Patent Publication Number: US-11395649-B2

Title: Suture passing device

Description:
CROSS-REFERENCE TO RELATED APPLICATION(S) 
     This application is a continuation of U.S. patent application Ser. No. 16/400,681, filed May 1, 2019, which claims benefit of U.S. Provisional Application No. 62/667,021 filed on May 4, 2018, and U.S. Provisional Application No. 62/689,388 filed on Jun. 25, 2018, which are hereby incorporated by reference herein in their entirety. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates in general to medical devices. More particularly, the invention is directed to a suture passer. 
     2. Description of Prior Art and Related Information 
     Often times an important aspect of a surgical procedure is to pass suture through tissue. This could be required to mend a tear or connect two or more pieces of soft tissue. Though this task is common it can be challenging for the surgeon especially in an arthroscopic procedure where visualization is limited. 
     Many devices have been created to address difficult suturing scenarios but there are still certain procedures and anatomies where the average surgeon still struggles. For example, suturing the labrum at times can prove challenging particularly when the tissue is severely damaged. In such cases decreasing the overall profile of the feature penetrating the tissue and optimizing the working profile of the instrument to improve access to the working site can be critical factors to facilitate suturing. 
     Within this smaller needle profile, a mechanism must be housed that allows easy passing and retrieving of suture by the doctor in an arthroscopic atmosphere. With many devices currently on the market a very small loop of suture is provided during tissue passing such that the surgeon is challenged to hit the miniscule target and retrieve the suture. 
     A device is required that easily passes suture through tissue and provides a large amount of suture on the other side of the tissue that will be relatively easy for the surgeon to grab and pull out of the arthroscopic portal. This system must also be relatively simple so that the manufacturing cost can be kept at a reasonable level. 
     SUMMARY OF THE INVENTION 
     In one aspect, a suture passing device is provided. The device comprises a handle and a shaft coupled to the handle. The shaft comprises a sharp distal tip that defines a shaft axis. The shaft defines a lumen. 
     A jaw assembly is housed within the shaft. The jaw assembly comprises a first jaw member and a second jaw member. The first jaw member and the second jaw member are movable with respect to each other between a closed position and an open position. The jaw assembly comprising a push-pull suture capturing mechanism. An actuating mechanism is coupled to the jaw assembly and configured to move the jaw assembly between the closed position and the open configuration. 
     The first jaw member and the second jaw member are biased away from each towards the open position and moved to the open position when the actuator moves the jaw assembly distally with respect to the shaft such that first jaw member and the second jaw member each diverge from the shaft axis when exiting the shaft. The first jaw member and the second jaw member are moved to the closed position when the actuating mechanism is moved to retract the jaw assembly proximally with respect to the shaft. 
     The suture capturing mechanism may preferably comprise teeth. The suture capturing mechanism may comprise a first plurality of pointy teeth included in the first jaw member to form a first scalloped edge, and a second plurality of pointy teeth included in the second jaw member to form a second scalloped edge. The first plurality of teeth may preferably be nestable with the second plurality of teeth when the jaw assembly is in the closed configuration. 
     The shaft may comprise a bent shaft portion. 
     The sharp distal tip may comprise a blade tip at the distal end. A distal end of the jaw assembly may be retracted into the shaft in a preferred range of 10 mm to 45 mm from the blade tip. 
     The device may further comprise a stacked jaw assembly where a third jaw member stacked on and movable in unison with the first jaw, and a fourth jaw member stacked on and movable in unison with the second jaw. 
     The jaw assembly may further comprise a second loose suturing capturing mechanism. 
     The jaw assembly may further comprise a cutout proximal to the suture capturing mechanism. 
     The jaw assembly may preferably comprise a thickness in the range of 0.4 mm to 4.0 mm. 
     The jaw assembly comprises an exterior and the shaft comprises an interior shaft surface, and a gap between the exterior of the jaw assembly and the interior shaft surface is less than 1 mm. 
     In a further aspect, a suture passing device is provided having a jaw assembly comprising a push-pull suture passing mechanism. The device comprises a handle and a shaft coupled to the handle. The shaft comprises a sharp distal tip that defines a shaft axis. The shaft defines a lumen. 
     A jaw assembly is housed within the shaft. The jaw assembly comprises a first jaw member and a second jaw member. The first jaw member and the second jaw member are movable with respect to each other between a closed position and an open position. 
     An actuating mechanism is coupled to the jaw assembly and configured to move the jaw assembly between the closed position and the open configuration. The first jaw member and the second jaw member are biased away from each towards the open position and moved to the open position when the actuating mechanism moves the jaw assembly distally with respect to the shaft such that first jaw member and the second jaw member each diverge from the shaft axis when exiting the shaft. The first jaw member and the second jaw member are moved to the closed position when the actuating mechanism is moved to retract the jaw assembly proximally with respect to the shaft. The push-pull suture capturing mechanism comprises a set of teeth formed on at least one of the first jaw member and second jaw member. 
     The shaft may comprise a bent shaft portion. 
     The jaw assembly may comprise a second loose suturing capturing mechanism. 
     The jaw assembly may comprise a cutout proximal to the push-pull suture capturing mechanism. 
     The device may comprise a stacked jaw assembly where a third jaw member is stacked on the first jaw and a fourth jaw member is stacked on the second jaw. The third jaw and the fourth jaw preferably converge and diverge from each other in unison with the first jaw and second jaw. 
     In a further aspect, a suture passing device is provided having a stacked jaw assembly minimizing jaw movement within a shaft in which the jaw assembly is housed. The shaft is coupled to a handle. The shaft comprises a sharp distal tip that defines a shaft axis. The shaft defines a lumen. A dual-stack jaw assembly housed within the shaft comprises a first pair of jaw members and a second pair of jaw members stacked on the first pair of jaw members to form a first jaw member stack and a second jaw member stack. The first jaw member stack and the second jaw member stack are movable with respect to each other between a closed position and an open position. The jaw assembly comprises a push-pull suture capturing mechanism. 
     An actuating mechanism is coupled to the jaw assembly and configured to move the jaw assembly between the closed position and the open configuration. The first jaw member stack and the second jaw member stack are biased away from each towards the open position and moved to the open position when the actuating mechanism moves the jaw assembly distally with respect to the shaft such that first jaw a member stack and the second jaw member stack each diverge from the shaft axis when exiting the shaft. The first jaw member stack and the second jaw member stack are moved to the closed position when the actuating mechanism is moved to retract the jaw assembly proximally with respect to the shaft. 
     The first jaw member comprises a first set of teeth configured to capture suture and the second jaw member comprises a second set of teeth configured to capture suture. 
     The shaft comprises a cutout proximal to the jaw assembly. 
     The push-pull suture capturing mechanism preferably comprises a scalloped edge. 
     Methods of passing suture are also provided. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a top perspective view of a suture passing device according to first preferred embodiment. 
         FIG. 2A  is a perspective view of the first preferred embodiment of the suture passing device with jaw assembly in an open configuration. 
         FIG. 2B  is a perspective view of the first preferred embodiment of the suture passing device with jaw assembly in a partially retracted configuration. 
         FIG. 2C  is a perspective view of the first preferred embodiment of the suture passing device with jaw assembly in a further retracted configuration. 
         FIG. 2D  is a perspective view of the first preferred embodiment of the suture passing device with jaw assembly in a retracted, closed configuration. 
         FIG. 3A  is a perspective view of the first preferred embodiment of the suture passing device with jaw assembly in an open configuration to receive suture. 
         FIG. 3B  is a perspective view of the first preferred embodiment of the suture passing device with jaw assembly in a partially retracted configuration to begin grasping suture. 
         FIG. 3C  is a perspective view of the first preferred embodiment of the suture passing device with jaw assembly in a closed configuration to capture suture. 
         FIG. 3D  is a perspective view of the first preferred embodiment of the suture passing device with jaw assembly in a fully retracted, closed configuration carrying suture within the distal tip. 
         FIG. 4A  is a perspective view of the first preferred embodiment of the suture passing device carrying suture prior to penetrating tissue. 
         FIG. 4B  is a perspective view of the first preferred embodiment of the suture passing device penetrating tissue with the carried suture. 
         FIG. 4C  is a cross-sectional perspective view showing the first preferred embodiment of the suture passing device in the position illustrated in  FIG. 4B ; 
         FIG. 4D  is a perspective view of the first preferred embodiment of the suture passing device releasing suture after being carried through tissue. 
         FIG. 4E  is a perspective view of the first preferred embodiment of the suture passing device penetrating tissue to grasp a loop section of the suture. 
         FIG. 5A  is a top plan view of the first preferred jaw assembly. 
         FIG. 5B  is a side elevation view of the first preferred jaw assembly. 
         FIG. 5C  is a cross-sectional view of the first preferred jaw assembly taken along lines  5 C- 5 C of  FIG. 5A . 
         FIG. 6  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 7  is a top plan view of a further alternative embodiment of a jaw assembly. 
         FIG. 8A  is a top plan view of a further alternative embodiment of a jaw assembly. 
         FIG. 8B  is a top plan view of a further alternative embodiment of a jaw assembly. 
         FIG. 8C  is a top plan view of a further alternative embodiment of a jaw assembly. 
         FIG. 9A  is a top plan view of a further alternative embodiment of a jaw assembly. 
         FIG. 9B  is a top plan view of a further alternative embodiment of a jaw assembly. 
         FIG. 9C  is a top plan view of a further alternative embodiment of a jaw assembly. 
         FIG. 10A  is a cross-sectional view of an alternative embodiment of a ribbon of a jaw assembly. 
         FIG. 10B  is a cross-sectional view of an alternative embodiment of a ribbon of a jaw assembly. 
         FIG. 10C  is a cross-sectional view of an alternative embodiment of a ribbon of a jaw assembly. 
         FIG. 10D  is a cross-sectional view of an alternative embodiment of a ribbon of a jaw assembly. 
         FIG. 10E  is a cross-sectional view of an alternative embodiment of a ribbon of a jaw assembly. 
         FIG. 11A  is a cross-sectional view of an alternative embodiment of a ribbon of a jaw assembly. 
         FIG. 11B  is a cross-sectional view of an alternative embodiment of a ribbon of a jaw assembly. 
         FIG. 12  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 13  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 14  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 15  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 16  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 17  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 18  is a perspective view of an alternative embodiment of a jaw assembly. 
         FIG. 19  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 20  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 21  is a perspective view of an alternative embodiment of a jaw assembly. 
         FIG. 22  is a perspective view of an alternative embodiment of a jaw assembly. 
         FIG. 23  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 24  is a perspective view of an alternative embodiment of a jaw assembly. 
         FIG. 25  is a top plan view of an alternative embodiment of a jaw assembly. 
         FIG. 26  is a perspective view of a second preferred embodiment of a suture passing device. 
         FIG. 27  is a perspective view of a third preferred embodiment of a suture passing device. 
         FIG. 28  is a perspective view of a fourth preferred embodiment of a suture passing device. 
         FIG. 29  is a perspective view of a fifth preferred embodiment of a suture passing device. 
         FIG. 30  is a perspective view of a sixth preferred embodiment of a suture passing device. 
         FIG. 31  is a perspective view of an alternative embodiment of a distal needle tip having a curve. 
         FIG. 32  is a perspective view of a seventh embodiment of a suture passing device. 
         FIG. 33  is a diagram of a preferred method of passing suture. 
         FIG. 34  is a diagram of a further preferred method of passing suture. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     The following preferred embodiments, in general, are directed to devices and methods for manipulating and passing suture. As will be appreciated, aspects of the suture passing device and its embodiments provide convenience for grasping suture and passing captured suture through tissue. Moreover, aspects disclosed are useful and superior to conventional suture passing devices because the preferred elements provide a reliable and more convenient capture of sutures. In general, preferred devices are disclosed which include a jaw assembly having a suture capturing mechanism that securely pushes and pulls a captured suture. It will be understood that the embodiments disclosed may include different jaw assemblies and suture capturing mechanisms in combination and no one jaw assembly is necessarily operated with any particular suture capturing mechanism disclosed. Thus, enumeration in the following does not imply that a jaw assembly with the same number series must be operated by a suture capturing mechanism of the same number series. 
     Referring now to  FIG. 1 , a first preferred embodiment of a suture passing device or suturing device  10  is shown. The device  10  preferably comprises a proximal portion  20  and a distal portion  22 . The proximal portion  20  includes a handle  24  and an actuating mechanism which may comprise a thumb slide  26 . The thumb slide  26  communicates with and actuates a jaw assembly  30  included in the distal portion  22  of the device  10 . An actuator (not shown) is coupled to the thumb slide and the jaw assembly  30  which is housed in a shaft  32 . The shaft  32  defines a shaft axis A. 
     The device  10  comprises a distal tip  34 . In the preferred embodiment, the distal tip  34  comprises a sharp needle tip. While the distal tip  34  is shown in a straight configuration for simplicity, it should be expressly understood that this tip can be bent in a number of different curves as required. 
     In  FIG. 2A , a close-up of the first preferred distal needle tip  34  is shown with the jaw assembly  30  in a default open configuration when the actuating mechanism  26  of  FIG. 1  is moved distally. The distal tip  34  may comprise a sharpened distal blade that enhances its ability to puncture tissue. In the first preferred embodiment, the jaw assembly  30  preferably comprises a pair of jaw members, or first and second jaw members,  41 . In the preferred embodiment, the full length of the first and second jaw members  41  can range from 2 mm to 15 mm or longer depending on the amount of spread and reach desired for suture manipulation. 
     The jaw assembly  30  comprises a push-pull suturing capturing mechanism  44  preferably formed on the pair of jaw members  41 . In the first preferred embodiment, the suture capturing mechanism  44  may comprise a series of valleys  45  and teeth  46  formed on each jaw member  41  in a preferably alternating pattern. In the preferred embodiment, the height of the teeth  46 , or depth of the valleys  45  can range from 0.1 mm to 5 mm depending on the constraining tube diameter and suture to be manipulated. The number of valleys  45  and teeth  46  can vary from one to multiple quantities. The number of valleys  45  need not match the number of teeth  46 . And the configuration on one jaw member  41  relative to the other opposite jaw member  41  can mesh as shown in the illustrated embodiment, comprise a mirror image (which would not mesh) or interact in a more random manner. Each jaw member  41  can also have a different pattern relative to the other jaw member  41  such as staggered teeth. As a further example, one jaw member  41  may comprise a flat face, i.e. no valleys or teeth, while the opposite jaw member  41  comprises valleys and teeth. 
     In the preferred embodiment, the push-pull suture capturing mechanism  44  is configured to both push and pull a captured portion of suture. The suture capturing mechanism  44  may accomplish this dual push-pull action by having, for example, teeth  46  that affix to and lock on a specific point of suture. That fixed point of suture may be both pulled—e.g., when the jaw assembly  30  is retracted into the into hollow shaft  32 —and pushed—e.g., when the jaw assembly  30  exits out the shaft carrying the affixed point of suture until the jaw members  41  diverge from each other so as to release the suture. 
     In the preferred embodiment, the jaw assembly  30  may preferably be composed of a variety of materials including plastic and/or metal. One preferred material may be Nitinol which can be shape-set in the spread-out configuration as shown in  FIG. 2A . In the illustrated embodiment, the jaws may be preconfigured to a default spread-apart configuration shown in  FIG. 2A  when at rest and can be brought together as in  FIG. 2D  without yielding the material. In the first preferred embodiment, there are no hooks located at the distal ends of the jaws. 
     In the default open position of the jaw assembly  30  as shown in  FIG. 2A , the first and second jaws  41  diverge away from the shaft axis A, and thus diverge away from each other  41 . When the jaws  41  are moved distally to exit the distal tip  34 , the jaws  41  are biased to this flared-out open configuration where neither jaw  41  is parallel to the shaft axis A. 
     In  FIGS. 2B, 2C, and 2D , the jaw assembly  30  is being drawn in to a lumen  50  defined within the shaft  32  when the actuating mechanism  26  shown in  FIG. 1  is moved proximally. As shown in  FIG. 2B , an inner wall  52  of the shaft  32  slowly forces the two jaw members  41  together as the jaw assembly  30  is retracted into the distal tip  34  and further into the shaft  32 . The inner wall  52  causes the pair of jaw members  41  to converge towards each other as the jaw assembly  30  is drawn into lumen  40 . In  FIG. 2D , the jaw assembly  30  is retracted into distal tip  34  and moved to a closed configuration when the actuating mechanism is moved further proximally. The inner wall  52  is preferably abutting not only one jaw member  41 , but both jaw members  41  to cause the pair of jaw members  41  to converge when retracted into the shaft  32 . This is accomplished in part to the default shape of each jaw  41  which is preferably biased away (i.e., opposite direction) from the opposing jaw  41  as shown in  FIG. 2A . 
     In the first preferred embodiment where similar geometries are formed on each jaw member  41 , this convergence can be likened to two sets of teeth meshing in a zipper-type action when retracted into the shaft  32 . In the illustrated embodiment, it should be noted that the jaw members  41  are shown coming together on the same plane but it is a common occurrence for jaw members  41  to come in to the distal tip  34  at slightly different planes especially if suture is also being pulled in. Also, the two jaw members  41  not need be symmetrical. For example, one jaw member could be curved as shown and the other jaw member relatively straight. 
     In the preferred embodiment shown in  FIG. 2D , the device  10  comprises a kerf  57  that forms a space between the two jaw members  41  which can vary from touching to a distance capable of holding a particular suture of a desired size. This gap can be as large as 0.5 mm and still hold some of the larger suture sizes. For smaller suture sizes this gap will often be closer to a range between 0 mm and 0.25 mm. In the preferred embodiment, the distal end  58  of the jaw assembly  30  may be retracted into the shaft  32  in a preferred range of 10 mm to 45 mm from the blade tip  36 . 
       FIGS. 3A-3D  illustrate operative views of the preferred suturing device  10 .  FIG. 3A  shows the deployed jaw assembly  30  extending distally out from the shaft  32  and surrounding a piece of suture  62  with a wide capture space, or region  63  that is generally shaped as a flared-out funnel or flared-out horn. In this deployed configuration, the jaw members  41  are extended distally out of the shaft  32  and positioned on opposite sides of the suture  62  in their default divergent configuration. The jaw members  41  are biased to a diverging configuration when deployed and moved to a converging configuration when retracted into the tube  32 . The spread of the distal jaw tips  43  will be dependent on what the nearby anatomy of the patient will allow, but the ability to spread between 5 and 10 mm will be desired in most instances. In this default diverging configuration shown in  FIG. 3A , the jaw members  41  are preferably flared out such that the distance between counterpart portions of the jaw members  41  increases starting from the proximal jaw portion  59  to the distal jaw portion  58 . This flared-out configuration between the jaw members  41  creates a wide capture space for receiving a suture to be captured. 
     In  FIG. 3B , the jaw assembly  30  is partially drawn into the shaft  32  which pushes the jaw members  41  towards each other to capture the suture  62 . In particular, the inner wall  52  of the shaft  32  causes the jaws  41  to converge as the jaw assembly  30  is retracted into the lumen  50 . The suture  62  is retracted further in  FIG. 3C  which illustrates a closed configuration of the jaw assembly  30  wherein the jaws  41  abut each other. In this closed position in  FIG. 3C , the suture  62  is captured as a fixed point  64  of suture  60  is locked between the valleys  45  and teeth  46  of the jaw members  41 . In the preferred embodiment, the captured portion of suture  62  may be retracted into the lumen  50  in a preferred range of 10 mm to 45 mm from the distal tip  34 . 
     In  FIG. 3D , the closed jaw assembly is further retracted into the shaft  32  carrying the suture  62  further within the distal tip  34 . It should be noted that the suture  62  can be pulled in a relatively long distance such that when the suture  62  is pushed out, a large loop can be formed with the deployed length. This length could be 10 mm to 45 mm, or more. The captured suture portion  62  is pushed out by virtue of the suture capturing mechanism (disposed within the shaft in  FIG. 3D ) locking onto a fixed point of suture and carrying the affixed point of captured suture in a distal direction. This push dynamic is distinguishable from prior art jaw assemblies that loosely hook onto a suture and thus cannot distally push a fixed point of suture. 
       FIGS. 4A-4E  show a preferred method for passing suture  62  with the first preferred embodiment of the suturing device  10 . In  FIG. 4A , the suture  62  has been loaded in the passer  10  as shown in  FIG. 3D . In  FIG. 4B , the sharp distal tip  34  is pushed through the tissue  66  carrying at least portion of suture  62  through the tissue  66 . 
     In the retracted position shown in  FIG. 4C , the jaw assembly  30  carries the captured suture portion  62  into the shaft  32  for a preferred distance in the range of 10 mm to 45 mm measured from the blade tip  36  end of the distal tip  34 . In the preferred embodiment, the suture capturing mechanism  44  locks onto a fixed point  64  of suture  62  and distally pushes this affixed point  64  of suture  62  when the jaw assembly  30  is translated distally with respect to the shaft  32 . Jaw mechanisms configured to lock onto a fixed point of suture may comprise teeth/valley combinations as discussed above, and a variety of gripping or securing jaw combinations as discussed below in reference to  FIGS. 8A-31 , except  FIG. 14 . 
     In  FIG. 4D  the jaw assembly  30  is deployed out the tip  34  so that the jaw members  41  push and pull the suture  62  out of the tip  34  and release a large suture loop  67  once the proper spread is achieved between the jaw members  41 . This leaves the large loop  67  that can easily be grabbed by the passer  10  once it has adjusted to a new position as shown in  FIG. 4E . It should be noted that an addition or variation to this method is to pierce the tissue  66  with a distal tip  34  that is not loaded with suture. The jaw assembly  30  can then grab the suture  62  on the other side of the tissue  66  similar to  FIG. 4E . 
       FIG. 5A  illustrates details of the preferred jaw assembly  30  having a suture capturing mechanism  44  that prevents or inhibits captured suture from sliding. For machining purposes there may be a witness kerf  57 . This acts to form the pattern of teeth  45  and valleys  46  between the two jaw members though the two jaws do not necessarily have to nest as shown in the illustrated embodiment. Also, the kerf  57  can vary in width over its length to create smaller or larger gaps between the two jaws  41 . 
     In  FIG. 5A , the jaw assembly  30  may preferably comprise thinned sections  68  with cutouts  70  that allow for the pair of jaws  41  to bend outwards away from each other bend outwards (as shown in  FIG. 3A ) or inwards with minimal imparted stresses as shown in  FIG. 3A . This diverging motion is represented in  FIG. 5C  with movement arrows  79  indicating that the jaw assembly  30  as a whole is more flexible along the plane shown in  FIG. 5C . The thinned sections  68  shown in  FIG. 5A  also provide greater flexibility for the jaw assembly  30  to bend as indicated by the movement arrows  77  in  FIG. 5B . The thinned sections  68  also allow for twisting of the jaw assembly  30  under torsion forces, thereby allowing the jaw assembly  30  to pass through non-linear tubes that may be bent in multiple planes. Referring back to  FIG. 5A , the thinned sections  68  are preferably located proximal to suture capturing mechanism  44  and collectively form a void  71  when the suture capturing mechanism is in the closed position as shown. For proper flexibility without imparting yielding stresses, the length and displacement must be taken into account but in general the thickness can preferably range from 0.2 mm to 2 mm. 
     And for jaw assemblies  30  composed of memory materials such as Nitinol the thinned sections  68  allow for shape set in an open position. The proximal relief is a feature that minimizes the stress on the part when the jaw members  41  are displaced. In the first preferred embodiment, the jaw members  41  preferably comprise distal portions of a unitary jaw structure  30 . Thinned sections  68  are shown to have uniform cross section along their length but this cross-section area may vary over that length in order to evenly distribute stresses during bending. For instance, the cross-sectional area of the thinned section  68  can decrease as it gets closer to the teeth  46  in a way to even out stresses during bending. 
     A 90° view of  FIG. 5A  is shown in  FIG. 5B . It is obvious that this aspect is much thinner than that of  FIG. 5A  which allows for relative flexure ease as shown with arrows  77  while minimizing imparted stresses. Another view of the relative planar thicknesses is shown in  FIG. 5C . 
     In the following alternative embodiments, elements of similar structure are designated by the same reference numerals followed by at least one lower case letter (e.g., jaw assembly  30   b ) 
       FIGS. 6-10E  illustrate alternative embodiments of the jaw assembly, each having a preferred suture capturing mechanism configured to lock onto a point of suture and both push and pull the affixed point of suture. 
       FIG. 6  shows an alternative embodiment of the jaw assembly  30   b  comprising teeth  46   b  that need not be rectangular but can be curved or round as shown. The teeth can also be triangular, or a combination of different shapes as shown in the following embodiments. 
       FIG. 7  illustrates a jaw assembly  30   c  comprising an axial slit  72  that makes the jaw ribbon  74  more flexible. This allows for the two halves  76  of the ribbon  74  to move independently while keeping most of the compressive and tensile properties of the ribbon  74 . This becomes most important when the ribbon  74  is moving through constraining components that have bends in multiple axis. 
       FIG. 8A  illustrates a jaw assembly  30   d  having a second suture capture mechanism  78  that enables suture to slide once it has been captured. The gentle geometry of the cutout distal curve  78  can be positioned such that the suture captured by the jaw assembly  30   d  will slide within the curve  78  when the device pulls on the suture. In the configuration shown, access  84  to the kerf  57   d  is proximal to the distal-most portion  82  of the curve  78  such that the suture would tend to settle in to the curve  78  when the suture is moved distally with respect to the jaw assembly  30   d  (i.e., when the jaw assembly  30   d  is retracted proximally). This prevents the suture from getting stuck in the kerf access  84 . The cutout distal curve  78  thus comprises a hook  78  that enables captured suture to slide transversely (i.e., in and out of the page in the view of  FIG. 8A ) with respect to the jaw assembly  30   d . Thus, the jaw assembly  30   d  comprises two suture capture mechanisms  44   d ,  78 : namely, a first push-pull suture capturing mechanism  44   d  that locks onto a fixed point of suture and a second loose suture capturing mechanism  78  that captures suture while allowing the capture suture to slide. 
     In  FIG. 8B , the cutout  70   e  of the jaw assembly  30   e  defines a distal cutout curve, or hook,  78   e  positioned even more distally with respect to the kerf access  84   e . In comparison to the jaw assembly  30   d  shown in  FIG. 8A , the kerf access  84   e  in  FIG. 8B  is positioned more proximally with respect to the hook  78   e . The jaw assembly  30   e  thus comprises a first push-pull suture capturing mechanism  44   e  that locks onto a fixed point of suture and a second loose suture capturing mechanism  78   e  that allows captured suture to slide. 
     In  FIG. 8C , the cutout  70   f  of the jaw assembly  30   f  defines two distal cutout curves, or hooks,  78   f  positioned distally to the kerf access  84   f , which enables the captured suture to seat in to either of the hooks  78   e  and away from the kerf access  84   f . The jaw assembly  30   f  thus comprises a first push-pull suture capturing mechanism  44   f  that locks onto a fixed point of suture and a second loose suture capturing mechanism  78   f  having two hooks that allow captured suture to slide. 
       FIGS. 9A-9C  show alternative embodiments of the push-pull suture capturing mechanism having asymmetrical patterns of teeth and valleys, namely, where the pattern on a first jaw is not symmetrical to the pattern on the opposing second jaw. The teeth themselves can have a consistent or varying width and height along the length of the jaws. The number of teeth can also vary from one to more than one. 
     In  FIG. 9A , the suture capturing mechanism  44   g  may comprise teeth  46   g  on only one jaw  41   g - 1  with the second jaw  41   g - 2  having a relatively flat jaw surface  86 . 
     In  FIG. 9B , the suturing capturing mechanism  44   h  comprises a first jaw  41   h - 1  with a first geometry of teeth  45   g - 1  while a second jaw  41   h - 2  comprises a different second geometry of teeth  45   g - 2 . 
     In  FIG. 9C , the suturing capturing mechanism  44   i  comprises different tooth geometries within the same jaw  41   i - 1 ,  41   i - 2 . For example, the first jaw  41   i - 1  may have both rectangular and triangular teeth  46   i - 1 . Similarly, the second jaw  41   i - 2  may itself have differently shaped teeth. 
       FIGS. 10A-11B  illustrate different cross-sectional profiles of preferred ribbons.  FIG. 10A  shows a ribbon  74   j  having a circular profile.  FIG. 10B  illustrates a ribbon  74   k  having a rectangular profile, which may comprise a square.  FIG. 10C  illustrates a ribbon  74   l  with a triangular profile.  FIG. 10D  illustrates a ribbon  74   m  having a hexagonal profile.  FIG. 10E  illustrates a ribbon  74   n  having an oval profile. 
       FIG. 11A  shows an assembly of two ribbons  74   o  stacked on top of each other lengthwise.  FIG. 11B  shows an assembly of two ribbons  74   p  stacked on top of each other widthwise. 
       FIG. 12  illustrates a preferred jaw assembly  30   p  where each jaw  41   p  comprises an alternating pattern of pointy teeth  46   p  and curved valleys  45   p  to form a scalloped edge  80 . In  FIG. 12 , the two scalloped edges  41   p  are staggered with respect to each other so as to nest at least slightly when the jaws  41   p  are closed. 
       FIG. 13  illustrates a pair of jaws  41   q  with symmetrical scalloped edges  80   q  such that opposing pointy teeth  46   q  contact each other when the pair of jaws  41   q  is closed. 
       FIG. 14  illustrates a jaw assembly  30   r  where a first jaw  41   r - 1  comprises a distal U-shaped hook structure  86  that defines a hook  78   r  located distally to a distal end of the second jaw  41   r - 2  which comprises a substantially flat surface  88 . This illustrated embodiment  30   r  would allow captured suture to slide. 
       FIG. 15  illustrates a jaw assembly  30   s  where a first jaw  41   s - 1  comprises a distal U-shaped hook structure  86   s  that defines a hook  78   s  located distally to a distal end of the second jaw  41   s - 2 . Each jaw  41   s - 1 ,  41   s - 2  comprises a scalloped edge  80   s  that is preferably staggered with respect to the opposite edge. The jaw assembly  30   s  thus comprises a first push-pull suture capturing mechanism  44   e  that locks onto a fixed point of suture and a second loose suture capturing mechanism  78   s  that allows captured suture to slide. In the preferred embodiment of  FIG. 15 , the loose suture capturing mechanism  78   s  is preferably distal to the fixed suture capturing mechanism  44   s.    
     In any of the preferred embodiments disclosed herein having a loose suture capturing mechanism, it may be preferable to bring the loosely captured suture into the hollow shaft a preferred distance of 1 mm to 15 mm from a blade tip of the distal tip. 
       FIG. 16  illustrates a jaw assembly  30   t  where each jaw  41   t  comprises tapered teeth  46   t  and valleys  45   t  with curved bases  90 . A cutout  70   t  located proximal to the suture capturing mechanism  44   t  defines a hook  78   t  positioned distal to the kerf access  84   t . The jaw assembly  30   t  thus comprises a first push-pull suture capturing mechanism  44   t  that locks onto a fixed point of suture and a second loose suture capturing mechanism  78   t  that allows captured suture to slide. In the preferred embodiment of  FIG. 16 , the loose suture capturing mechanism  78   t  is preferably proximal to the fixed suture capturing mechanism  44   t.    
       FIG. 17  illustrates a jaw assembly  30   u  where each jaw  41   u  comprises tapered teeth  46   u  and valleys  45   u  spaced apart from the counterpart teeth  46   u  and valleys  45   u  on the opposite jaw  41   u  so as to form a larger kerf  57   u , namely, a greater gap or space between the medial edge of a tooth  46   t  and the base of the corresponding valley  45   u.    
       FIG. 18  illustrates a dual-stack jaw assembly  30   v  that inhibits unwanted jaw movement within the hollow shaft by filling up more of space therein with multiple pairs of jaw members  41   v  stacked on one another. In this preferred embodiment, two pairs of jaw members  41   v  along with corresponding ribbons  74   v  are stacked upon each other so as to form a first jaw member stack  141 - 1  and a second jaw member stack  141 - 2 . The first and second jaw member stacks  141 - 1 ,  141 - 2  diverge from each other in the same manner as unstacked first and second jaw members do as described in the foregoing embodiments. The stacked jaw members in each jaw member stack  141 - 1 ,  141 - 2  preferably move in unison. 
     The dual-stack jaw assembly  30   v  may comprise two pairs of jaw members that are either discrete from each other or integral to each other. If discrete pairs of jaw members are stacked, each pair may be connected, adhered, fused or otherwise coupled to the other pair to form a stack. Alternatively, a dual-stack jaw assembly  30   v  may comprise the equivalent of a discretely stacked pair of jaws by having a single unitary pair of jaws with a greater thickness in the preferred range of 0.4 mm to 4.0 mm. In the preferred embodiment, this inner diameter of the shaft may have a range of 0.75 mm to 2 mm. In the preferred embodiment, the jaw assembly has a thickness that reduces the gap between the exterior of the jaw assembly and the internal surface of the shaft, which distance is preferably between 0.2 mm to 1 mm. This stacked jaw assembly  30   v  inhibits jaw movement within the shaft while maintaining the flexibility for the jaw members to move through the curves of a shaft or tube. 
     According to the invention, a preferred suture passing device may comprise a dual stack of any of the preferred jaw assemblies disclosed herein. 
       FIG. 19  illustrates a jaw assembly  30   w  having multiple elongate cutouts  70   w  spaced apart along the jaw assembly axis. In this illustrated embodiment which preferably comprises three cutouts  70   w  where the length of a particular cutout can be made larger if increased flexibility is required as shown in  FIG. 19 . One or more bridges  92  can then be added to manipulate the flexibility of the jaw assembly as shown in  FIG. 19 . The bridges  92  can also be strategically placed to prevent the jaws from crossing within the hollow shaft, which is advantageous in curved tubes (see  FIG. 32 ). 
       FIG. 20  illustrates a jaw assembly  30   x  having distal elongate cutouts  70   x - 1  and a proximal elongate cutout  70   x - 2  with a substantially greater axial length than that of the distal cutout  70   x - 1 . The distal elongate cutouts  70   x - 1  collectively form a first void  71   x  directly proximal to the suture capturing mechanism  44   x  and having a preferred length of 4 mm to 20 mm including the suture capturing mechanism when the jaw assembly  30   x  is closed. The proximal elongate cutout  70   x - 2  comprises a second void  70   x - 2  with a preferred width in the range of 0.03 mm to 0.75 mm and a preferred length in the range of 10 mm to 40 mm. 
       FIG. 21  illustrates a cylindrical jaw assembly  30   y  having four jaw members  41   y  that collectively form a cylinder. In particular, the jaw assembly  30   y  comprises a pair of top jaw members  41   y - t  and a pair of bottom jaw members  41   y - b . With some of these thicker cross-sections such as the circle, the stiffness may become too great for bending around corners so it may be advantageous to make cuts  70   y - 1  along a first plane and additional cuts  70   y - 2  along a second plane orthogonal to the first plane as shown in  FIG. 21 . 
       FIG. 22  illustrates a jaw assembly  30   z  having a pair jaw members  41   z  that collectively form a cylinder. The jaw assembly  30   z  comprises a planar ribbon  74   z  with a cutout  70   z  proximal to the pair of jaws  41   z .  FIG. 22  shows cuts made to removal material in the flexible section but leaving the round distal portion full to form a cylinder at the distal end of the jaw assembly  30   z . In both cases the extra cut is shown 90° to the original cut but it/they can be at any angle that leaves sufficient material for the jaws&#39; operation. 
       FIG. 23  illustrates a jaw assembly  30   aa  that may be manufactured from a rod as opposed to the ribbon associated with the foregoing embodiments. The jaw assembly  30   aa  comprises curved valleys  45   aa  and teeth  46   aa . A cutout  70   aa  defines a hook  86   aa  located distal to a kerf access  84   aa.    
     In  FIG. 24 , it will be appreciated that forming the jaw assembly  30   aa  manufactured from a rod provides a more substantial three-dimensional jaw body than the planar jaw assemblies of foregoing embodiments. This provides the jaw assembly  30   aa  with a jaw height or thickness  94  such that top indentations and bottom indentations  96 , or grooves, may be formed in an alternating pattern with peaks  98 . In this preferred embodiment, the top and bottom indentations  98  of a first jaw member  41   aa  are aligned with those  96  on the second jaw member  41   aa.    
       FIG. 25  illustrates a jaw assembly  30   bb  manufactured from a rod having tapered teeth  46   bb  and tapered valleys  45   bb  shaped to receive the teeth  46   bb  to form a nesting relationship. 
     In  FIG. 26 , a second preferred embodiment of a suture passing device  10   cc  comprises a dual-stack jaw assembly  30   cc  having two pairs of jaws  41   cc - 1 ,  41   cc - 2  stacked on top of each other. In this preferred embodiment, a first pair of jaws  41   cc - 1  is stacked on top of a second pair of jaws  41   cc - 2  to form a first jaw member stack  141   cc - 1  that diverges away from a second jaw member stack  141   cc - 2  in the open configuration. The second pair of jaws  41   cc - 2  can be a replica of the first pair of jaws  41   cc - 1 . 
       FIG. 27  shows a third preferred embodiment of a suture passing device  10   dd  having a flattened or planar hollow shaft  32   dd  to minimize unwanted jaw movement within when housing a planar jaw assembly  30   dd  with a planar jaw ribbon. It will be appreciated that the cross-sectional ribbon profiles shown in  FIGS. 10A-10D  may also aid in taking up open space within the tube and minimize unwanted movement of the jaws. 
       FIG. 28  shows a fourth preferred embodiment of a suture passing device  10   ee  having a jaw assembly  30   ee  where a first side portion  102  comprises a single jaw member  41   ee - 1  and a second side portion  104  comprises a pair of stacked jaw members  41   ee - 2 . It will be appreciated that a jaw assembly  30   ee  may comprise different and asymmetrical jaw members. 
       FIG. 29  illustrates a fifth preferred embodiment of a suture passing device  10   ff  where each jaw member  41   ff  comprises a distal spacer  106  that prevents unwanted jaw movement within the shaft  32   ff . Each jaw member  41   ff  thus comprises dual distal tips stacked on each other. In a preferred embodiment, the spacers  106  may comprise teeth  108  and valleys  110 . Though the spacers are attached to the distal tip in this illustrated embodiment, they can be attached anywhere along the length of the jaw assembly  30   ff  to manipulate the movement within the shaft  32   ff . Though it is not required that the stacked jaw assemblies be attached the resultant stiffness can be manipulated by strategically attaching the assemblies at various points along the length of the assembly. For example, attaching the assemblies at distal tips as shown in  FIG. 29  and leaving the rest of the construct free would result in a jaw assembly with a stiffer tip. This design methodology can also be advantageous to keep the distal tips pieces from crossing within the tube but allowing the shaft portion of the pieces to move relative to each other and thus be more flexible. The opposite can also be done by welding a portion of the shaft but not the jaw tips such that the shafts will move together but the tips can move relative to each other for more flexibility. 
     The advantage described in the above paragraph is most evident in curved tubes (see  FIG. 32 ) where relative position is important as is flexibility. Though the preferred means of attachment is laser welding there are a variety of methods that can be used to attach the jaw assemblies such as a variety of adhesives. 
       FIG. 30  illustrates a sixth preferred embodiment of a suture passing device  10   gg  where each jaw member  41   gg  diverges linearly away from each along the distal direction, as opposed to foregoing embodiments where each jaw member increasingly diverges away from each along the distal direction. Each jaw member  41   gg  preferably comprises a scalloped edge  80   gg.    
       FIG. 31  illustrates a seventh preferred embodiment of a suture passing device  10   hh  having a jaw assembly  30   hh  where each jaw  41   hh  comprises a first proximal bend  112  and a second distal bend  114 . The first bend  112  of each jaw  41   hh  is diverging while the second bend  114  of each jaw  41   hh  is converging such that distal jaw portions  116  containing the suture capturing mechanism  44   hh  extend in a substantially parallel manner when the jaw assembly  30   hh  is in the open configuration as shown in  FIG. 31 . 
       FIG. 32  illustrates a curved hollow needle shaft  32   ii  that may be used with any of the foregoing preferred embodiments of the suture passing needle. The curved shaft  32   ii  comprises a shaft bend  120  proximal to the sharp needle tip  34   ii.    
     In all of the foregoing embodiments where the jaw assembly comprises a proximal ribbon portion, the ribbon may have a thickness in the preferred range of 0.2 mm to 2 mm, and a width in the preferred range of 1 mm to 2 mm. 
     In all of the foregoing embodiments where the jaw assembly comprises one or more cutouts, the cutout may have a length in the preferred range of 10 mm to 30 mm, and a width in the preferred range of 0.03 mm to 0.75 mm. 
     In all of the foregoing embodiments where a preferred jaw assembly is shown in the closed configuration but without an accompanying shaft, it is to be expressly understood that the jaw members are shown closed for illustrative purposes only and that such Figures do not imply that the jaw assembly defaults to a closed configuration without a shaft. 
     It is to be expressly understood that a preferred suturing passing device according to the invention may comprise a dual stack of any foregoing preferred jaw assemblies having any of the foregoing preferred suture capturing mechanisms and any of the foregoing preferred cutouts. 
     A preferred method of passing suture  200  is also provided and illustrated in  FIG. 33 . The method  200  comprises the step  210  of diverging a pair of jaw members of a suture passing device from each other by translating a jaw assembly distally with respect to a hollow shaft to cause the outwardly biased jaw members to exit a distal needle tip. This step  210  creates a preferably flared-out capture space for receiving a portion of suture. This steps  210  also comprises diverging each of the jaw members away from an axis defined by the shaft. 
     In step  220 , the suture passing device is moved to surround a suture with the open jaw members. In step  220 , the suture would be disposed within a suture capture space that is defined between the two diverging jaw members and preferably shaped as a funnel. 
     In step  230 , the jaw assembly is retracted with respect to the tube such that the inner wall of the tube causes the jaw members to converge toward each other. 
     In step  240 , the jaw members are moved to a closed configuration so as to capture the suture and lock onto a fixed point of the suture to prevent sliding of the captured suture. 
     In step  250 , the captured suture is retracted into the tube in a preferred range of 10 mm to 45 mm from a blade tip of the shaft. 
     In step  260 , the captured suture is pushed out of the shaft by the jaw members carrying a fixed point of suture to exit the shaft. 
     In step  270 , the suture is released when the jaw members are moved to an open configuration. In the preferred method, the suture is not immediately released as soon as a distal portion of the jaw members exits the shaft. Instead, the suture is preferably retained for a short distance of after the suture capturing mechanism exits the lumen of the shaft. 
     A preferred method of passing loosely captured suture  300  is also provided and illustrated in  FIG. 34 . The method  300  comprises the step  310  of diverging a pair of jaw members of a suture passing device from each other by translating a jaw assembly distally with respect to a hollow shaft to cause the outwardly biased jaw members to exit a distal needle tip. This step  310  creates a preferably flared-out capture space for receiving a portion of suture. This steps  310  also comprises diverging each of the jaw members away from an axis defined by the shaft. 
     In step  320 , the suture passing device is moved to surround a suture with the open jaw members. In step  320 , the suture would be disposed within a suture capture space that is defined between the two diverging jaw members and preferably shaped as a funnel. 
     In step  330 , the jaw assembly is retracted with respect to the tube such that the inner wall of the tube causes the jaw members to converge toward each other. 
     In step  340 , the jaw members are moved to a closed configuration so as to loosely capture the suture and while allowing the loosely captured suture to slide. 
     In step  350 , the loosely captured suture is retracted into the tube in a preferred range of 1 mm to 15 mm from a blade tip of the shaft. 
     In step  360 , the suture is released when the jaw members are moved to an open configuration. In the preferred method, the suture is not immediately released as soon as a distal portion of the jaw members exits the shaft. Instead, the suture is preferably retained for a short distance of after the suture capturing mechanism exits the lumen of the shaft. 
     Terms such as “top,” “bottom,” “front,” “rear,” “above,” “below” and the like as used in this disclosure should be understood as referring to an arbitrary frame of reference, rather than to the ordinary gravitational frame of reference. Thus, a top surface, a bottom surface, a front surface, and a rear surface may extend upwardly, downwardly, diagonally, or horizontally in a gravitational frame of reference. Similarly, an item disposed above another item may be located above or below the other item along a vertical, horizontal or diagonal direction; and an item disposed below another item may be located below or above the other item along a vertical, horizontal or diagonal direction. While some features are shown facing away from gravity, it will be understood that features can be rotated or positioned perpendicular to gravity and work to hold, knot, or cut a suture in the same way as shown. 
     The word “exemplary” is used herein to mean “serving as an example or illustration.” Any aspect or design described herein as “exemplary” is not necessarily to be construed as preferred or advantageous over other aspects or designs. 
     All structural and functional equivalents to the elements of the various aspects described throughout this disclosure that are known or later come to be known to those of ordinary skill in the art are expressly incorporated herein by reference and are intended to be encompassed by the claims. Moreover, nothing disclosed herein is intended to be dedicated to the public regardless of whether such disclosure is explicitly recited in the claims. No claim element is to be construed under the provisions of 35 U.S.C. § 112, sixth paragraph, unless the element is expressly recited using the phrase “means for” or, in the case of a method claim, the element is recited using the phrase “step for.” Furthermore, to the extent that the term “include,” “have,” or the like is used in the description or the claims, such term is intended to be inclusive in a manner similar to the term “comprise” as “comprise” is interpreted when employed as a transitional word in a claim. 
     Many alterations and modifications may be made by those having ordinary skill in the art without departing from the spirit and scope of the invention. Therefore, it must be understood that the illustrated embodiments have been set forth only for the purposes of examples and that they should not be taken as limiting the invention as defined by the following claims. For example, notwithstanding the fact that the elements of a claim are set forth below in a certain combination, it must be expressly understood that the invention includes other combinations of fewer, more or different ones of the disclosed elements. 
     The words used in this specification to describe the invention and its various embodiments are to be understood not only in the sense of their commonly defined meanings, but to include by special definition in this specification the generic structure, material or acts of which they represent a single species. 
     The definitions of the words or elements of the following claims are, therefore, defined in this specification to not only include the combination of elements which are literally set forth. In this sense it is therefore contemplated that an equivalent substitution of two or more elements may be made for any one of the elements in the claims below or that a single element may be substituted for two or more elements in a claim. Although elements may be described above as acting in certain combinations and even initially claimed as such, it is to be expressly understood that one or more elements from a claimed combination can in some cases be excised from the combination and that the claimed combination may be directed to a subcombination or variation of a sub combination. 
     Insubstantial changes from the claimed subject matter as viewed by a person with ordinary skill in the art, now known or later devised, are expressly contemplated as being equivalently within the scope of the claims. Therefore, obvious substitutions now or later known to one with ordinary skill in the art are defined to be within the scope of the defined elements. 
     The claims are thus to be understood to include what is specifically illustrated and described above, what is conceptually equivalent, what can be obviously substituted and also what incorporates the essential idea of the invention.