Patent Publication Number: US-2020275922-A1

Title: Suture passer and method of tissue repair

Description:
BACKGROUND 
     The disclosure relates to the field of surgery and, more specifically, to suturing instruments and methods of passing suture. 
     SUMMARY 
     A suture passer and methods for surgical repairs are disclosed. A suture passer can pass a first portion of a suturing construct through tissue and another portion of the suturing construct around the tissue. The suturing construct may be a loop terminating in a single tail. 
     Methods of passing suture are also disclosed. A first portion of a flexible strand is passed through soft tissue while a second portion of the flexible strand is passed around the soft tissue, in one step. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  illustrates a cross-sectional view of a suture passing instrument according to an exemplary embodiment. 
         FIG. 2  illustrates another cross-sectional view of the suture passing instrument of  FIG. 1 . 
         FIG. 3  illustrates an enlarged view of the distal end of the suture passing instrument of  FIG. 1 . 
         FIG. 4  illustrates a perspective view of the distal end of the suture passing instrument of  FIG. 3 . 
         FIG. 5  illustrates an enlarged view of the distal end of the suture passing instrument of  FIG. 2 . 
         FIG. 6  illustrates a perspective view of the distal end of the suture passing instrument of  FIG. 5 . 
         FIG. 7  is a perspective view of a needle of the suture passing instrument of  FIG. 1 . 
         FIG. 8  is an enlarged view of the distal end of the needle of  FIG. 8 . 
         FIG. 9  illustrates a flexible construct of the suture passing instrument of  FIG. 1 . 
         FIGS. 10-13  illustrate schematic steps of a tissue repair with the suture passing instrument of  FIG. 1 . 
         FIG. 14  illustrates a suture passing instrument according to another exemplary embodiment. 
         FIGS. 15-28  illustrate an exemplary method of tissue repair with the suture passing instrument of  FIG. 1 . 
     
    
    
     DETAILED DESCRIPTION 
     The disclosure provides a suture passer and techniques for surgical repairs such as endoscopic surgical repairs (for example, arthroscopic surgeries). A suture passer can clamp or secure a tissue in place, pass a needle through the tissue, load a first portion of a flexible construct into the needle, retract the needle with the first portion back through the tissue, and position a second portion of the same flexible construct around the same tissue. The flexible construct may be a suture loop terminating in a single tail. In an embodiment, the tissue can be soil tissue such as tendon or ligament. In an embodiment, the tissue can be a capsule. A suture passer can facilitate suture placement in soft tissue and formation of a Loop ‘N’ Tack™ stitch in one step. 
     A suture passing instrument can include an elongated tubular member that has a channel housing a needle, and a tip configured to be loaded with a flexible construct in the form of a loop terminating in a single tail. The loop and the single tail are passed independently and without the need to pull the instrument out of the surgical site for reloading. The flexible construct is loaded onto the instrument outside of the surgical site. The loop is loaded onto a jaw and the single tail is loaded onto an opposite jaw. The loop and the single tail are then independently passed inside the surgical site (without the need to pull the instrument out of the surgical site to reload the sutures). A needle captures the single tail and passes the single tail through the loop and through the tissue at the surgical site. The loop surrounds the tissue. The suture passing instrument eliminates multiple instruments needed to perform a stitch, improving OR time and the efficiency of the overall procedure. 
     The suture passing instrument is first loaded with the required suture which then allows the user to encompass (encapsulate) the soft tissue with the suture. Once the tissue is captured and the sutures are properly positioned to encapsulate the tissue, the needle can be deployed to penetrate the tissue. When the needle is retracted, the needle retrieves the suture and pulls it through the tissue. When the user reduces slack, what is produced is a Loop ‘N’ Tack™ stitch. 
     A suture passing instrument can include an elongated tubular member that has a channel housing, a needle, and a tip configured to be loaded with a flexible construct in the form of a suture loop terminating in a single tail. The suture passing instrument can include a handle assembly located at the proximal end of the elongated tubular member. The tip is located at the distal end of the elongated tubular member. The tip comprises a fixed lower jaw and an upper movable jaw. The handle assembly can comprise a first trigger mechanism, a second trigger mechanism, and a handle, the first and second trigger mechanisms being connected to the handle. The handle assembly provides for opening and closing of the upper jaw coupled to the tip of the instrument. A ratcheting mechanism may provide for locking and unlocking of the upper jaw as desired by the user. Additionally, the handle assembly houses a mechanism for advancing and retracting the needle. 
     A trigger mechanism can articulate the upper jaw (movable jaw or movable member) relative to the tip. A loop of the flexible construct can be placed in a securing mechanism (slot or opening) of the upper jaw. A single tail of the flexible construct can be placed in a slot or opening of the lower jaw (stationary jaw or immobile jaw) of the instrument. By squeezing one trigger mechanism, the movable jaw can pivot/move towards the stationary jaw, thereby securing contact with tissue and clamping the tissue between the jaws. By actuating another trigger mechanism, a needle can be advanced relative to a body of the instrument. The needle can be pushed forward in a direction about parallel to the longitudinal axis of the instrument, to capture the single tail extending within the slot in the lower jaw and when pulled back, the single tail (i.e., captured by the needle) passes through the loop and the tissue. Pulling on the single tail allows the loop to surround the tissue. 
     In an illustrative embodiment, a suture passing instrument comprises two securing mechanisms. A securing mechanism can include a transversal slot or opening, or multiple slots or openings. In an embodiment, a first jaw comprises a distal opening for securing a tail of a flexible construct. A first jaw can be fixedly mounted to a distal end of a shaft. In an embodiment a second jaw is movable in respect to a first jaw. In an embodiment, a second jaw comprises a securing mechanism (a distal opening) for securing a loop of the flexible construct. A suture passing instrument can also include a handle assembly. A handle assembly can move the needle from a first position to a second position, and can also move the second jaw with respect to the first jaw. In an illustrative embodiment, the single tail is captured by and loaded onto the needle (e.g., onto a hook of a needle), thereby passing the single tail of the flexible construct through the tissue and through the loop. 
     In an embodiment, a suture passer instrument comprises: a shaft having a longitudinal axis, a distal end, and a proximal end; a tip at the distal end of the shaft, the tip having an opening for a needle to pass through and a securing mechanism to allow secure placement of single tail of a flexible construct; and a needle with a capturing mechanism for capturing and retaining the single tail, wherein contact of the needle with the single tail allows the single tail to move in a direction about parallel to a longitudinal axis of the needle and of the shaft. A movable jaw (movable member or upper jaw) is configured to pivot towards the tip and provided with a securing mechanism for secure placement of a loop of the flexible construct. 
     Another exemplary suture passer instrument comprises: a Shaft having a longitudinal axis, a distal end, and a proximal end; a stationary jaw (stationary member or tip) at the distal end of the shaft, the stationary jaw having an opening for a needle to pass through and a securing mechanism for securely holding a suture tail of a suturing construct, and then loading the suture tail into a hook of the needle when the needle passes through the opening; a movable jaw (movable member) configured to pivot towards the stationary jaw and having a securing mechanism for securely holding a suture loop of the suturing construct; a needle with a hook for retaining the single suture tail; and an actuator configured to move the movable jaw with respect the stationary jaw. 
     Another embodiment of a suture passer instrument includes: a hollow shaft having a longitudinal axis, a distal end, and a proximal end; a mounted distal jaw fixedly mounted to the shaft at the distal end of the shaft; a movable jaw (movable member) configured to pivot towards the mounted distal jaw to clamp tissue between the mounted distal jaw and the movable jaw, and to retract from the distal jaw to release tissue clamped between the mounted distal jaw and the movable jaw; a needle configured to slidably extend through tissue being clamped between the movable jaw and the mounted distal jaw, where the needle can extend independently of the movable jaw, the needle having a pointed end for piercing through tissue, and a hook configured to retain suture while the needle is pulled back through the tissue; the mounted distal jaw having an opening for the needle to pass through, and a securing mechanism to securely hold a single tail of a suturing construct and then load the single tail into the hook of the needle when the needle passes through the opening; the moving jaw having a securing mechanism to securely hold a loop of the suturing construct; and a handle configured to move the moving jaw with respect to the mounted distal jaw. 
     Methods of passing sutures are also disclosed. A first portion of a flexible construct is passed through tissue and a second portion of the flexible construct is positioned around the tissue, in one step. The first portion is passed through the second portion and then through the tissue. The flexible construct may be a suture loop terminating in a single tail. The single tail is passed through the suture loop and through the tissue. 
     Methods of suturing tissue are also disclosed. In an embodiment, tissue can be sutured with an instrument by securing a flexible strand within a tip of a suture passing instrument; capturing a single tail of the flexible strand with a needle; and passing the single tail of the flexible strand through a continuous, uninterrupted loop of the flexible strand and through the tissue. 
     An exemplary method of suturing tissue comprises: (i) clamping, securing, or holding at least a portion of a tissue with a suture passing instrument; (ii) securing a flexible construct formed of a flexible strand with a loop terminating in a single tail within a tip of the instrument; (iii) capturing the single tail with a needle; and (iv) pulling back the needle to pass the single tail through the loop and the clamped tissue. 
     Referring now to the drawings, where like elements are designated by like reference numerals,  FIGS. 1-14  illustrate various structural elements of suture passing instrument  100 ,  200  of the present disclosure provided with a tip configured to allow a flexible construct formed of a flexible strand having a loop terminating in a single tail to be loaded thereon and a handle assembly allowing the two components (loop and single tail) to be passed independently (and without the need to remove the instrument from the surgical site to reload it with an additional strand).  FIGS. 15-28  illustrate an exemplary method of tissue repair with the suture passing instrument  100 ,  200 . 
     As shown in  FIGS. 1-6 , suture passing instrument  100  (suture passer  100 ; instrument  100 ; surgical instrument  100  comprises an elongated tubular member or shaft  12  having a longitudinal axis  12   a,  a proximal end  11  a distal end  13  and an axial throughbore therein. Shaft  12  may he a tube or a narrow-diameter rod of dimensions that permit the tubular member to he introduced through an associated cannula (for example, an 8.25 cannula) in a minimally invasive procedure, such as arthroscopic or other endoscopic procedures, or into a body cavity, such as the abdominal cavity. Alternatively, shaft  12  may be an open U channel (and not a closed tube). 
     Elongated tubular member  12  connects, and extends between, a handle assembly  40  and a tip  10  consisting of a pair of jaws comprising a distal jaw  20  (first jaw  20 , or stationary jaw  20 ) and a proximal jaw  30  (second jaw  30 , movable jaw  30 , movable member  30 , or clamp  30 ). 
     Distal jaw  20  is provided at the distal end  13  of the instrument and is preferably integral with (fixedly mounted to) the tubular member  12 . Proximal jaw  30  is movable with respect to the distal jaw  20  and pivots with respect to it. As illustrated in  FIGS. 1-5 , distal jaw  20  is substantially straight with respect to the shaft, while the proximal jaw  30  may be either straight or curved, and may be provided with a plurality of teeth to enhance tissue grasping and suture passing stability. 
     Distal jaw  20  of instrument  100  includes a securing mechanism  25  provided at the distal end of the jaw  20  that is configured to releasably support a length of flexible strand  81  therein. The securing mechanism  25  is formed integrally with the jaw  20  and includes an opening or slot  25  which may be a transversal suture loading slot  25 . Slot  25  can be arcuate, to allow suture or a strand of flexible material to extend therethrough, in a position about perpendicular to the longitudinal axis of the elongated tubular member. Slot  25  may include a transversal channel with two lateral slots, grooves or wedges, each of the lateral slots, grooves or wedges being disposed on each end of the transversal slot, to allow increased suture positioning for facture suture manipulation with the needle construct. 
     In an embodiment, the securing mechanism  25  is designed to allow secure placement of the flexible strand  81  within it, while allowing a needle  55  to travel in a to- and fro-direction relative to the transversal flexible strand. In this manner, when needle  55  is advanced to travel toward the distal jaw  20 , to capture the flexible strand  81 , the needle can pass past the transversal slot to allow capturing of the flexible strand in notch  56  of hook  55   a,  and then pull back in an opposite direction (again passing past the transversal slot) to allow pulling of the flexible strand  81  away from the distal end of the instrument. 
     Distal jaw  20  is also provided with a needle passage  28  and an opening  29  that allows needle  55  to pass and extend therethrough, as more clearly illustrated in  FIGS. 3 and 11 , for example. Opening  29  ( FIG. 11 ) is provided in a most distal end of jaw  20  and communicates with the needle passage  28 . Preferably, the opening  29  has the shape of a channel with a rectangular or square cross-section to allow the needle (which may have a generally square or rectangular cross-section, or a generally circular cross-section) to pass therethrough. As shown in  FIG. 11 , distal opening  29  allows needle  55  to exit in a direction about parallel to the longitudinal axis of the instrument. 
     In an exemplary embodiment, needle  55  also passes through a channel or needle passage  38  ( FIG. 33  of the proximal jaw  30  (movable jaw  30 ) when the proximal jaw  30  is in the operative, piercing, deployed or closed position. Needle  55  is substantially disposed within the shaft  12  when the needle is in a non-operative, non-piercing, or non-deployed position. In an operative position, and as detailed below, the needle is advanced distally to pass through the passage  38  of the proximal jaw  30  and through the passage  28  of the distal jaw, to exit opening  29  in the distal law  20 . 
     Preferably, needle  55  has a narrow, pointed tip at a distal end and a hook  55   a  that is adjacent the pointed tip and that has an opening (notch)  56  facing the proximal end of the instrument ( FIG. 8 ). The opening  56  of hook  55   a  also preferably faces downwardly (i.e., in a plane extending below the longitudinal axis  12   a  of the instrument). Needle  55  may preferably be formed of nitinol or other suitable material. 
     Needle actuator  50  ( FIG. 7 ) houses needle  55  and comprises shaft  52  (which is slidingly received in the axial throughbore (channel) of the elongated tubular member  12 ) and a most proximal end  54  provided with a slot that is engaged securely into a cross pin  54   a  on the proximal end of handle  40  of the suture passing instrument ( FIG. 1 ). The needle actuator facilitates passing the flexible strand  81  through the tissue. In use, needle actuator  50  is actuated relative to the longitudinal axis  12   a  of the tubular member, and needle  55  is pushed forward toward opening  29  to exit the opening as shown in  FIG. 11 , for example. 
     Proximal jaw  30  forms part of the tip  10  and may pivot with respect to the tip or distal jaw  20 . The proximal jaw  30  includes longitudinal channel  38  and a securing mechanism  35  provided at the distal end of the proximal jaw  30 . In exemplary embodiments, the securing mechanism  35  may be a suture loading slot  35  (tooth  35 ). Slot  35  can be arcuate, to allow suture or a strand of flexible material to extend therethrough, in a position about perpendicular to the longitudinal axis of the elongated tubular member. Slot  35  may include a transversal channel with two lateral slots, grooves or wedges, each of the lateral slots, grooves or wedges being disposed on each end of the transversal slot, to allow increased suture positioning for future suture manipulation with the needle construct. The longitudinal channel and the securing mechanism (loading slot) are configured to allow at least one flexible loop  83  (a continuous, flexible, uninterrupted loop  83  of flexible material  80 ) to extend therethrough and to be securely positioned within the securing mechanism (loading slot). Slot  35  may have various configurations, for example, a groove (such as a V groove) or a wedge, to allow suture positioning for future suture manipulation with the instrument  100 . The securing mechanism  35  is formed integrally with the proximal jaw  30 . 
       FIG. 9  illustrates an exemplary flexible strand  80  (flexible material  80 , suture construct  80 , suturing construct  80 , single tail/loop construct  80 ) to be loaded onto the tip  10  of the instrument. Flexible strand  80  has a first region  81  and a second region  83 . In an embodiment, the first region  81  is a single end or single tail  81 , and the second region  83  is a continuous, uninterrupted, flexible loop  83 . 
     Flexible strand  80  is formed of a single strand of material that is looped joined to form loop  83  and single tail  81 . In an embodiment, flexible strand  80  has a length and two ends that form a loop  83  terminating in a single tail  81 . In an embodiment, flexible strand  80  has one end that forms loop  83  and the other end forming single tail  81  (flexible end  81 ). Loop  83  may be a continuous, uninterrupted, flexible loop formed of a material such as suture. Loop  83  terminates in single flexible end or tail  81 . In one embodiment, the perimeter of loop  83  may be fixed. In one embodiment, loop  83  and tail  81  may be formed of suture having a round cross-section. The suture may have the same or different diameters. Loop  83  may be formed by splicing the flexible strand through itself, or by other methods known in the art, such as fusion, gluing, bonding, joining, braiding, interlinking, etc. 
     Flexible strand  80  (suturing construct  80 ) may include a single filament, or fiber, or can include multiple continuous filaments, segments or regions of filaments that have different configurations (for example, different diameters and/or different compositions). The filament regions/segments may each be homogenous (i.e., formed of a same material) or may be a combination of homogenous and heterogenous (i.e., formed of a plurality of materials). Exemplary materials may include suture, silk, cotton, nylon, polypropylene, polyethylene, ultrahigh molecular weight polyethylene (UHMWPE), polyethylene terephthalate PET), and polyesters and copolymers thereof, or combinations thereof. 
     In an embodiment, the flexible strand  80  is made of any known suture construct, such as multifilament, braided, knitted, woven suture, or including fibers of ultrahigh molecular weight polyethylene (UHMWPE) or the FiberWire® suture (disclosed in U.S. Pat. No. 6,716,234, the disclosure of which is hereby incorporated by reference in its entirety herein). The flexible strand may be also formed of suture tape, for example, Arthrex FiberTape®, which is a high strength suture tape that is braided and rectangular-like in cross section and as disclosed in U.S. Pat. No. 7,892,256, the disclosure of which is incorporated by reference in its entirety herein. 
     Flexible strand  80  may also include, and be manufactured with, any kind of material (suture, nylon, silk, UHMWPE. metal, bioabsorbable, etc.) that can allow the flexible strand to form a loop terminating in a single tail. 
     In an exemplary embodiment, flexible strand  80  is loaded onto the instrument  100  as shown in  FIG. 10 , i.e., with loop  83  loaded onto securing mechanism  35  (loading slot) through the longitudinal channel of the proximal jaw  30 , and with the single tail  81  loaded through the longitudinal channel and into slot  25  of the distal jaw  20  for further engagement by needle  55 . 
     Handle assembly  40  of the suturing instrument  100  (illustrated in  FIGS. 1 and 2 ) is provided at the proximal end  11  of the instrument and includes a trigger mechanism  42  (or actuating mechanism  42 ) and a handle  48 , the trigger mechanism  42  being pivotally connected to the handle  46 . The trigger mechanism  42  may consist of a finger lever  42  which, when actuated, is designed to move/pivot the proximal jaw  30  (movable member  30 ) relative to the distal jaw  20 . The finger lever  42  is designed to move from a first position to a second position, with a spring  42   a  provided to maintain tension on the finger lever  42  and to force the finger lever  42  to go back to a default position. At its default position, the finger lever  42  is closest from the distal end of the handle  28 . 
     instrument  100  further includes an actuator or a second trigger mechanism (not shown), which is provided within the shaft  12  and at the distal end of the shaft The actuator is connected to the finger lever  42  and is designed to pivot the movable jaw  30  from a first position to a second position as the finger lever  42  is moved from a first position to a second position, and to clamp or secure tissue  90  between the movable jaw  30  and the tip or stationary jaw  20 . 
       FIGS. 10-13  illustrate schematic steps of a method of tissue repair (e.g., tendon or ligament repair) with instrument  100  and exemplary flexible strand  80 . 
       FIG. 10 : suture loop  83  is pulled into slot  35  of proximal jaw  30 ; single tail  81  is placed into slot  25  of distal jaw  20 . Instrument  100  loaded with flexible strand  80  is advanced to hold tissue  90  securely; tissue  90  is clamped or secured between the pair of jaws  20 ,  30  (i.e., tip  20  and movable jaw  30 ). 
       FIG. 11 : proximal jaw  30  pivots to the operative position; needle  55  is advanced to penetrate tissue  90  and pass through channel  38  of proximal jaw  30  and through channel  28  of distal jaw  20 ; needle  55  is advanced in the direction of arrow A. 
       FIG. 12 : when the needle hook  55   a  passes the suture tail  81 , the tail  81  is pushed into the needle notch  56 ; the needle  55  is pulled back, retrieving suture  81  from tip  20  and through the loop  83 ; needle  55  is pulled back in the direction of arrow B. 
       FIG. 13 : the needle  55  pulls suture tail  81  back through the tissue  90  penetrating tissue  90  at location or point “P”; advance the needle  55  and pull down on single tail  81  to release; loop  83  is pulled by pulling, the single tail  81  to be positioned around tissue  90  to complete a Loop ‘N’ Tack™ stitch in one step. 
     Soft tissue  90  is luggage-tagged with looped suture  83  (or suture tape  83 ) while—and after—the soft tissue is pierced with the free end  81  of the suture  80 . A Loop ‘N’ Tack™ knotless tenodesis technique is an all-arthroscopic technique using a SutureTape FiberLink™ suture  80 . The biceps is “luggage tagged” with the loop  83  of the FiberLink™ suture  80  and the free end  81  of the FiberLink™ suture  80  which pierces the biceps  90  and passes through it. A fixation device (for example, a SwiveLock® or PushLock® anchor) or similar structures may be employed to anchor the free suture end  81  and the biceps  90  intra-articularly at the top of the bicipital groove. 
       FIG. 14  illustrates suture passing instrument  200  (suture passer  200 ; instrument  200 ; surgical instrument  200 ) Which is about similar to suture passing instrument  100  (detailed above) but differs from it in the shape and configuration of handle  148  of handle assembly  140 . Handle  148  comprises a proximal end and a distal end that could be actuated and brought together. The proximal and distal ends of the handle  148  may be connected via a link (not shown) and tension between the proximal and distal ends may be additionally maintained using springs. By actuating the hand mechanism  148  (i.e., by bringing together the proximal and distal ends of the handle  148 ), pusher  54  of the needle actuator  50  advances needle  55  to capture the single tail or end  81  of flexible strand  80  positioned within slot  25 , and to further pull back the flexible strand  81  (captured in notch  56  of hook  55   a  of the needle) through loop  83  and through tissue  90  to be sutured. 
     Instrument  100 ,  200  is a one-step instrument that allows a loop  83  of a flexible construct  80  to be positioned around tendon  90  (surrounding the tendon) while passing/driving a distal end  81  of the suture loop construct  80  through the tendon  90 . The novel instrument eliminates multiple instruments needed to perform a Loop ‘N’ Tack™ stitch, improving OR time and the efficiency of the overall procedure. 
     The instrument allows surgeons to conduct a Loop ‘N’ Tack™ stitch on a tendon with improved efficiency and by eliminating multiple instruments necessary in open or arthroscopic procedures. The instrument  100  includes a shaft (movable jaw  30 ) with a tooth  35  that captures the suture loop  83 . The free end  81  of suture  80  is captured by the end (distal jaw  20 ) of the shaft. 
       FIGS. 15-28  illustrate an exemplary method of tissue repair  101  with exemplary suture passing instrument  100 ,  200 . Repair  101  is a Loop ‘N’ Tack™ stitch repair. A method of employing instrument  100 ,  200  begins by loading the needle  55  into the cannulation on the proximal end of the shaft  12  of instrument  100 . The slot on the proximal end  54  of the needle actuator  50  is engaged securely into cross pin  54   a  on the proximal end of handle  28  of the instrument. 
     Flexible strand  80  is loaded onto the instrument, as shown in  FIGS. 15-17 . Loop  83  is positioned onto securing mechanism  35  of the proximal jaw  30  while single end  81  is loaded onto securing mechanism  25  (transversal slot  25 ) on the distal jaw  20  of the instrument  100 .  FIG. 17  shows both the loop  83  and single tail  81  (free end  81 ) secured onto instrument  100  with the proximal jaw  30  open. 
     Reference is now made to  FIG. 18 . Using the finger lever  42  on the suture passing instrument  100  (i.e., actuating the finger lever  42  in the direction of arrow A′ of  FIG. 2 ), the proximal jaw  30  pivots towards the distal jaw  10  and tissue  90  is clamped between the two jaws  20 ,  30 . With the jaws closed, loop  83  is located proximally to the single end  81 . 
     With the tissue  90  clamped between the jaws and the sutures positioned around tissue  90 , needle  55  is advanced distally ( FIG. 19 ) such that the needle exits the opening  29  on the distal jaw  20  ( FIG. 20 ). The pointed tip of the needle  55  pierces completely through the tissue (e.g., tendon or articular capsule), passes through channel  38  of proximal jaw  30  (loaded with loop  83 ) and through the loop  83 , and then the hook  55   a  on the needle  55  captures the tail  81  (loaded in the slot  25  of the distal jaw  20 ), as shown in  FIG. 20 . 
     By releasing the distal and proximal ends of handle  148  (for example), the needle  55  is pulled back ( FIG. 21 ) and the suture  81  captured in hook  55   a  and notch  56  of the needle is pulled through the loop  83  and then pierces tissue  90  at a location “T” ( FIG. 21 ). 
     Free end  81  of the suture construct  80  is pulled back through the soft tissue  90  in a direction about parallel to longitudinal axis  12   a  of the shaft  12  of the instrument, pulling, the loop  83  closer to tissue  90  ( FIGS. 22 and 23 ). By releasing, the finger lever  42 , the proximal jaw  30  pivots to the open position (pulls away from the distal law  20 ) and the tissue  90  is released, as shown in  FIG. 24 .  FIGS. 25 and 26  illustrate formation of loop  99  around tissue  90  and adjacent location “P” where the free end  81  pierces the tissue  90 . Pulling on the free end  81  tightens loop  99  around tissue  90  to complete repair  101  or luggage tag stitch  101  ( FIGS. 26-28 ). 
     A suture passer as disclosed herein may be employed in various surgical medical procedures for advancing a suture in proximity of a surgical site. A suture passer as disclosed herein may also be employed with a suture and a cannulated instrument during such surgical procedures. For example, instrument  100 ,  200  may be employed in endoscopic surgery. The term “endoscopic surgery” refers to surgical procedures within a patient&#39;s body through small openings as opposed to conventional open surgery through large incisions. Additionally, a suture passer as disclosed herein may be utilized in other general surgical and specialty procedures that require suturing. A suture passer as disclosed herein may be also used in repairs where suture visibility or finger access can be limited. 
     It will be appreciated, of course, that While a suture passer as disclosed herein may be particularly useful for performing remote procedures through access sheaths, trocars and cannulated surgical instruments, a suture passer as disclosed herein can also be used in open surgical procedures. 
     In an illustrative embodiment, a method of suturing tissue using, a suture passer  100 ,  200  comprises: (i) engaging a tail  81  of a flexible strand  80  within a slot  25  of a securing mechanism  25  at the distal end  20  of the instrument; (ii) engaging a continuous, uninterrupted, flexible loop  83  of the flexible strand  80  within a slot  35  of a securing mechanism  35  at a proximal jaw  30  of the instrument; (iii) advancing a needle  55  through tissue and through passages thrilled in jaws  20 ,  30  of the instrument; and (iv) subsequently, capturing tail  81  of the flexible strand  80  with the needle  55  and advancing the tail  81  in a direction about parallel to the longitudinal axis  12   a  of the instrument, and through the continuous, uninterrupted, flexible, loop  83  and through tissue  90 . 
     According to another exemplary and illustrative embodiment only, a method of suturing a tissue using the suture passing instrument  100 ,  200  comprises: (i) loading a needle  55  onto the instrument; (ii) loading a suture  80  formed of a suture loop  83  terminating in a single tail  81  into slots formed in jaws  20 ,  30  of the instrument; (iii) bringing a proximal jaw  30  towards the distal jaw  20  by actuating a finger lever  42 , so that the proximal jaw  30  and the distal jaw  20  clamp tissue  90  therebetween; (iv) actuating a handle  48  to advance the needle  55  into a first direction (towards the tail loaded onto the slot of the distal jaw); (v) pulling the needle  55  in a second direction which is opposite the first direction, and capturing the tail  81  of the suture  80  with a hook  56  and notch  56   a  of the needle  55 ; and (vi) pulling the tail  81  through the suture loop  83  and through tissue  90  in a direction about parallel to the longitudinal axis  12   a  of the instrument. 
     A suture passing instrument  100 ,  200  comprises: a shaft  12  having a longitudinal axis  12   a,  a distal end  13 , and a proximal end  11 ; a first jaw  20  fixedly mounted to the distal end of the shaft  12 , the first jaw  20  having a passage  28  for receiving a needle  55 , and a distal opening  29  to allow the needle  55  to pass therethrough; a second jaw  30  being movable with respect to the first jaw  20 , the second jaw  30  having a passage  38  for receiving needle  55 ; and a handle assembly  40  configured to move the needle  55  from a first position to a second position, and to move the second jaw  30  with respect to the first jaw  20 , wherein the first jaw  20  comprises a securing mechanism  25  to secure a single end  81  of a flexible strand  80  at its most distal end, and wherein the second jaw  30  comprises a securing mechanism  35  to secure a continuous, uninterrupted, flexible loop  83  terminating in end  81  of the flexible strand  80 . 
     According to another exemplary and illustrative embodiment only, a method of suturing a tissue using the suture passing instrument  100 ,  200  of the present disclosure comprises the steps of: (i) loading a first portion  81  of a suture strand  80  onto a bottom jaw  20  of a suture passing instrument  100 ,  200 ; (ii) loading a second portion  83  of the same suture strand  80  onto a top jaw  30  of the suture passing instrument; (iii) closing the jaws  20 ,  30  on a desired, first region of the tissue  90  using a finger lever and advancing a needle  55  through the first region of the tissue  90  at a location P; (iv) capturing the first portion  81  of the suture strand  80  with the needle  55 ; (v) retracting the needle  55  with the captured first portion  81  through the second portion  83  of the same suture strand  80  and through the first region on the tissue  90 ; and (vi) securing the second portion  83  of the same suture strand around a second region of the tissue  90  to form a loop  99  around the second region. 
     The device  100 ,  200  is first loaded with the required suture  80  which then allows the user to encompass the soft tissue  90  with the suture  80 . Once the jaw  30  closes around tissue  90 , free end  81  and loop  83  of suture  80  are positioned around tissue  90  (even if suture  80  is not tightened around tissue  90 ). Once the tissue  90  is captured and the sutures  81 ,  83  are properly positioned to encapsulate the tissue, the needle  55  can be deployed to penetrate the tissue  90 . When the needle  55  is retracted, it retrieves the free end  81  of suture and pulls it through the loop  83  and through the tissue  90 . The free end  81  passes through both the loop  83  and through the tissue  90 . The device (instrument)  100 ,  200  is removed and the free end  81  of the suture (passed through the loop and through the tissue) is tightened to produce the stitch  101  around and through tissue  90 . When the user reduces slack, what is produced is the Loop ‘N’ Tack™ (a luggage tag stitch)  101  around and through soft tissue  90 . 
     Flexible strand  80  may be in the form of any elongated members, fibers, or materials, or combinations thereof. Flexible strand  80  can include a single filament, or fiber, or can include multiple continuous filaments, segments or regions of filaments that have different configurations (for example, different diameters and/or different compositions). The filament regions/segments may each be homogenous (i.e., formed of a same material or may be a combination of homogenous and heterogenous (i.e., formed of a plurality of materials). Exemplary materials may include suture, silk, cotton, nylon, polypropylene, polyethylene, ultrahigh molecular weight polyethylene (UHMWPE), polyethylene terephthalate (PET), and polyesters and copolymers thereof, or combinations thereof. 
     Flexible strand  80  may be formed of suture tape, for example, Arthrex FiberTape®, which is a high strength suture tape that is braided and rectangular-like in cross section and as disclosed in U.S. Pat. No. 7,892,256, the disclosure of which is incorporated by reference in its entirety herein. In an embodiment, flexible strand  80  may be made of fibers of ultrahigh molecular weight polyethylene (UHMWPE) or the FiberWire® suture (disclosed in U.S. Pat. No. 6,716,234, the disclosure of which is hereby incorporated by reference in its entirety herein). High strength suture such as FiberWiret suture (Arthrex), FiberWire® suture is formed of an advanced, high-strength fiber material, namely ultrahigh molecular weight polyethylene (UHMWPE), sold under the tradenames Spectra® (Honeywell International Inc., Colonial Heights, Va.) and Dyneemat (DSM N.V., Heerlen, the Netherlands), braided with at least one other fiber, natural or synthetic, to form lengths of suture material. 
     Flexible strand  80  may be coated (partially or totally) with wax (beeswax, petroleum wax, polyethylene wax, or others), silicone (Dow Corning silicone fluid  202 A or others), silicone rubbers (Nusil Med 2245, Nusil Med 2174 with a bonding catalyst, or others) PTFE (Teflon, Hostaflon, or others), PBA (polybutylate acid), ethyl cellulose (Filodel) or other coatings, to improve lubricity of the suture, loop security, pliability, handleability or abrasion resistance, for example. 
     Flexible strand  80  may be also provided with tinted tracing strands, or otherwise contrast visually with other areas/regions of the construct, which remains a plain, solid color, or displays a different tracing pattern, for example. Various structural elements of flexible strand  80  such as loop  83  and/or tail  81  may be visually coded, making identification and handling of the suture loops and ends simpler. Easy identification of suture in situ is advantageous in surgical procedures. 
     The term “high strength suture” is defined as any elongated flexible member, the choice of material and size being dependent upon the particular application. For the purposes of illustration and without limitation the term “suture” as used herein may be a cable, filament, thread, wire, fabric, or any other flexible member suitable for tissue fixation in the body. 
     The term “luggage tag stitch” is defined as any cinch or suture loop that is formed by the luggage tag technique.