved totally independently of the tissue penetrator  50 . The jaws may be used to grasp and manipulate tissue prior to suture passage. As described below, since the tissue penetrator and jaws operate independently of one another, the jaws may be used as graspers without having to expose the tissue penetrator. 
     In one embodiment, the upper and lower jaws  20  and  21  may move kinematically in that they may remain substantially parallel to one another when the lower jaw is brought away from the upper jaw. For example, in  FIGS. 30A-B , illustrating one embodiment, lower jaw is pivotally attached to pivot arm  19 . Pivot arm  19  is then attached to sliding element  18  which may slide along the outer surface of shaft  17 . In this example, when lower jaw is moved away from upper jaw, sliding element  18  moves distally along shaft  17  such that lower jaw may remain parallel to upper jaw. This sliding movement compensates for the tracking error of the pivot arm, also known as a 4-bar linkage, such that the lower jaw may track the arc traversed by the tissue penetrator  50 . Additionally, this movement of the sliding element  18  allows the lower jaw  21  to remain substantially directly opposite the upper jaw  20  throughout the range of motion of the lower jaw. As a further example, if the lower jaw were not attached to the sliding element, the lower jaw, as it moves away from the upper jaw, would also move proximally, relative to the upper jaw, and thus be out of alignment with upper jaw. 
     Aside from the sliding pivot arm example above, other mechanisms such as, for example, gear drives, linkages, cable drives, and the like, may be used to ensure proper alignment of top and bottom jaws  20  and  21  during jaw actuation. The upper jaw  20  may be fixed in place as to shaft  17 . The fixed upper jaw may provide many advantages to a moveable upper jaw, such as providing a reference point for the surgeon, allowing for independent adjustability of the jaws and tissue penetrator engagement position, and the like. The parallel relationship of the upper and lower jaws  20  and  21  of this embodiment allow for easier manipulation of tissue, while also preventing the jaws from overly impinging any portion of the tissue. For example, if the jaws opened as a typical V-shaped pattern, then the proximal tissue, deeper into the V shape, would have excess force on it than the distal portion of the tissue, within the jaws. The parallel relationship ensures that the force of the jaws is spread equally throughout the tissue in between the jaws. 
     In an alternative embodiment, the upper jaw  20  may slide distally and proximally, while the attachment point of pivot arm  17  remains stationary. Thus, as the lower jaw moves away from the upper jaw, the upper jaw moves proximally to maintain alignment with the lower jaw. FIGS.  31  and  32 A-C illustrate this embodiment. Also illustrated in  FIG. 31  are the various entry angles of the tissue penetrator when the upper and lower jaws are at various distances from one another. 
     For example, the tissue penetrator will meet the shuttle retainer seat, located in the lower jaw, no matter the separation between the upper and lower jaws. Thus, the jaws may be clamped to tissue of any depth, and the tissue penetrator will pass through the tissue and hit the lower jaw directly at the shuttle retainer seat. For example, in  FIG. 31 , upper and lower jaws  20  and  21  may have an initial position (a). The expansion of the jaws, illustrated by positions (a)-(c), may occur by the lower jaw  21  pivoting away from upper  20 , while upper jaw  20  slides proximally to maintain a functional relationship between the jaws as the lower jaw  21  pivots.  FIG. 31  also illustrates the extension of tissue penetrator  50  from the upper jaw  20  to the lower  21 , in positions (a) and (b) to (d) and (e). Positions (d)-(h) of  FIG. 31  illustrate a further method wherein the simultaneous expansion of jaws  20  and  21  and extension of tissue penetrator  50  may occur. Additionally,  FIG. 31  illustrates in positions (c) to (h), the extension of the tissue penetrator  50  when jaws  20  and  21  are expanded. As such,  FIG. 31  illustrates one embodiment of the device  10  in which the lower jaw  21  may track the arcuate path of tissue penetrator  50 , such that tissue penetrator  50  may engage the lower jaw  21  at the substantially same position regardless of the position of the lower jaw  21 .  FIGS. 32A-C  further illustrate the arcuate path the lower jaw  21  may travel. 
     The size of the suture passer device  10  may be any size useful in performing surgery on the body. For example, for many arthroscopic joint surgeries, the upper and lower jaws may be around 16 mm in length, though a length of up to about 25 mm is obtainable. This may be significantly scaled down for a device for use in, for example, wrist surgery. Alternatively, a larger device, with larger jaws, may be useful for hip or torso surgery. 
     In further examples, the suture passer device may, for example, be able to pass suture through any tissue up to about 10 mm, though a scaled up version of the device may allow for greater amounts of tissue. Moreover, in most embodiments, the device may pass through a standard 8 mm cannula. 
     Actuator Mechanism Examples 
     The suture passer devices  10  described above may include, for example, three types of controlled motion: (1) the open/close movement of the jaws, whereby at least one jaw moves relative to the other; (2) the extension/retraction of the tissue penetrator; and, optionally, ( 3 ) the retention/release of the shuttle retaining pin  30  from the seat  25  on the second jaw. Although there are numerous ways in which these motions may be accomplished, including those described in the Ser. No. 11/773,338 application, and various provisional applications already incorporated by reference herein, described below are mechanical assemblies (also referred to as “layers”) that may be used to precisely control these three types of motions of the suture passer. These layers are referred to as the jaw motion control layer or the conjugate motion control layer (controlling the relative motion of the jaws), the tissue penetrator control layer (controlling the motion of the tissue penetrator), and the retaining pin control layer (controlling the motion of the shuttle retainer seat and/or retaining pin). 
     Although these layers are described here in the context of a suture passer, it should be clear that the techniques and principles described herein may be applicable to other devices, particularly those having movable jaws and/or other movable features. For example, the conjugate motion control layer may be used to control a forceps, clamp, or other device. Thus, the invention should not be limited to the figures described herein, or the specific embodiments. 
     1. Jaw Motion Control Layer 
     The jaws  20  and  21  move to open and close in parallel. This means that the inner surfaces of the jaws (e.g., the downward-facing surface of the upper jaw and the upward-facing surface of the lower jaw) open and close so that they are substantially parallel. The jaws also move so that the tissue penetrator  50  extending from the first jaw contacts roughly the same position on the second jaw, for example, the shuttle retainer seat  25 , when the tissue penetrator is extended, regardless of how open or how closed the jaws are relative to each other. 
     It should also be pointed out that the conjugate motion of the jaws may also be semi-parallel. For example, in one variation, the device may have a non-parallel 4-bar linkage by changing the length of the links, resulting in a semi-parallel motion. This may be beneficial for some surgical procedures. 
     In a first embodiment, illustrated in  FIG. 33 , the lower jaw control mechanism may control both the lower jaw  21  opening and closing, as well as the movement of sliding element  18 . While two separate mechanisms may perform the same function overall, the present invention is capable of using a single lower jaw control mechanism to perform both movements with a single mechanism. The coordination of these two motions allow lower jaw  21  to accurately track the arcuate path of the tissue penetrator  50  extending from upper jaw  20 , which in this example, is stationary. 
     In this example, the actuator  15  encloses a jaw trigger  304  which may serve as the manual interface for the user. The trigger  304  may be pushed or pulled, along arc B, depending on the desire of the surgeon to open or close the lower jaw  21 . The mechanism may include two linear bushings  302 , which drive the respective control rods and links  301  to activate the sliding element  18  and the lower jaw  21  and pivot arm  19 . Each bushing is responsible for the movement of one of the lower jaw  21  and pivot arm  19  or the sliding element  18 . The pivot point  303  of the trigger  304  is at different distances from the two linear bushings  302 . Thus, the bushings drive the control rods and links  301  at relatively different rates and distances. Thus, the actual traveling distances of the lower jaw  21  and sliding element  18  may be different. These distances may be determined and set so that the lower jaw  21  travel approximates the same arcuate path as tissue penetrator  50 . 
     This mechanism may be rigid in order to minimize errors as to clamping pressure and location during use. 
     The jaws  20  and  21  may also be locked in any position by a lock, such as a valve, latch, pin or the like. This is important because it allows leverage for penetrating the tissue, such that one may bear down on the trigger for the tissue penetrator without worrying about damaging the tissue. 
     In one embodiment, illustrated in  FIGS. 34A-C , a locking mechanism may be a ratchet mechanism  309 . Ratchet  309  may be positioned on trigger  304 , and may further have an interface portion  306  placed on finger spaces of trigger  304 , which allows for convenient use by a user. A pawl  305  includes the ratchet  309 , interface portion  306  and a pivot  307 . A spring  308  may be included to provide a set position of pawl  305 . In the illustrated example, the spring  308  provides a set position of the ratchet being engaged, however, any configuration may be used. 
     In operation, this exemplary lock may allow the user to lock the jaws  20  and  21  at a set distance from one another. The user may pull trigger  304  backward, using a first finger at location  304 a, until the jaws are at the desired clamped position around tissue. While the trigger is pulled, the ratchet, in the engaged set position, allows the trigger to move backward, but will not allow the trigger to move forward. Spring  308  maintains a force on pawl  305  to ensure ratchet remains engaged. Thus, the trigger moves from a first position,  FIG. 34A , to a second position,  FIG. 34B , and is secured by ratchet  309 . The user may then proceed to do other procedures, such as extending the tissue penetrator or the like. This mechanism may assist the user in maintaining jaw position during tissue penetrator deployment, as well as maintaining constant pressure on the tissue to increase tissue penetrator targeting accuracy. Of course, engaging the ratchet and locking the jaws in place may solely be used as a grasper, without deploying the tissue penetrator. Once the user has completed the task, and is ready to disengage the jaws  20  and  21 , the user may press the trigger at the second position  304   b,  using a second finger, thereby also pressing on interface portion  306  which may disengage the ratchet  309 . The interface portion  306  is pressed hard enough to disengage the ratchet, but light enough to allow the trigger  304  to move forward and open the jaws, as illustrated in  FIG. 34C . 
     In one embodiment, the pawl  305  is attached to trigger  304  at pivot  307 , and the ratchet portion  309  may be secured to the actuator shell ( 15 , generally) such that it is in a fixed position. 
     2. Tissue Penetrator Control Layer 
     As illustrated in  FIGS. 35A-B , one embodiment of the components that make up the tissue penetrator control layer may include at least the tissue penetrator  50 , coaxial tissue penetrator push/pull rod (not shown, but connects drive block  356  with tissue penetrator  50 ), and the subassembly linking the push/pull rod to the tissue penetrator control trigger  355 . The tissue penetrator control trigger  355  may act directly on the tissue penetrator. 
     In one embodiment, the trigger  355  is a push/pull system, meaning the trigger can be either pushed or pulled, along path LC, to direct the tissue penetrator in or out of upper jaw  20 . The trigger  355  may be spring loaded, such that, for example, the trigger is biased such that the tissue penetrator  50  is retracted, within the upper jaw  20 . 
     The trigger  355  may further include a first pivot  359 , wherein the rotational motion of the trigger  355  is turned into linear motion of the drive block  356 , along path D, through the connection at a pin and slot interface  358 . The drive block is limited to linear motion by the use of at least one linear bearing  357 . The linear motion of drive block  356  applies a force directly on the tissue penetrator  50  to push and pull the tissue penetrator as desired by the manual motions of the surgeon. 
     As illustrated in  FIGS. 38A-C , the tissue penetrator control may further include limit stop capabilities to prevent tissue penetrator from advancing too far into shuttle retainer seat  25 . Further, the limit stop  349  is correlated to the amount the jaws  20  and  21  are open, such that for example, the limit stop  349  allows a wide range of motion when the jaws are spread far apart, and a narrower range of motion when the jaws are closer together. 
     The limit stop  349  may be directly correlated such that the stop occurs precisely when the tissue penetrator  50  is in the correct location within the seat  25 . Furthermore, this limit stop  349  may be related to limit stop  335  in retainer pin  30  actuator ( FIG. 37A ), such that retainer pin  30  only actuates when tissue penetrator is within seat  25  in a location wherein it may collect shuttle  70 . 
     Limit stop  349  may be located on drive block  356 , but interacts with the jaw control layer, discussed above, such that it may provide a proper limit stop customized to the position of lower jaw  21  in relation to upper jaw  20 . 
     Limit stop  349  operates to limit the motion of drive block  356  to a certain distance required. This certain distance is determined by the distance the jaws are spread apart. For example, in  FIGS. 38A-B , the trigger  304  is positioned such that the jaws are fully open. Thus, the tissue penetrator, if activated at the point as shown in  FIG. 38A , the tissue penetrator would have to travel a long distance, to the position shown in  FIG. 38B , to span the gap between the upper and lower jaws. Thus, as can be seen by the change in distance between the two reference lines a′ and b′, from  FIG. 38A  to  FIG. 38B , the drive block  356  travels a large distance, denoting a large distance the tissue penetrator has moved. Conversely, in  FIG. 38C , the trigger is positioned such that the jaws are in a closed position. Comparing the reference lines a′ and b′ in  FIGS. 38A and 38C  illustrate that the drive block would travel a much shorter distance in  FIG. 38C , than in  FIG. 38A  to  FIG. 38B . The distance the drive block can travel is in direct relation to the change in position of trigger  304  altering the distance between it and the stop limit  349 . 
     3. Retaining Pin Actuator Control Layer 
     In one embodiment, the retaining pin actuator control may be located within and incorporated into the tissue penetrator control layer, previously discussed. Such a relationship between the tissue penetrator and actuator pin may be beneficial in achieving accurate communication between both elements in the jaws  20  and  21 .  FIGS. 36A-B  illustrate two pivot points  358  and  359  within the tissue penetrator control layer, which may work consecutively. Pivot point  358  is the aforementioned pin and slot interface which may interface the trigger  355  with the retainer control layer. Pivot point  359  may control tissue penetrator  50 . 
     In operation of this first embodiment, the trigger  355  is pulled, for example, and may pivot around first pivot  359  to extend tissue penetrator  50 . Once tissue penetrator is fully extended, the trigger reaches a stop, at the position illustrated in  FIGS. 35B and 36A . If the user continues pulling on the trigger, the trigger may then pivot around the pin and slot interface  358 , which may pull the retaining pin  30  proximally, and away from shuttle retainer seat  25  and shuttle  70 . 
     As discussed above, in one embodiment, the retainer pin  30  may be passive, meaning that the tissue penetrator  50  may be inserted into the lower jaw  21  without having to first retract the retainer pin  30 . This is possible because of the pin radius  31  and spring  32 . 
     Retainer pin control layer may further include, in one embodiment, a capstan  340 ,  FIGS. 37A-C , which interfaces the retainer pin  30  with trigger  355 . Capstan  340  may include a connection with retaining pin  30 , such as a wire  333 , a spring  336 , and a reset interface  334  and stop pin  335 . The capstan may be pulled proximally by trigger  355 , in the direction shown as line E in  FIG. 37B . Capstan moves proximally, as reset interface  334  moves past stop pin  335 . A projection  337  on reset interface  334  may move from one side to the other of stop pin. At this point, capstan may be secured in place, thereby securing the retainer pin  30  in place at a position proximal to its normal, passive position adjacent shuttle retainer seat  25 . Stop pin  335  may be released when driver block  356  returns to its rest location. Once trigger  355  is released, driver block  356  may return to its starting position, which may release capstan  340  by interfacing with the reset interface  334 , to disengage stop pin  335 , which then may return retainer pin  30  to its starting position. 
     Wire  333 , as illustrated in  FIGS. 37A-C , may connect capstan  340  with retaining pin  30 . Wire  333  may run through two pulleys,  333 ′ and  333 ″. At least one of the pulleys, as shown in  FIGS. 39A-B , shown as pulley  333 ′, may be positioned within actuator  15  in a stationary position such that does not move relative to the device  10 . Pulley  333 ″, however, may be positioned such that it moves with the jaw actuation mechanism layer. For example, in  FIG. 39A , the jaws  20  and  21  are open relative to one another, and in  FIG. 39B  the jaws are closed. When the lower jaw moves to a closed position, it comes in line with shaft  17 , in effect, shortening the distance between retainer pin  30 , in the lower jaw  21 , and pulley  333 ″. As a result, the wire  333  would be too long. However, if pulley  333 ″ moves backward, as shown in  FIG. 39B , it will maintain the same distance between retainer pin  30  and pulley  333 ″, thereby preventing the wire  333  from losing tension as lower jaw  21  closes. 
     The retainer actuator control layer may further include a bi-modal stroke limiter, or the like. This limiter ensures that the retaining pin  30  is only actuated when shuttle  70  is properly positioned within shuttle retainer seat  25 .  FIGS. 40-43  illustrate various configurations of the bi-modal stroke limiter. 
     For example, in a typical tissue penetrator operation cycle, the tissue penetrator trigger  355  may pull capstan  340  in the proximal direction, thus pulling retainer pin  30  using wire  333 . Spring  336 , extending from capstan  340 , links with trigger  355 . Trigger  355  may include slide block  341 , which houses, on its underside, a wire-form pin  342 . The operation cycle has, for example, four cycles in which wire-form pin has four positions: 1) stable resting position, 2) short travel position, 3) stable resting position, and 4) long travel position. Position (1) is illustrated in  FIGS. 40A-B  and  43 A. The spring  336  is lax, and trigger  355  is not engaged. Wire-form pin  342  is also at a resting position, against the body of slide block  341 . Position (3) is identical to Position (1), except the actual position of wire-form pin  342  may be different, as in  FIG. 43C , but still designates a rest position. Position (2), illustrated in  FIGS. 41A-B  and  43 B, is for a short travel, in which only the tissue penetrator  50  is activated. The capstan remains in position, and retainer pin  30  remains in position adjacent shuttle retainer seat. In Position (4), as in  FIGS. 42A-B  and  43 D, long travel takes place in which spring  336 , capstan, wire  333  and retainer pin are activated, thereby moving retainer pin proximally. 
     The wire-form pin  342  is located within a labyrinth  343  on the underside of side block  341 . The various cycles are denoted by the various positions of the wire-form pin within the labyrinth. 
     Undesirable movement within the linkage between the capstan  340  and trigger  355  may be absorbed by spring  336 . Once spring is extended, over-travel of mechanism may be handled by the stiff extension property of the spring  336 . Spring  336 , therefore, operates to absorb shocks and unwanted movements within the mechanism, which may ensure smooth and predictable operation. 
     In some other embodiments of the device, at least a portion of the device, for example, a control system, may be electronic. For example, hardware, firmware, and/or software may be used to control the motion of the jaws, shuttle retainer/seat, shuttle, and/or tissue penetrator. For example, a RISC chip, e.g., a PIC (Microchip Corp.) processor may coordinate and control the upper jaw position relative to the lower jaw (conjugate motion), in the embodiment where the upper jaw is movable, by using a potentiometer or similar position encoder on the trigger. A linear or rotational electromagnetic actuator may be used to position the upper jaw. Further, it could also control an electromagnetic brake, if needed, to lock the position of the upper jaw. 
     Additionally or alternatively, a processor could also handle all of the retainer actuator functions. It could receive input or calculate whether the shuttle is going up or down, and it could control the retainer cable tension by way of another electromagnetic actuator, such as a simple solenoid or length of shape memory alloy actuator wire. Such devices could trade many machined and molded parts, as previously described, for off the shelf actuators commonly used in high volume consumer devices. This could drastically reduce total cost of goods and allow more precise timing of retainer actuator events. 
     In a further example, the tissue penetrator and/or shuttle retainer seat relative position could also be monitored with a sensor and thus close the loop, electronically ensuring that the tissue penetrator always finds its target even under severe usage conditions. This kind of closed loop control may be regulated with a microprocessor. Electronics, or firmware, is very reliable and immune to tolerances. As the device is scaled, for example, shrunk for laparoscopic applications, there may be additional ways to offset the added expense and adapt to the even more severe precision requirements. An embedded/electromagnetic solution is one possibility. 
     In some embodiments, the suture passer device  110  may pass a suture back and forth through a tissue or tissues without the use of a suture shuttle. 
     In general, the shuttleless suture passers may have two jaws that may open and close in parallel and pass a suture between them. A tissue-penetrating member may releasably grasp a suture and hand it off to a suture retainer that can also releasably grasp the suture.  FIG. 44  illustrates one embodiment of a shuttleless suture passer that includes an upper jaw with a suture grasper and a lower jaw with another suture grasper. 
     In  FIG. 44 , the suture  90  is initially held in the upper jaw of the suture passer. The lower jaw and the upper jaw may be opened and closed in parallel to any degree, so that tissue can be secured between them. The tissue penetrator can be extended from within the upper jaw, through any tissue between the jaws, and into the engagement region on the lower jaw. Once in the engagement region, the upper suture grasper (not visible) releases the suture into the lower suture grasper in the lower jaw. After retracting the tissue penetrator, at least part way, out of the engagement region, the device may be repositioned so that the suture can be passed from the lower jaw to the upper jaw. The tissue penetrator including a suture grasper may be extended into the engagement region again, and the suture grasper in the lower jaw can be toggled by, for example, engaging the tissue penetrator, to release the suture into the suture grasper on the tissue penetrator. Retracting the tissue penetrator pulls the suture back through the tissue towards the upper jaw. 
     As mentioned, any appropriate suture grasper may be used. For example, mechanical suture graspers may releasably secure the suture between two or more surfaces by squeezing the surfaces together. In general, the suture graspers such as the surfaces or jaws may be controlled automatically or manually. 
     In another embodiment of tissue penetrator, the tissue penetrator  250  may include a carabiner element which may secure the shuttle to the tissue penetrator. For example, the carabiner element pivots on one end and provides an opening on the opposite end, as illustrated in  44 . The shuttle  370 , or alternatively, the suture  90 , may interact with the flexible carabiner element to latch onto the tissue penetrator. Alternatively, one end of the carabiner element may pivot on an hinge, and thus the carabiner element may be rigid. 
     In some embodiments, there may be additional shuttle retention devices. For example, in  FIGS. 46-48 , a shuttle retention device may include a passive spring latch  52 ′ that is integral to the tissue penetrator. For example, the passive spring latch may be a small wire-formed or etched spring steel part attached to the tissue penetrator  350  on the backside in the groove for retaining pin clearance. Attachment may be, for example, through welding, gluing, screwing, clipping, or the like. Further, spring latch  52 ′ may be part of tissue penetrator  350 , wherein no attachment is necessary since spring latch  52 ′ is integral to tissue penetrator  350 . The shuttle retention may be assured with this snap latch feature. This may allow relaxing tolerances on the shuttle and reduce engage/disengagement forces overall. The same retainer pin that is alternately disposed in the shuttle&#39;s slot feature  274  to retain it in the lower jaw may still be used. Now, in this example, it may push the new latch beam spring part in distally, thereby releasing the shuttle from the tissue penetrator. As the tissue penetrator is retracted, the retainer pin  30  works as usual to retain the shuttle as it is pulled off the tissue penetrator. 
     One variation of this embodiment may be a leaf-spring member  52 ′ with a tab/hook on the end which may be laser-welded to the tissue penetrator, and may form a clip that retains the shuttle. The retainer pin  30  would press the tab to release the shuttle at the appropriate time. 
     Surgical Methods 
     The exemplary methods described herein may be performed with continuous suture passers such as those described above, including those having jaws that open and close while remaining in an approximately parallel orientation (e.g., relative to the upper and lower tissue-contacting surfaces of the jaws). In addition, the suture passer jaws may lock so that tissue can be secured between them, and the suture passed by means of a tissue penetrator that carries the suture, which may be attached to suture shuttle, between the two jaws. In particular, these methods may be performed using a device that is configured to pass the suture between the jaws regardless of the position of the jaws relative to each other, and thus the jaws are not required to be in a particular position in order to pass the suture therebetween. 
     Many of the continuous suture passers described above are configured so that the tissue penetrating member (e.g., needle element) may be completely retracted into the device during operation, preventing damage to tissue. In general, this may mean that the distal end (the leading end) of the tissue penetrating member may be withdrawn completely into the jaw of the continuous suture passer from which it may be extended. Thus, this jaw may have a substantially flat (atraumatic) surface for contacting tissue when the tissue penetrating member is completely retracted. Many of these continuous suture passers may therefore be used as a clamp or grasper when the tissue penetrating member is completely retracted. In some variations, using the device when the tissue penetrating member is partially extended may allow the device to be operated to cut tissue (via the tissue penetrating member). 
     Any of the continuous suture passers described herein may be used to form one or more complex suture patterns in tissue. Because these devices may be used to pass a suture (continuously, without requiring ‘reloading’ of the suture), they may be used to stitch or perform a procedure having a complex suture stitching pattern that requires passing the suture through a tissue in multiple directions (e.g., first up through the tissue, then down through the tissue). 
     The following methods are examples only, the present invention is not limited to these explicitly recited examples but may be used in other similar surgical methods. 
     The present invention is capable of tying numerous types of sutures and knots known in the art including, but not limited to Modified Mason-Allen stitch, Figure-8 stitch, Margin Convergence Stitch, Incline Mattress Stitch, and Medial Row Modified Mason-Allen Stitch. Examples of these are provided below, and illustrated. 
     1. Medial or Lateral Meniscus Repair 
     An arthroscope may be inserted through a standard anteromedial or anterolateral portal and the knee joint is distended with saline in standard fashion. A posteromedial posterolateral portal site may be created and the suture passing device may be placed into the joint. The jaws of the suture passing device may open and be placed around the peripherally torn meniscus in such a fashion that the tear is spanned by the jaws in an approximately perpendicular fashion as illustrated in  FIG. 49 . The meniscus capsule is slightly depressed by the capsular sided jaw to allow good purchase across the tear. The tissue penetrator may be, in one embodiment, passed from the first jaw to the second jaw with the suture. Alternatively, in another embodiment, the suture shuttle may be passed across the meniscal tear via its reversible attachment to the tissue penetrator, while the tissue penetrator is not released from the upper jaw. 
     The knot may then be tied and the meniscus hence repaired. An alternate design embodiment may allow passage of suture from the anteromedial or anterolateral portal, as illustrated in  FIGS. 50A-D . 
     2. ACL Repair and Reefing 
     Standard anteromedial and anterolateral arthroscopic knee portals may be established and the camera and the suture passing device may be inserted into the joint. The parallel jaws may be open and may be moved into position around the attenuated (post traumatically healed in an elongated state) anterior cruciate ligament, as is illustrated in  FIG. 51 . The tissue penetrator may then be deployed from the first jaw to interact with the second jaw, thereby passing the shuttle and/or suture across the ligament. The distal end of the suture passer may then be moved to a different position on the ligament and the shuttle and/or suture may then be passed back from the second jaw to the first, thereby contacting the tissue penetrator once again. The suture may be tied by alternating the suture end between the jaws in standard knot tying fashion. The procedure is repeated until the ACL is of the appropriate length and tension. 
     3. Medial Patellofemoral Ligament Reefing 
     The arthroscope may be inserted through a standard inferolateral portal and the knee joint is distended with saline in standard fashion. The inferomedial portal is then created and the suture passing device may be inserted into the patellofemoral joint space. The attenuated medial patellofemoral ligament is identified. Sutures may be arthroscopically placed across the length of the ligament with the suture passing device alternating the shuttle and/or suture between the first and second jaws. Knots may be tied with the device by placing the free end of suture between the jaws and passing the shuttle and/or suture from the first to the second jaw. This may be repeated after moving the jaws into standard simple knot forming positions and the knot is cinched by moving the distal end of the passer away from the suture site while holding tension on the opposite suture limb. This may be repeated until about 3-4 hitches are placed, and then the free ends are cut. This process may be repeated as necessary until the ligament is shortened, reefed, imbricated, or the like to the desired length and tension. Lateral patellar glide is then checked and confirmed to be decreased. 
     4. Medial Patellofemoral Ligament Repair 
     The arthroscope may be inserted through a standard inferolateral portal and the knee joint is distended with saline in standard fashion. The inferomedial portal is then created and the suture passing device may be inserted into patellofemoral joint space. The edges of the torn medial patellofemoral ligament are identified and the suture passer jaws may be approximated around the medial aspect of the torn leading edge of the ligament. A horizontal mattress or simple type suture pattern, for example, may be passed arthroscopically with the suture passer device by passing the shuttle and/or suture from the first jaw to the second jaw. The lateral leading edge of the torn medial patellofemoral ligament is then identified and the device may be used to pass the shuttle and/or suture from the second jaw back to the first jaw, and the knot is tied to secure the repair. This process may be repeated until the two ends of the ruptured ligament are reapproximated and hence repaired 
     5. Minimally Invasive Achilles Tendon Repair 
     An about 1-2 cm transverse or vertical incision, for example, may be made in close approximation to the site of rupture of the Achilles tendon. The peritendon is identified and separated from the torn tendon. The edges of the tear are debrided and prepared in standard fashion. The skin and soft tissues may be gently retracted to allow insertion of the suture passing device. The suture passer may be slid underneath the peritendon and the jaws are opened and approximated around the leading edge of the proximal stump of the torn Achilles tendon, as illustrated in  FIG. 52 . A horizontal mattress or simple type suture pattern, for example, may be passed with the suture passer device by passing the shuttle and/or suture from the first jaw to the second jaw, moving to an alternate location on the same tendon fragment, and then passing from second jaw to first jaw. This process is repeated on the distal tendon stump. The two ends of the ruptured ligament are then reapproximated by tying the placed sutures together at the rupture site. 
     6. Superior Labrum Anterior Posterior Repair 
     A posterior shoulder portal may be created for camera placement in standard fashion. A standard anterior portal may be made just superior to the subscapularis tendon and an about 8 mm cannula is placed into the shoulder joint. A standard labral repair suture anchor is placed into the superior glenoid rim in the appropriate position for the repair. One limb of the suture is then brought out of the anterior portal with a crochet hook. The suture passer device may then be loaded with the free end of the suture and inserted through the cannula. The jaws are approximated around the superior labral tear as depicted in  FIGS. 53A-C . The suture may then be passed from the first jaw to the second jaw. The suture may then either be tied using the suture passer by alternating the shuttle and/or suture between the jaws or it can be tied using standard sliding knots and a knot pusher. 
     7. Arthroscopic Bankart Repair and Capsular Shift for Glenohumeral Labral Repair: Anterior Inferior or Posterior Inferior 
     Standard shoulder arthroscopy portals may be created and the suture passer device may be inserted into the glenohumeral joint. A suture anchor may be placed at either the 7 or 5 o&#39;clock position on the glenoid rim. One limb of suture from this anchor may then be brought out through a cannula and loaded into the suture passer device. The unstable inferior labral tissue and capacious capsule may be grasped by the suture passer device and the tissue penetrator may then be deployed sending the shuttle and/or suture through the desired tissue from the first jaw to the second jaw, as illustrated in  FIG. 54 . The suture is then tied to the other suture limb in standard labral repair fashion. 
     8. Arthroscopic Biceps Tenodesis 
     A standard shoulder arthroscopy is performed. The jaws of the suture passer may be placed around the biceps tendon and the shuttle and/or suture is passed back and forth across the tendon. The biceps is then cut from its superior labral attachment and tenodesed in standard fashion. 
     9. Arthroscopic Hip Labral Repair 
     Standard hip arthroscopy portals are created. The hip labral tear is evaluated and a portal may be created to maximize positioning of the cannula for insertion of the suture passer. A suture anchor is placed in the acetabular rim at the level of the labral tear in standard fashion. The passer may be loaded with a free end from the anchor and the jaws may be placed around the torn labrum. The shuttle and/or suture may be passed from the first jaw to the second jaw through the labral tissue. The suture ends are tied in standard fashion. 
     10. Arthroscopic Brostrom for Ankle Ligament Instability 
     Standard ankle arthroscopy portals are created. The suture passer device may be inserted into the ankle joint and the attenuated lateral ankle capsule and calcaneofibular ligament are identified. Multiple sutures may then be passed through the ligament and capsule by alternating the shuttle and/or suture from the first jaw to the second jaw and back to the first, as necessary. As standard knots may be tied the CFL and capacious capsule are tightened to the appropriate tension and the lateral ankle hence stabilized. 
     11. Arthroscopic Triangular Fibrocartilagenous Complex Repair (TFCC Repair) 
     Standard wrist arthroscopy portals are created and the arthroscope may be inserted into the wrist and directed toward the ulnar side. A small-sized embodiment of the suture passer device may then be inserted into the wrist joint. The tear in the TFCC may then be grasped with the suture passer device and suture may be passed from the first to the second jaw. The distal end of the passer may then be moved to surround the opposite side of the TFCC tear and the tissue penetrator may again be deployed, this time sending the suture from the second jaw to the first. The suture is tied in standard arthroscopic knot tying fashion. This pattern is repeated until the TFCC tear is completely repaired. 
     12. Medial Row Modified Masson-Allen Double Row Rotator Cuff Repair 
     Standard shoulder arthroscopy portals are created and the camera is inserted into the subacromial space. A standard subacromial decompression is performed. A suture anchor may then be placed at the medial aspect of the greater tuberosity in close proximity to the humoral head cartilaginous surface. One limb of suture from the anchor may then be loaded into the suture passer device and the device may be inserted into the joint. The jaws may be placed around the leading edge of the rotator cuff tear and the tissue penetrator may be deployed to send the shuttle and/or suture from the first jaw to the second jaw. This passed suture end is then removed from the subacromial space through an anterior portal, illustrated in  FIG. 55A . The suture passer device may then be loaded with the other suture strand from the medial row anchor and the device is reinserted into the subacromial space. The jaws may again be approximated around the leading edge of the torn rotator cuff tendon and the suture is passed from the first jaw to the second jaw, as in  FIG. 55B . The distal end of the suture passer device may then be moved to the right or left and the tissue penetrator may be re-deployed to send the suture from the second jaw to the first, as illustrated in  FIG. 55C . The distal end of the suture passer device may then be moved into a position that is medial to and in between the previous passes and the suture may again be passed from the first jaw to the second jaw, as in  FIG. 55D . The knot may be tied using the suture passer device or using standard knot tying techniques, as those illustrated in  FIGS. 55E and 56A . The two strands of remaining suture from the tied knot may then be brought laterally and tied down to a lateral row knotless anchor using standard techniques, such as those in  FIGS. 56B-C . 
     13. Spinal Surgery 
     Dural tears are a common complication during spine surgery. If improperly closed they can lead to the development of dural-cutaneous fistulas, pseudomeningocele, and meningitis. Dural tear that are discovered or caused intraoperatively are best treated by direct repair, a facial graft, or both. 
     Annular incisions are commonly made during microdiscectomy to allow access to the nuclear material. The annular incision is uncommonly closed secondary to difficulty manipulating suture and the tissue penetrator in this space. Sewing the annular incision would likely decrease recurrence rates of disc herniation. Thus a continuous suture passer would be useful to repair this incision. 
     A standard microdiscectomy posterior approach to the spine is performed. As  FIGS. 57-58  illustrate, the jaws of the suture passer device may be placed around the dura (or annulus) at one side of the tear. The suture,may be passed from the first jaw to the second jaw. The jaws may then be positioned around the contralateral side of the tear, and the suture may be passed from the second jaw to the first jaw. A standard knot may then be tied. The procedure may be repeated until the tear is completely repaired. 
     The continuous sutures passers described herein may be used to repair tissue in a manner that offers many advantages over other methods of tissue repair. For example, during repair of a tendon of the knee, such as the medial collateral ligament, the continuous suture passers described herein may be used to repair the tendon in a more minimally invasive way than other suture passers, including other continuous suture passers.  FIGS. 59A to 59D  illustrate the repair of a tendon using the continuous suture passer described herein. The region adjacent an above the tendon in the figure is the medial bursa. In  FIG. 59A , the suture passer is positioned around the tendon by opening the jaws with the tissue penetrating member completely retracted into the upper jaw (not visible in  FIG. 59A ). A suture shuttle, preloaded with a suture, is secured in the lower jaw in a shuttle retainer seat. In  FIG. 59B  the upper jaw fits between the tendon to be sutured and the medial bursa without requiring substantial removal/cutting of the medial bursa. This may help preserve the blood supply to the tendon, and therefore enhance healing. 
     In  FIG. 59C , the tissue penetrating element is extended from the upper jaw, through the tissue, to engage the shuttle retainer seat in the lower jaw, where the suture shuttle is located, allowing the suture shuttle to engage the tissue penetrator so that it can be withdrawn back through the tissue with the tissue penetrator, pulling the suture though the tissue, as illustrated in  FIG. 59D . 
     As indicated above, a continuous suture passer including one or more of the features described herein may also be used to perform complex suture patterns. A complex suture pattern typically involves passing the suture back and forth (e.g., “top to bottom”) through the tissue multiple times, as indicated in the examples described below in  FIGS. 60A-73B . 
     For example,  FIGS. 60A-60R  step through one method of performing a complex suture technique that may be used to repair tissue. In this example the tissue shown is the rotator cuff, including the tendon (rotator cuff tendon) and humerus bone. In  FIG. 60A , the tendon is shown and may be accessed by one or more cannula (two are shown) for arthroscopic repair. The method described is a method for arthroscopic repair of the tissue involving a medial row modified Mason-Allen repair. As shown in  FIG. 60A , a suture may be initially anchored to the tissue (in this example, the humerus) by a screw or other anchor. The ends of the suture are held through a first cannula; the first cannula may provide access for the device and step of anchoring the suture. In  FIG. 60B  a hook (e.g., a crochet hook or crab claw type hook, or any other appropriate grasper) is used to pull one end of the suture into the second cannula, as illustrated in  FIG. 60C . This end of the suture may be connected to a suture passer (not shown), which may be extended through the second cannula as shown in  FIG. 60D . 
     In this example, the suture passer includes two jaws that may be opened substantially in parallel with each other, as discussed above. The suture passer also includes a tissue penetrating member (needle) to which a shuttle may be releasably attached. The suture is attached to the shuttle, as discussed above.  FIGS. 60E and 60F  illustrate the opening of the jaws of the suture passer, and positioning the jaws over the tissue to be stitched. In this example, the jaws open so that the tissue-contacting surfaces between the jaws are substantially parallel. In addition, the distal end of the tissue penetrating member is completely retracted into the jaw from which it extends (the upper jaw in this example). This allows the continuous suture passer extend well over the tissue to be stitched, allowing it to be positioned over the tissue without injuring it. The suture passer may also act as a clamp by closing the jaws over the tissue. 
     Once the jaws are positioned over the tissue, they may be closed over the tissue or left loose, as shown, ( FIG. 60E ) and the tissue penetrator (shown as a needle-like element extending from the upper jaw to engage the lower jaw in  FIG. 60F ) is extended through the tissue to mate with a seat on the opposite jaw (not visible). The suture is connected to a shuttle that is initially held in this lower jaw; when the tissue penetrating element engages the seat, the suture shuttle locks onto the tissue penetrator, which can then be withdrawn back through the tissue, pulling the suture with it, so that the continuous suture passer may then be moved to a second position through which the suture may be passed back through the tendon, as illustrated in  FIG. 60G . In this example showing a modified Mason-Allen stitch, the suture is passed up through the tissue, then moved to an adjacent position and passed back down through the tissue, then the suture passer is moved back towards the first stitch (see  FIG. 60G ); thereafter a hook may be used to pull the stitch towards the first cannula, as shown in  FIG. 60H . the suture is again passed through the tissue ( FIG. 60H ) and the suture passer may be withdrawn back into the cannula, pulling the stitch taut ( FIGS. 60I and 60J ). 
     Once this first cross-stitch is pulled, a hook or grasper may then be used to draw the end of the suture connected to the continuous suture passer back into the first cannula (disengaging it from the suture passer) as shown in  FIGS. 60K and 60L . Finally, the other end of the suture may then be hooked and pulled into the second cannula  FIG. 60M  and attached to the continuous suture passer (not shown). The suture passer may then be used to pass the second end of the suture through the tissue,  FIG. 60N . Finally, the suture passer may be again withdrawn through the second cannula,  FIG. 60   o , and a hook may drawn the (disengaged) second end of the suture back into the first cannula ( FIG. 60P ), where the ends may be pulled and/or anchored or knotted off, as indicated in  FIG. 60Q . The suture end(s) may then be pulled to draw the tissue to the desired position/configuration, and the end of the suture(s) may be anchored and/or tied off, and may be trimmed. 
     In general, these complex suture patterns may include steps for positioning the jaws of the continuous suture passer over the tissue to be penetrated. In particular, the positioning step may include the step of completely retracting the tissue penetrating element that is configured to pass the suture into the jaw (e.g., upper jaw) so that it won&#39;t damage the tissue or inhibit the positioning of the continuous suture passer. In some variations, the method of forming complex suture patterns may include the steps of pulling or hooking the suture with a separate grasper/hook device in conjunction with a continuous suture passer, as illustrated above. 
       FIGS. 61A-61B  illustrate a method of passing an interweave stitch using a continuous suture passer, as described herein. In this example, three cannula are shown ( FIG. 61A ). In any of the method variations described herein, more than one cannula may be used (e.g., two, three, or more). In some of the complex stitch patterns described, more than a single suture may be used. For example, two, three, four, or more sutures may be used, including sutures that are anchored into tissue (e.g., bone) in an initial step prior to suture passing. 
     The following illustrations exemplify different stitches that may be made:  FIGS. 61A-73B . For example,  FIGS. 62A-62B  illustrate a method of performing a medial row modified Mason-Allen double row repair using a continuous suture passer.  FIGS. 63A-63B  illustrate a method of performing a “baseball stitch” using a continuous suture passer as described herein.  FIGS. 64A-64B  illustrate a method of performing a baseball stitch incorporated into a double row repair using a continuous suture passer as described herein.  FIGS. 65A-65B  illustrate a method of performing a modified Mason-Allen stitch using a continuous suture passer.  FIGS. 66A-66B  illustrate a method of performing an inverted mattress stitch using a continuous suture passer.  FIGS. 67A-67B  illustrate a method of making a figure eight margin convergence stitch using a continuous suture passer. 
       FIGS. 68A-68B  illustrate a method of making a buried figure of eight margin convergence stitch using a continuous suture passer.  FIGS. 69A-69B  illustrate a method of performing a medial row modified Mason-Allen double row repair using a continuous suture passer.  FIGS. 70A-70B  illustrate a method of performing a Baseball stitch double row repair using a continuous suture passer.  FIGS. 71A-71B  illustrate a modified Mason-Allen repair using two lateral double loaded anchors and a continuous suture passer.  FIGS. 72A-72B  illustrate a method of performing a basic tension setting repair using a continuous suture passer. Finally,  FIGS. 73A-73B  illustrate a method of performing an advanced tension-setting repair using a continuous suture passer. 
     The complex suture patterns described herein may help improve patient outcomes, and may decrease operating times. For example, the complex suture patterns may allow strong tissue-suture interface, may enhance early post-op range of motion, may involve repair site healing via potential mechanical stimulation, and may be less traumatic (particularly because of the parallel configuration of the jaw motion described above). As mentioned above, these suture passers may also allow improved blood supply (by decreasing damage/trauma to vascular tissue around the stitch site), and many of the procedures described herein may be performed in fewer steps and with simplified suture management, particularly compared to existing method of stitching. These, and other, advantages may be realized by using a continuous suture passer having one or more of the characteristics described herein. 
     Although the invention herein has been described with reference to particular embodiments, it is to be understood that these embodiments are merely illustrative of the principles and applications of the present invention. It is therefore to be understood that numerous modifications may be made to the illustrative embodiments and that other arrangements may be devised without departing from the spirit and scope of the present invention as defined by the appended claims.