Patent Publication Number: US-2022218330-A1

Title: Needle holder for endoscope and operating method of suture needle

Description:
This application is a continuation application of International Patent Application No. PCT/JP2019/041694 filed on Oct. 24, 2019, the content of which is incorporated herein by reference in its entirety. 
     The present disclosure relates to a needle holder for an endoscope and an operating method of a suture needle. 
    
    
     BACKGROUND 
     In the related art, a needle holder for an endoscope that grasps and moves a suture needle when performing a surgery on a part in a body cavity under the observation by an endoscope is known. 
     For example, a surgical grasper that grasps a suture needle is known. The surgical grasper has a grasper at a distal end of a rigid shaft. The grasper can adjust a force of grasping an object to be grasped. The direction or position of the suture needle can be changed to a desired direction or position without a need for the grasper to regrasp the suture needle. 
     SUMMARY 
     A needle holder for an endoscope including a sheath having a longitudinal axis; a grasper capable of grasping a target object; an operation portion capable of opening and closing the grasper; and an operation wire extending along the longitudinal axis of the sheath. The operation portion includes: a main body; a slider slidably attached to the main body; and an elastic member that is elastically deformable depending on an opening and closing position of the grasper. The slider is connected to the grasper via the operation wire. The grasper can release grasping of the target object and can grasp the target object with a first grasping force by moving the slider against a restoring force of the elastic member. The grasper can grasp the target object with a second grasping force smaller than the first grasping force when the restoring force of the elastic member and a tension of the operation wire are balanced. 
     An operating method of a suture needle includes: introducing a suture needle into a luminal organ through a natural opening; and changing a direction of a tip of the suture needle while pressing a part of the suture needle positioned inside the luminal organ against a digestive wall. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is an overall view of a treatment system including a needle holder according to an exemplary embodiment. 
         FIG. 2  is an overall view showing the needle holder. 
         FIG. 3  is a cross sectional view of a cross section of a distal end of a sheath of the needle holder, which is horizontal to an axial direction. 
         FIG. 4  is a perspective view showing a grasper of the needle holder. 
         FIG. 5  is a perspective view showing the grasper of the needle holder. 
         FIG. 6  is an enlarged cross sectional view of a cross section of a connection part between an operation portion and the sheath of the needle holder, which is horizontal to the axial direction. 
         FIG. 7  is a cross sectional view taken along line A-A of  FIG. 6 . 
         FIG. 8  is a cross sectional view taken along line B-B of  FIG. 6 . 
         FIG. 9  is a view showing actions of the operation portion and the sheath when using the needle holder. 
         FIG. 10  is a view showing the needle holder when the grasper does not grasp a suture needle. 
         FIG. 11  is a view showing the needle holder when the grasper grasps the suture needle. 
         FIG. 12  is a view showing the needle holder when the grasper gently grasps the suture needle. 
         FIG. 13  is a view showing an example of a first step of grasping the suture needle with the grasper. 
         FIG. 14  is a view showing an example of the first step of grasping the suture needle in procedures by using the needle holder. 
         FIG. 15  is a front view of the grasper, which shows an example of a third step in the procedures in which the needle holder is used. 
         FIG. 16  is a front view of the grasper, which shows another example of the third step. 
         FIG. 17  is a front view of the grasper, which shows still another example of the third step. 
         FIG. 18  is a view showing an example of a fourth step in the procedures by using the needle holder. 
         FIG. 19  is a view showing a modified example of the operation portion of the needle holder. 
         FIG. 20  is a view showing another modified example of the operation portion of the needle holder. 
         FIG. 21  is a view showing still another modified example of the grasper of the needle holder. 
         FIG. 22  is a view showing still another modified example of the grasper of the needle holder. 
         FIG. 23  is a view showing still another modified example of the grasper of the needle holder. 
         FIG. 24  is a view showing still another modified example of the grasper of the needle holder. 
         FIG. 25  is a view showing still another modified example of the grasper of the needle holder. 
         FIG. 26  is a view showing still another modified example of the grasper of the needle holder. 
         FIG. 27  is a view showing a needle holder according to an exemplary embodiment. 
     
    
    
     DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTS 
     A needle holder for an endoscope (hereinafter, referred to as a “needle holder”)  100  according to an exemplary embodiment of the present disclosure will be described with reference to  FIGS. 1 to 18 .  FIG. 1  is an overall view of a treatment system  300  including the needle holder  100  according to the present embodiment. 
     [Treatment System  300 ] 
     As shown in  FIG. 1 , the treatment system  300  includes a flexible endoscope  200  and the needle holder  100 . The needle holder  100  is used by being inserted into the flexible endoscope  200 . 
     [Flexible Endoscope  200 ] 
     As shown in  FIG. 1 , the flexible endoscope  200  includes an insertion portion  202  and an operation portion  207 . The insertion portion  202  is inserted into a body from a distal end. The operation portion  207  is attached to a proximal end of the insertion portion  202 . 
     The insertion portion  202  has an imaging portion  203 , an active bending portion  204 , and a flexible portion  205 . The imaging portion  203 , the active bending portion  204 , and the flexible portion  205  are disposed in this order from the distal end of the insertion portion  202 . A channel  206  for inserting the needle holder  100  is provided inside the insertion portion  202 . A distal end opening portion  206   a  of the channel  206  is provided in the distal end of the insertion portion  202 . 
     The imaging portion  203  includes, for example, CCD or CMOS, and is configured to image a part, which is a treatment target. The imaging portion  203  is configured to image a grasper  3  of the needle holder  100 , which is to be described later, in a state where the needle holder  100  protrudes from the distal end opening portion  206   a  of the channel  206 . The active bending portion  204  can be positively bent in response to an operation of the operation portion  207  by an operator. The flexible portion  205  is a tubular part having flexibility. 
     The operation portion  207  is connected to the flexible portion  205 . The operation portion  207  has a grip  208 , an input portion  209 , a proximal end opening portion  206   b  of the channel  206 , and a universal cord  210 . The grip  208  is a part grasped by the operator. The input portion  209  receives an operation input for bending the active bending portion  204 . The universal cord  210  outputs an image captured by the imaging portion  203  to the outside. The universal cord  210  is configured to be connected to a display device such as a liquid crystal device via an image processing device such as a processor. 
     [Needle Holder  100 ] 
       FIG. 2  is an overall view showing the needle holder  100 . 
     The needle holder  100  has a sheath  1 , a hard portion  2 , the grasper  3 , an operation portion  4 , and an operation wire  5  inserted through the sheath  1 . 
     The sheath  1  is an elongated member that has flexibility and extends from a distal end  1   a  to a proximal end  1   b . As shown in  FIG. 1 , the sheath  1  has an outer diameter allowing the sheath to be inserted into the channel  206  of the flexible endoscope  200 . In a state where the sheath  1  is inserted in the channel  206 , the distal end  1   a  of the sheath  1  is capable of protruding from and retracting to the distal end opening portion  206   a  of the channel  206 . The distal end  1   a  of the sheath  1  can enter an imaging field view of the imaging portion  203  of the flexible endoscope  200 , and is imaged by the imaging portion  203 . 
     As shown in  FIG. 2 , the hard portion  2  is provided at the distal end  1   a  of the sheath  1 . The hard portion  2  is formed of a hard material such as stainless steel (SUS). The grasper  3  is provided at the hard portion  2 . The operation portion  4  is provided at the proximal end  1   b  of the sheath  1 . 
       FIG. 3  is a cross sectional view of the distal end  1   a  of the sheath  1 . 
     The sheath  1  is a member endoscopically inserted into a body cavity, and has a first coil sheath  11  through which the operation wire  5  is inserted and a second coil sheath  12  through which the first coil sheath  11  is inserted. Without being limited to a coil sheath, the first coil sheath  11  may be a resin tube excellent in compression resistance such as PEEK. 
     The first coil sheath  11  is a so-called single-strand coil sheath formed by tightly winding one metal wire in a loop shape, has compression resistance to the inserted operation wire  5 , and suitably transmits an opening and closing operation of the grasper  3  to the grasper  3  via the operation portion  4 . 
     The second coil sheath  12  is a so-called multi-strand coil sheath formed by arranging a plurality of metal wires in a radial direction and tightly winding in a loop shape and suitably transmits an operation for rotating the grasper  3  to the grasper  3 . The number of metal wires of the second coil sheath  12  may be determined as appropriate. 
     Although an example in which the first coil sheath  11  is formed by a metal wire of which a cross section metal wire is rectangular and the second coil sheath  12  is formed by a metal wire of which a cross section is circular has been described in the present embodiment shown in  FIG. 3 , the shapes of the cross sections of the metal wires are not limited thereto, and may be selected as appropriate according to a design value of the sheath  1 . 
     As shown in  FIG. 3 , a region having a predetermined length from a distal end  12 A of the second coil sheath  12  is processed to have a flat inner peripheral surface  12 B through cutting or the like. A proximal end side of the hard portion  2  is formed in a tubular shape, and has an outer surface. The outer surface  2 A is connected and fixed to the inner peripheral surface  12 B of the second coil sheath  12 . The inner peripheral surface  12 B of the second coil sheath  12  and the outer surface  2 A on the proximal end side of the hard portion  2  are fixed to each other through laser welding or brazing or the like. 
     A distal end  11 A of the first coil sheath  11  is fixed to the proximal end of the hard portion  2  through laser welding or brazing or the like. 
     The distal end  12 A of the second coil sheath  12  is fixed to the outer surface  2 A of the hard portion  2 . The distal end  12 A of the second coil sheath  12  cannot rotate about an axis thereof with respect to the hard portion  2 , and cannot move in an axial direction relatively to the first coil sheath  11 . 
     A connection form between the hard portion  2  and the sheath  1  is not particularly limited to the description made above. For example, a configuration where in the proximal end part of the hard portion  2  formed in a tubular shape, the second coil sheath  12  is fixed to an outer surface, and the first coil sheath  11  is fixed to an inner surface may be adopted. In addition, the shape of a part of the hard portion  2 , to which the sheath  1  is fixed, may not be tubular. 
       FIGS. 4 and 5  are perspective views showing the grasper  3  of the needle holder  100 . 
     The grasper  3  has a first grasp member  31 , a second grasp member  32 , and a link mechanism  36 . The first grasp member  31  and the second grasp member  32  are configured to be openable and closable.  FIG. 4  shows a state where the first grasp member  31  and the second grasp member  32  are closed.  FIG. 5  shows a state where the first grasp member  31  and the second grasp member  32  are opened. 
     The first grasp member  31  is a part of a distal end portion of the hard portion  2 . The first grasp member  31  extends along a longitudinal axis Y 1  of the sheath  1 . In the needle holder  100  of the present embodiment, the first grasp member  31  and the hard portion  2  are integrally molded. 
     The second grasp member  32  is connected to the hard portion  2  so as to be openable and closable with respect to the first grasp member  31 . Specifically, for example, as a connecting shaft  37  is inserted into a through-hole  38  formed in the second grasp member  32  and a through-hole  39  formed in the hard portion  2 , the second grasp member  32  is connected to the hard portion  2  so as to be movable rotationally. The second grasp member  32  is movable rotationally about a longitudinal axis Y 2  of the connecting shaft  37 . 
     The first grasp member  31  has a first protrusion portion  311  and a second protrusion portion  312 . The first protrusion portion  311  and the second protrusion portion  312  are provided at a distal end portion of the first grasp member  31 , and protrude in a direction intersecting the longitudinal axis (central axis) Y 1 . The first protrusion portion  311  and the second protrusion portion  312  are provided as a pair with the longitudinal axis Y 1  of the sheath  1  interposed therebetween, and a distal end portion of the second grasp member  32  is positioned between the first protrusion portion  311  and the second protrusion portion  312  in a state where the first grasp member  31  and the second grasp member  32  are closed. 
     The link mechanism  36  is configured by a first link member  36   a , a first joint member  36   b , a second link member  36   c , and a second joint member  36   d . The first link member  36   a  is connected to the second link member  36   c  by the first joint member  36   b . The second link member  36   c  is connected to the second grasp member  32  by the second joint member  36   d.    
       FIG. 6  is an enlarged cross sectional view of a connection part between the operation portion (handle)  4  and the sheath  1 . 
     The operation portion  4  has a main body  40 , a slider  41 , a fixing mechanism  42 , a release button  43 , a sliding member (key)  44 , a locking member (disk)  45 , and an elastic member  46 . 
     A proximal end  12 C of the second coil sheath  12  is fixed to the sliding member  44  inside the main body  40 . A proximal end  11 B of the first coil sheath  11  extending from the second coil sheath  12  is fixed to the locking member  45 . The operation wire  5  extending from the first coil sheath  11  is connected to the slider  41  through the inside of the main body  40 . 
     The slider  41  is connected to the main body  40  so as to be advanceable and retractable, and is advanceable and retractable along an axial direction of the main body  40 . 
     The fixing mechanism  42  is a ratchet mechanism provided at the slider  41 , and has a spring  42 S and an engaging portion (claw)  42 E. Although the slider  41  is allowed to retract along the axial direction of the main body  40  with respect to the main body  40 , the fixing mechanism  42  does not allow advancement. 
     The engaging portion  42 E of the fixing mechanism  42  engages with an engaged portion (ratchet tooth)  40 E provided at the main body  40  through a restoring force of the spring  42 S. In a case where the engaging portion  42 E and the engaged portion  40 E are engaged with each other, the slider  41  cannot advance with respect to the main body  40 . On the other hand, even in a case where the engaging portion  42 E and the engaged portion  40 E are engaged with each other, the slider  41  can retract with respect to the main body  40 . 
     The release button  43  is a button for releasing engagement between the engaging portion  42 E and the engaged portion  40 E by being pressed. A surgeon can advance the slider  41  along the axial direction of the main body  40  with respect to the main body  40  only in a case where the release button  43  is pressed. That is, since engagement (connection) between the engaging portion  42 E and the engaged portion  40 E is released by pushing the release button  43 , the slider  41  can be advanced along the axial direction of the main body  40  with respect to the main body  40 . 
       FIG. 7  is cross sectional view taken along line A-A of  FIG. 6 . 
     The sliding member  44  is a member that slides inside the main body  40 , and has a through-hole through which the first coil sheath  11  is inserted. Since a cross sectional shape of the sliding member  44  in a width direction of the main body  40  is a substantially oblong, the sliding member  44  is caught in a slide groove  40   g  when the main body  40  is rotated about an axis. Therefore, also the sliding member  44  and the second coil sheath  12  rotate about the axis together with the main body  40 . 
     The sliding member  44  is slidable inside the slide groove  40   g  provided to extend in a longitudinal direction inside the main body  40 . That is, the proximal end  12 C of the second coil sheath  12  is attached so as not to be movable rotationally about the axis with respect to the main body  40  and so as to be movable in the axial direction relatively to the main body  40  and the first coil sheath  11 . 
       FIG. 8  is a cross sectional view taken along line B-B of  FIG. 6 . 
     The locking member  45  has a substantially cylindrical shape or a ring shape, and has an outer diameter larger than the first coil sheath  11 . The proximal end  11 B of the first coil sheath  11  fixed to the locking member  45  is attached so as to be rotatable about the axis with respect to the main body  40  and so as not to be relatively movable in the axial direction. 
       FIG. 9  is a view showing an action when using the operation portion  4  and the sheath  1 . 
     According to the shape of an organ in the body cavity or the posture of a patient, meandering or bending occurs in the elongated insertion portion  202  of the flexible endoscope  200  or the sheath  1  of the needle holder  100  inserted in the insertion portion  202  in some cases. However, even in a case where the first coil sheath  11  and the second coil sheath  12 , which configure the sheath  1 , are relatively moved through the meandering of the sheath  1 , a difference between the lengths of the first coil sheath  11  and the second coil sheath  12 , which has occurred due to a relative movement of the proximal end  12 C of the second coil sheath  12  relative to the first coil sheath  11  in the axial direction, is offset as the sliding member  44  connected to the proximal end  12 C of the second coil sheath  12  slides in the slide groove  40   g  inside the main body  40  to a distal end side (a direction shown by arrows shown in  FIG. 9 ) in the axial direction, as shown in  FIG. 9 . 
     It is preferable to set a positional relationship of the sliding member  44  in the slide groove  40   g  such that deflection does not occur in the sheath  1  even in a case where the sheath  1  is bent to the maximum and such that the sliding member  44  is not in contact with an end surface of the slide groove  40   g  in the longitudinal direction at all times. 
     As shown in  FIG. 6 , the elastic member  46  is a compression spring disposed along the axial direction of the main body  40  in which the slider  41  advances and retracts. A distal end of the elastic member  46  is attached to the main body  40  and a proximal end of the elastic member  46  is attached to the slider  41 . The expanding and contracting direction of the elastic member  46  is the axial direction of the main body  40 . 
     As shown in  FIG. 3 , the operation wire  5  is disposed along the longitudinal axis Y 1  of the sheath  1  inside the sheath  1 . The operation wire  5  is a soft wire, and can transmit an operation force from the operation portion  4 . 
     As shown in  FIG. 3 , a distal end of the operation wire  5  is fixed to the first link member  36   a  of the link mechanism  36 . As shown in  FIG. 6 , a proximal end of the operation wire  5  is connected to the slider  41  of the operation portion  4 . That is, the distal end of the operation wire  5  and the second grasp member  32  are connected to each other via the link mechanism  36 . For this reason, an operation force for operating an opening and closing operation of the second grasp member  32  with respect to the first grasp member  31  is transmitted from the operation portion  4  to the second grasp member  32  via the operation wire  5  and the link mechanism  36 . 
     As the slider  41  advances and retracts along the main body  40 , the operation wire  5  can be advanced and retracted along the longitudinal axis Y 1  of the sheath  1 . In the present embodiment, the operation wire  5  can be pulled to an operation portion  4  side by moving the slider  41  to the proximal end side along the main body  40 . 
     When the engaging portion  42 E and the engaged portion  40 E are engaged with each other in a state where the slider  41  pulls the operation wire  5 , a state where the operation wire  5  is pulled can be maintained. 
     As the operation wire  5  is pulled to the operation portion  4  side, the second grasp member  32  moves in a closing direction with respect to the first grasp member  31 . On the other hand, as the operation wire  5  is pushed out to a grasper  3  side, the second grasp member  32  moves in an opening direction with respect to the first grasp member  31 . 
     [Actions of Needle Holder  100 ] 
     Next, actions of the needle holder  100  of the present embodiment will be described.  FIGS. 10 to 12  are views showing the needle holder  100  when the slider  41  is advanced and retracted. 
       FIG. 10  is a view showing the needle holder  100  in which the grasper  3  does not grasp a suture needle N. 
     The surgeon advances the slider  41  along the axial direction of the main body  40  with respect to the main body  40  while maintaining a state where the release button  43  is pressed. As a result, as shown in  FIG. 10 , the second grasp member  32  moves in the opening direction with respect to the first grasp member  31 . 
     As shown in  FIG. 10 , since the operation wire  5  is pushed with the advancement of the slider  41  and the elastic member  46  receives a compressive force in a state where the grasper  3  (the first grasp member  31  and the second grasp member  32 ) is opened (hereinafter, referred to as an “open state”), an elastic force generated by the elastic member  46  is larger than the tension of the operation wire  5 . The elastic member  46  comes into a state of being contracted in the expanding and contracting direction from an initial state. The position of the slider  41  where the grasping state of the suture needle N by the grasper  3  is the open state will be referred to as a “first position P 1 ”. In a case where the slider  41  is moved to the first position P 1 , it is necessary for the surgeon to advance the slider  41  against a restoring force of the elastic member  46 . 
       FIG. 11  is a view showing the needle holder  100  in which the grasper  3  grasps the suture needle N. 
     The surgeon retracts the slider  41  along the axial direction of the main body  40  with respect to the main body  40 . As a result, as shown in  FIG. 11 , the second grasp member  32  moves in the closing direction with respect to the first grasp member  31 . The suture needle N is grasped by the second grasp member  32  and the first grasp member  31  and is fixed such that the direction or position thereof cannot be changed. Specifically, the suture needle N is held so as not to be movable rotationally about a longitudinal axis of the suture needle N. A grasping force of the grasper  3  at this time will be referred to as a “first grasping force”. 
     When the surgeon retracts the slider  41 , the surgeon may maintain or may not maintain a state where the release button  43  is pressed. The surgeon can retract the slider  41  along the axial direction of the main body  40  with respect to the main body  40  regardless of a state of the release button  43 . 
     As shown in  FIG. 11 , the operation wire  5  is pulled with a force larger than a restoring force generated by the elastic member  46  as the slider  41  is retracted in a state where the grasper  3  grasps the suture needle N with the first grasping force and the suture needle N is fixed so as not to be movable rotationally about the longitudinal axis of the suture needle N (hereinafter, referred to as a “first grasping state”). The elastic member  46  comes into a state of being expanded in the expanding and contracting direction from the initial state. The position of the slider  41  where the grasping state of the suture needle N by the grasper  3  is the first grasping state will be referred to as a “second position P 2 ”. It is necessary for the surgeon to move the slider  41  backward against the restoring force of the elastic member  46 . 
       FIG. 12  is a view showing the needle holder  100  in which the grasper  3  grasps the suture needle N with a low grasping force. 
     The surgeon moves the slider  41  to a position between the first position P 1  and the second position P 2 . The slider  41  is positioned as the restoring force of the elastic member  46  and the tension of the operation wire  5  are balanced. The suture needle N is grasped such that the direction or position thereof can be changed by the second grasp member  32  and the first grasp member  31 . Specifically, the suture needle N is held so as to be movable rotationally about the longitudinal axis of the suture needle N. A grasping force of the grasper  3  at this time will be referred to as a “second grasping force”. The second grasping force is smaller than the first grasping force. 
     As shown in  FIG. 12 , the elastic force of the elastic member  46  is balanced with the tension of the operation wire  5  in a state where the grasper  3  grasps the suture needle N with the second grasping force and the suture needle N is held so as to be movable rotationally about the longitudinal axis of the suture needle N (hereinafter, referred to as a “second grasping state”). The elastic member  46  hardly expands and contracts in the expanding and contracting direction from the initial state, and comes into a state where a restoring force is hardly generated. 
     The surgeon can change the direction or position of the suture needle N by moving the slider  41  to the position between the first position P 1  and the second position P 2  and grasping the suture needle N with the grasper  3  with a low grasping force (second grasping state). The surgeon changes the direction or position of the suture needle N, for example, by pressing the suture needle N grasped in the second grasping state against a digestive wall of a gastrointestinal tract. 
     Since the slider  41  is biased to move to the position between the first position P 1  and the second position P 2  insofar as the release button  43  is pressed even when the surgeon separates a hand from the main body  40 , the grasping state of the suture needle N by the grasper  3  is the second grasping state. For this reason, the suture needle N can be prevented from falling from the grasper  3  unintentionally. 
     After changing the direction or position of the suture needle N to a desired direction or position, the surgeon retracts the slider  41  to the second position P 2 . As a result, the grasping state of the suture needle N by the grasper  3  becomes the first grasping state, and the suture needle N is fixed in a state where the direction or position thereof cannot be changed. 
     [Using Method of Needle Holder  100 ] 
     Next, procedures (using method) in which the needle holder  100  of the present embodiment is used will be described with reference to  FIGS. 13 to 18 .  FIGS. 13 to 18  are views showing one process of the using method of the needle holder  100 . 
     Before inserting the flexible endoscope  200  into the digestive tract, the surgeon makes the grasper  3  of the needle holder  100  protrude from the distal end opening portion  206   a  of the channel  206  of the flexible endoscope  200 . The surgeon grasps the suture needle N with the grasper  3 . The surgeon may grasp a suture S attached to the suture needle N with the grasper  3 . 
     [First Step]ll 
     The surgeon inserts the flexible endoscope  200  from a natural opening of a patient into the digestive tract in a first step. The suture needle N or the suture S is introduced into the gastrointestinal tract in a state of being grasped by the grasper  3  protruding from the distal end opening portion  206   a.    
     In a case where the direction or position of the suture needle N introduced in the gastrointestinal tract is not grasped in a desired direction or position, the surgeon temporarily places the suture needle N on a digestive wall T, and regrasps the suture needle N with the grasper  3 . When introducing the suture needle N into the gastrointestinal tract, the suture needle N is temporarily placed on the digestive wall T, and the suture needle N is regrasped with the grasper  3  also in a case where the suture S is grasped. 
       FIG. 13  is a view showing an example of the first step of grasping the suture needle N with the grasper  3 . 
     Before a second step, in a state where the slider  41  is advanced to the first position P 1  with respect to the main body  40  against the restoring force of the elastic member  46  (see  FIG. 10 ), the surgeon brings the grasper  3  close to the suture needle N disposed on the digestive wall and grasps the suture needle N with the grasper  3  while observing an image captured by the imaging portion  203 . 
       FIG. 14  is a view showing an example of the first step of grasping the suture needle N. 
     For example, in a state where the surgeon makes a tip end N 1  and a base end N 2  of the suture needle N protrude forward from the grasper  3  in the longitudinal axis Y 1  of the sheath  1 , the grasper  3  grasps the suture needle with the first grasping force. 
     [Second Step] 
     The surgeon adjusts the grasping force of the grasper  3  that grasps the suture needle N positioned inside a luminal organ (gastrointestinal tract) in the second step. Specifically, the grasper  3  grasps the suture needle with the second grasping force by retracting the slider  41  to the position between the first position P 1  and the second position P 2  with respect to the main body  40  with the restoring force of the elastic member  46  (see  FIG. 12 ). The grasping state of the suture needle N by the grasper  3  becomes the second grasping state. In the second step, the restoring force of the elastic member  46  and the tension of the operation wire  5  are balanced, the slider  41  is positioned, and the suture needle N is grasped by the grasper  3 . 
     [Third Step] 
     After adjusting the grasping force of the grasper  3  that grasps the suture needle N into the second grasping force, the surgeon changes the direction of a tip of the suture needle N while pressing a part of the suture needle N against the digestive wall T in a state where the suture needle N is grasped by the grasper  3  in a third step. 
       FIG. 15  is a front view of the grasper  3 , which shows an example of the third step. 
     In a state where the suture needle N is grasped by the grasper  3  with the second grasping force, the surgeon adjusts the direction of the tip end of the suture needle N while pressing at least one of the tip end N 1  and the base end N 2  of the suture needle N against the digestive wall T. A part of the digestive wall T against which the suture needle is pressed is not limited insofar as it is a wall of the gastrointestinal tract. In an example of the third step shown in  FIG. 15 , there is a transition from a state where an intermediate portion of the suture needle N is grasped by the grasper  3  and the suture needle N is aligned in a tangential direction of a surface of the digestive wall T (see  FIG. 14 ) to a state where the tip end of the suture needle N is directed in a direction substantially perpendicular to the surface of the digestive wall T while pressing two places including a tip end N 1  side and a base end N 2  side of the suture needle N against the digestive wall T. 
       FIG. 16  is a front view of the grasper  3 , which shows another example of the third step. 
     In the example of the third step shown in  FIG. 16 , the intermediate portion of the suture needle N is grasped by the grasper  3 , and the direction of the tip of the suture needle N is adjusted while pressing one place which is the base end N 2  side of the suture needle N against the digestive wall T. 
       FIG. 17  is a front view of the grasper  3 , which shows still another example of the third step. 
     A place where the grasper  3  grasps the suture needle N does not matter in the third step. As shown in  FIG. 17 , in a case where the base end N 2  side of the suture needle N is grasped by the grasper  3 , the direction of the tip end of the suture needle N is adjusted while pressing the intermediate portion between the tip end N 1  side or the tip end N 1  and the base end N 2  of the suture needle N against the digestive wall T. 
     [Fourth Step] 
       FIG. 18  is a view showing an example of a fourth step. 
     After adjusting the direction of the tip end of the suture needle N, by retracting the slider  41  to the second position P 2  with respect to the main body  40  against the restoring force of the elastic member  46 , the suture needle N is grasped by the grasper  3  with the first grasping force (see  FIG. 11 ). As shown in  FIG. 18 , the grasping state of the suture needle N by the grasper  3  becomes the first grasping state. 
     After fixing the direction or position of the suture needle N to a desired direction or position, the surgeon sutures the treatment target. In a case of further changing the direction or position of the suture needle N, the surgeon performs the second step to the fourth step again. 
     In the needle holder for an endoscope  100  according to the present embodiment, in suturing work under the flexible endoscope, the direction or position of the suture needle N can be easily changed to a desired direction or position by adjusting a force of grasping the suture needle N. The surgeon can easily change the direction or position of the suture needle N by moving the slider  41  to the position between the first position P 1  and the second position P 2  and bringing the grasping state of the suture needle N by the grasper  3  to the second grasping state. 
     In the procedures (using method) in which the needle holder for an endoscope  100  according to the present embodiment is used, the surgeon can easily change the direction or position of the suture needle N by pressing the suture needle N in the second grasping state against the digestive wall of the gastrointestinal tract. 
     Although the present embodiment has been described in detail with reference to the drawings hereinbefore, a specific configuration is not limited to this embodiment, and includes design changes without departing from the gist of the present disclosure. In addition, it is possible to combine and configure components shown in the embodiment described above and modified examples as appropriate. 
     Although the operation portion  4  has the fixing mechanism  42 , which is the ratchet mechanism in the embodiment, the form of the operation portion is not limited thereto. The operation portion may not have the fixing mechanism  42 .  FIG. 19  is a view showing an operation portion  4 B, which is a modified example of the operation portion  4 . Even in a case where an operation portion does not have the fixing mechanism  42  like the operation portion  4 B, the slider  41  is biased to move to the position between the first position P 1  and the second position P 2 . Thus, the grasping state of the suture needle N by the grasper  3  becomes the second grasping state in a case where the surgeon has separated the hand from the slider  41 . 
     Modified Example 2 
     Although the engaged portion  40 E is provided at the main body  40  in the entire area in a range where the slider  41  advances and retracts in the embodiment, the form of the engaged portion is not limited thereto. The engaged portion may be provided only at a part of the range where the slider  41  advances and retracts.  FIG. 20  is a view showing an operation portion  4 C, which is a modified example of the operation portion  4 . Like an engaged portion  40 EC of the operation portion  4 C, an engaged portion may be provided in a range of engaging with the engaging portion  42 E only in a case where the slider  41  is at the first position P 1  and the second position P 2 . 
     Modified Example 3 
     Although the grasper  3  grasps the suture needle N as the second grasp member  32  opens and closes with respect to the first grasp member  31  in the embodiment, the form of the grasper is not limited thereto.  FIGS. 21 to 24  show modified examples of the grasper.  FIGS. 21A, 22A, 23A, and 24A  show the grasper of which the grasping state is the open state.  FIGS. 21B, 22B, 23B, and 24B  show the grasper of which the grasping state is the second grasping state. 
     A grasper  3 B, which is a modified example of the grasper shown in  FIGS. 21A and 21B , grasps the suture needle N as both of a first grasp member  31 B and a second grasp member  32 B open and close. 
     A grasper  3 C, which is a modified example of the grasper shown in  FIGS. 22A and 22B , grasps the suture needle N as a second grasp member  32 C advances and retracts along the longitudinal axis Y 1  with respect to a first grasp member  31 C. 
     A grasper  3 D, which is a modified example of the grasper shown in  FIG. 23B , grasps the suture needle N as a second grasp member  32 D performs a pantograph operation along a direction perpendicular to the longitudinal axis Y 1  with respect to a first grasp member  31 D. 
     A grasper  3 E, which is a modified example of the grasper shown in  FIGS. 24A and 24B , has a through-hole  31 H, through which the suture needle N can pass, in a first grasp member  31 E. The grasper  3 E grasps the suture needle N as a second grasp member  32 E advances and retracts along the longitudinal axis Y 1  in a state where the suture needle N has passed through the through-hole  31 H. 
     Modified Example 4 
     Although the second grasp member  32  moves in the closing direction with respect to the first grasp member  31  as the operation wire  5  is pulled to the operation portion  4  side in the embodiment, the form of the grasper  3  is not limited thereto.  FIGS. 25A to 26B  show modified examples of the grasper.  FIGS. 25A and 26A  show the grasper in a closed state.  FIGS. 25B and 26B  show the grasper in an open state. 
     Like a grasper  3 F, which is a modified example of the grasper shown in  FIGS. 25A, and 25B , a grasper may have a link mechanism  36 F in which the second grasp member  32  moves in the opening direction with respect to the first grasp member  31  as the operation wire  5  is pulled to the operation portion  4  side. 
     Like a grasper  3 G, which is a modified example of the grasper shown in  FIGS. 26A and 26B , a grasper may have a cam mechanism  36 G in which the second grasp member  32  moves in the opening direction with respect to the first grasp member  31  as the operation wire  5  is pulled to the operation portion  4  side. 
     A needle holder  100 K according to another exemplary embodiment of the present disclosure will be described with reference to  FIG. 27 . In the following description, configurations common to the previous description will be assigned the same reference signs, and a description thereof will be omitted.  FIG. 27  is a view showing the needle holder  100 K. 
     The needle holder  100 K has the sheath  1 , the hard portion  2 , the grasper  3 , an operation portion  4 K, and the operation wire  5  inserted through the sheath  1 . 
     The operation portion  4 K has the main body  40 , the slider  41 , the fixing mechanism  42 , the release button  43 , the sliding member  44 , the locking member  45 , and an elastic member  46 K. 
     The elastic member  46 K is a tension spring disposed along the axial direction of the main body  40  in which the slider  41  advances and retracts, and has a distal end attached to the slider  41  and a proximal end attached to the main body  40 . The expanding and contracting direction of the elastic member  46 K is the axial direction of the main body  40 . The elastic member  46 K may be a plurality of tension springs. In addition, the elastic member  46 K may not necessarily be a compression spring, and may be an elastic body that generates an elastic force between the slider  41  and the main body  40 . 
     Since the operation wire  5  is pushed with the advancement of the slider  41  and the elastic member  46 K receives a pulling force in a state where the grasper  3  is opened, the elastic force of the elastic member  46 K is larger than the tension of the operation wire  5 . 
     As the slider  41  is retracted when the grasping state of the suture needle N by the grasper  3  is in the first grasping state, the operation wire  5  is pulled with a force larger than the restoring force generated by the elastic member  46 K. 
     When the grasping state of the suture needle N by the grasper  3  is in the second grasping state, the elastic force of the elastic member  46 K is balanced with the tension of the operation wire  5 . 
     In the needle holder  100 K according to the present embodiment, like the needle holder  100  of the above embodiment described with respect to  FIGS. 1-18 , in suturing work under the flexible endoscope, the direction or position of the suture needle N can be easily changed to a desired direction or position by adjusting the force of grasping the suture needle N. 
     Although the present embodiment has been described in detail with reference to the drawings hereinbefore, a specific configuration is not limited to this embodiment, and includes design changes without departing from the gist of the present disclosure. In addition, it is possible to combine and configure components shown in the embodiments described above and modified examples as appropriate.