Abstract:
In laparoscopic surgery, tying of knots is not easy, as it involves the use of long handled graspers and the necessity to pass one end of the suture ligature around the opposite half of the suture, with release and re-grab of the passing end of the suture. The present invention avoids the “passing with the release and re-grab”, and makes the tying easier, faster and automatic. It conforms to the general size and shape of a standard laparoscopic instrument. The handle is pistol shaped with two control triggers, one for grasping and the other for rotating. The sheath is elongated and tubular, containing two control rods. The tip is bullet shaped, containing three operating mechanisms, one for grasping the leading end of a suture, a second for trapping the opposite half of the same suture, a third for rotating the grasped end of the suture 360 degrees around the trapped portion, thus forming a knot. 
     The trapping mechanism uses an axle with a hollow center and an open-ended side slot. The other members of the rotating and trapping mechanisms have these same features, which allow the suture to enter and exit the hollow center. Grasping is performed by a miniature grasper, which has no handle or shaft, with its entire body contained within a part that rotates, called the rotator. Rotation is generated by a slider-crank mechanism which converts linear motion to rotary motion, and avoids the dead centers with a patented L-shaped connecting rod and deflecting pillars (U.S. Pat. No. 9,194,468). The rotation is then transmitted through two modified spur gears to the rotator, and hence also to the miniature grasper. The rotator represents a short sagittal segment removed from the tip, modified to rotate and to contain the miniature grasper, and then replaced in position. To enable the grasper to rotate, there is an intentional discontinuity in its controlling rod, but control from the handle is maintained by the interposition of a semi-open ball and socket joint in the rod.

Description:
FIELD OF THE INVENTION 
     A laparoscopic surgical instrument for intra-corporeal knot tying which makes the throw automatically on a free strand of suture ligature, and avoids using the pass or the loop, or having one end of the suture attached to a needle, disc or cartridge It may be adapted for use in open surgery in deep cavities where the fingers cannot reach, or for use by the robot. 
     BACKGROUND OF THE INVENTION 
     Tying of knots is essential in any kind of surgery. It is relatively easy in open surgery, but is difficult in laparoscopic surgery. The current art of laparoscopic knot tying employs either the extra-corporeal method, involving tying the knot by hand outside the body and pushing the knot inside with a knot pusher, or the intra-corporeal method, involving manipulation of the suture with the tips of two laparoscopic graspers, which is cumbersome, and requires considerable skill. Laparoscopic clip appliers, staplers, pre-tied knots and the like are useful substitutes, but cannot totally replace tied knots. Despite considerable prior art, there still is no hand operated instrument that renders laparoscopic intra-corporeal knot tying easier and faster. 
     In order to describe the tying process, the different parts of the suture ligature need to be given names. As shown in  FIG. 59  in the drawings, after the suture ligature has passed around the tissue to be tied, it then presents with a head end ( 1 ), a tail end ( 2 ), a leading strand ( 3 ) and a tail strand ( 4 ), 
     There are two basic methods of tying a knot, whether done openly or laparoscopically. One method is making a “throw” which involves passing the head end of the suture around its tail strand. This is quite simple when performed with the fingers as in tying shoe laces. It does however involve a critical step which is the passing or release and re-grab of the head end of the suture, and wrapping it around the tail strand. In laparoscopic surgery this is difficult because the graspers are trapped in the abdominal wall, and the surgeon is limited to using only two laparoscopic graspers, one in each hand. Hence the reason for the present invention. 
     The second method of tying a knot involves making a loop or loops, which is commonly performed in open surgery by the surgeon making “instrument ties”, where he uses a needle holder and wraps the suture several times around it. This can be done laparoscopically but is generally difficult. There are many patents in the prior art that try to make the loop laparoscopically, but none has been commercially successful, and this is not the object of the present invention. 
     the present invention makes the knot differently and automatically without making the loop, or making the pass. Additionally it ties a knot in a free strand of suture ligature, without having one end of the suture being pre-fixed on to a disc or cartridge. It is therefore different in design and technique compared with other previous similar inventions. 
     Referring to the prior art, the Christoudias Double Grasper has 3 jaws, with a common middle jaw, and functions as a tissue approximator. Its spring loaded actuators are operated by two push buttons. The Ferzli Double Grasper, has a second pair of jaws positioned more proximally on the main shaft, whose purpose is to anchor one end of the suture prior to twisting it around the shaft of the instrument in order to produce a loop. The Hasson Suture Tying Forceps, is similar to the Ferzli, with  3  finger loops. The orthopedic suture passers are for passing sutures only through hard tissue, and these include the Arthrex Scorpion Suture Passer, and the Arthrex Birdbeak Suture Passer. Some suture passers are for passing sutures through a thickness of soft tissue such as the abdominal wall, and these include the Goretex and the Aesculap. There are devices which “pass the suture-needle” side to side, for inserting sutures into tissues, as well as for tying knots, e.g. the Autosuture&#39;s Endo-stitch, and the Japanese Maniceps. Note these only pass the suture needle, not the suture thread per se. There have been devices that attempt to “automatically” tie a knot, such as Jerrigan&#39;s experimental rotating slotted disc designed for robotic endo-cardiac surgery, but it was abandoned because of the requirement for a cartridge. There have been many devices that help to “create a loop”, with each functioning differently—(a) Kitano&#39;s grasper with the rotating sleeve, Japanese, (b) Donald Murphy&#39;s grasper with the extra horn, Australian, (c) Grice&#39;s sleeve catching instrument, (d) Bagnato &amp; Wilson&#39;s device which simulates the radiological pig-tail catheter, with a preformed loop built into the tip of the catheter, which is deformable and purportedly a loop former, but it is difficult to manufacture and apply, and has not yet been reduced to practice, (e) Ferzli&#39;s double grasper, which anchors one end of the suture, as described above. There have been devices using a “pre-formed knot”, (1) Ethicon&#39;s Endo-Loop, (2) the Duraknot, (3) LSI&#39;s device, (4) Pare&#39;s pre-tied knot, all of which do not help to tie knots. 
     Past inventions related to intra-corporeal laparoscopic knot tying fail to address the basic problem of “how to make the throw”. They usually offer various alternatives, such as making multiple loops, similar to fishing knots, using pre-tied knots, knot pushers, suture clips, cinchers, tissue fasteners, anchors, stapling devices, etc. The present invention however will assist in manual intra-corporeal knot tying, and will help to produce the knot automatically. 
     
       
         
               
             
               
               
               
               
               
             
           
               
                   
               
               
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     OTHER PUBLICATIONS 
     
         
         1. Endo-stitch—Autosuture—Manufacturer&#39;s item #173016. 
         2. Maniceps—Japanese suturing device, similar to Endo-stitch. 
         3. A Laparoscopic Device for Minimally Invasive Cardiac Surg (rotating slotted disc). Shaphan Jernigan, et. al. —European J. of Cardio-thoracic Surgery, Vol. 37, p.626-630. March 2010. 
         4. Knot Tying Intra-corporeally, with newly designed Forceps. (sliding sleeve). 
         5. Kitano et. al.—J. of Minimal Invasive Therapy &amp; Allied Tech, 1996. 5: 27-28. 
         6. Endoscopic Knot Tying Made Easier—(one jaw with extra bump). 
         7. Donald Murphy—ANZ J. Surg. 1995. 65, 507-509. 
         8. The Excalibur Suturing Needle Holder—(jaw with prominent heel, helps looping) 
         9. Uchida et. al. Surgical Endoscopy—vol. 3, 531-532 
         10. Alijizawi laparoscopic auto-knot device—(two dissolving balls). 
         11. A New Reusable Instrument designed for simple and secure knot tying in laparoscopic surgery. S. S. Miller 1996 Surg. Endos 10: 940-941 (pointed canula). 
         12. The Nobel Automatic Laparoscopic Knotting and Suturing Device. Mishra et. al. World Laparoscopy Hospital, India. (a knot pusher) 
         13. Automated Knot Tying for Fixation in Minimally Invasive Robot Assisted Cardiac Surgery. March 9(1):105-12. 
         14. Kuniholm &amp; Buckner—J. Biomed Eng. November 2005, Vol. 127, 1001-8. JSLS. Jan. 17, 2005. 
         15. M I Frecke—Laparoscopic multifunctional instruments: design and testing. Endosc Surg Allied Technol. 1994 December; 2(6):318-9. 
         16. G. Berci—Multifunctional laparoscopic Instruments. 
         17. http://www.ligasure.com/ligasure/pages.aspx?page=Products/Laparoscopi 
         18. http://www.freepatentsonline.com/y2010/0063437. 
         19. http//www.ncbi.nlm.nih.gov/pubmed/15791983 Multifunctional Laparoscopic Instruments. 
         SUGGESTED U.S. CLASSIFICATION: 606/139, 144, 145, 148. 
         SUGGESTED INTERNATIONAL CLASSIFICATION: A61B 17/00, 04, 28. 
         FIELD OF SEARCH: 606/139, 144, 145, 147, 148, 150, 151, 127, 128, 606/167, 168, 170, 174, 182, 185, 205, 207, 210, 211. 
         RELATED PRIOR PATENT: U.S. Pat. No. 9,194,468. 
       
    
     SUMMARY OF THE INVENTION 
     In laparoscopic surgery, the advent of laparoscopic clips and staples has been a great blessing to surgeons, but cannot totally replace the use of tied knots, which when performed intra-corporeally, is technically difficult, but still necessary. The instrument presented here is intended to facilitate intra-corporeal laparoscopic knot tying with a free strand of suture ligature. It conforms to the customary shape and size of a laparoscopic instrument, with an elongated round sheath, a pistol shaped handle at the proximal end, and a bullet shaped tip at the distal end. Three operating mechanisms are incorporated in the tip: firstly, a grasping mechanism involving the use of a mini-grasper, which is small enough to be contained inside an element that rotates, called the rotator; secondly, a trapping mechanism involving the use of a slotted hollow axle which is an axle with a hollow center, and also involving the use of an open-ended slot on the side of each member of the rotating mechanism, which enables a portion of the tail end of the suture to be trapped within the hollow center, whilst the rotation takes place; thirdly, a finger activated rotation system, which uses a slider-crank mechanism to convert linear into rotary motion, and uses a patented L-shaped connecting rod to avoid dead centers, and also uses a slotted driven spur gear to transmit the rotation to the slotted rotator, which houses the mini-grasper. 
     Other characteristics •of this instrument include: (1) manipulating both ends of the same suture with the same instrument, (2) being hand operated, avoiding the use of electricity or battery, (3) may be used with a robot, (4) may be used to tie knots in any deep and narrow cavity where the surgeon&#39;s fingers cannot reach, (5) allowing the surgeon to tie a knot laparoscopically and automatically, using only his own two hands, without need for help from an assistant. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is perspective view of the entire device from the right side, and 
         FIG. 2  is the entire device from the left side. 
         FIG. 3  is a transparent view of the left side of the handle, and 
         FIG. 4  is the same of the right side of the handle, showing the arrangement of the triggers. 
         FIG. 5  is a perspective view of the right side of the tip of the instrument, and 
         FIG. 6  is the left side of the tip, showing the different appearances of the two sides. 
         FIG. 7  is an exploded view of the handle-assembly from the left side, showing the numerous components within the handle, 
         FIG. 8  is a perspective view of the handle from the right side, and 
         FIG. 9  is the handle from the left side, showing the different features on the two sides. 
         FIG. 10  is a perspective view of the long connector to the trigger of the rotating system and 
         FIG. 11  is a perspective view of the trigger of this system. 
         FIG. 12  is a perspective view of the short connector of the grasper rod system. 
         FIG. 13  is a perspective view of the trigger of the grasper rod system. 
         FIG. 14  is a view of the thumb push knob. 
         FIG. 15  shows the long compression spring of the trigger of the rotation system; 
         FIG. 16  shows the short compression spring of the trigger of the grasper rod system; and 
         FIG. 17  shows the lid that covers the cavity on the left side the handle. 
         FIG. 18  shows the external sheath that covers the two rods. 
         FIG. 19  shows the proximal spacer, which bears two channels. 
         FIG. 20  shows push rod of the grasper system. 
         FIG. 21  shows pull rod extension of the rotation system. 
         FIG. 22  is a perspective view of the tip-assembly, whilst 
         FIG. 23  is an exploded view of the tip-assembly. 
         FIG. 24  is a top view of the tip-base; and 
         FIG. 25  is a perspective view of the tip-base, 
         FIG. 26  is a perspective view of the slotted hollow axle. 
         FIG. 27  shows one of the 3 pins that holds the slotted driven spur gear. 
         FIG. 28  is a picture of the driven slotted spur gear. 
         FIG. 29  is a picture of the shoulder screw that holds the driving spur gear. 
         FIG. 30  is a picture of the driving spur gear. 
         FIG. 31  is a perspective view of the gear rod. 
         FIG. 32  is a perspective view of the L-shaped connecting rod. 
         FIGS. 33 and 34  show the shoulder screws used at the ends of the L-rod. 
         FIG. 35  is a perspective view of the rotator sub-assembly, with the upper jaw closed. 
         FIG. 36  is the same with the upper jaw open and 
         FIG. 37  is an exploded view of the same. 
         FIG. 38  is a perspective view of rotator itself, showing its front end. 
         FIG. 39  is a perspective view of the same showing its rear end. 
         FIG. 40  is a perspective view of the upper jaw. 
         FIG. 41  is a view of the pin that acts as the fulcrum for the upper jaw; 
         FIG. 42  is a view of the pin that moves the upper jaw. 
         FIGS. 43, 44 and 45  show 3 of the components of the jaw sub-assembly that moves the upper jaw. 
         FIG. 46  is a side view of the entire jaw sub-assembly; 
         FIG. 47  is a top view of the jaw sub-assembly. 
         FIG. 48  is a picture of the ball with the stem. 
         FIG. 49  is a perspective view of the oval plate located at the top of the rotator. 
         FIG. 50  and  FIG. 51  are perspective views of the socket that contains the ball. 
         FIGS. 52, 53, 54, and 55 , show the different positions of the rotator during its 360 degree rotation. 
         FIGS. 56, 57 and 58  show the order of assembly of the major sub-assemblies of the device. 
         FIG. 59  is diagram indicating the names of the different parts of a suture ligature. 
         FIG. 60  is diagram showing how a standard throw is formed. 
         FIG. 61  is a diagram showing the current device being used in conjunction with a regular grasper to tie knot. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
     The invention here deploys the following steps in tying a knot: First, the head end of the strand is grasped by a miniature grasper,  FIG. 35 . Second, the tail strand is temporarily trapped and controlled inside a slotted tubular structure, part  20 ,  FIG. 26 . 
     Third, the miniature grasper which is holding the head end of the suture, is made to rotate 360 degrees around the trapped tail strand, which subsequently escapes from the entrapment, resulting in a tie. In essence, the process requires the tail strand to be temporarily constrained in space, whilst the head end of the suture rotates around it. 
     The trapping in this device is accomplished by using a slotted hollow axle, part  20 ,  FIG. 26 , which is an axle with a hollow center, and also a narrow slot along its entire side. The opening of the slot,  143  allows the tail strand to enter into the hollow space in the center of the axle,  142  and subsequently to escape from it. 
     In order for the rotation of the head end of the suture to occur whilst the tail strand is trapped, the hollow center and the open side slot are also required in all the other components of the rotation system: the base of the tip,  14 , to which the slotted hollow axle is attached, the driven spur gear  17 , and the rotator  15 , which bears the mini-grasper. This arrangement is necessary for the temporary entrapment and subsequent escape of the tail strand of the suture, as well as the rotation of the rotator. To function well, the slots in all these 4 components must line up precisely during trapping and release of the tail strand of the suture, and at rest, and at the end of a 360 degree rotation. 
     The crossing-over of the head strand over the tail strand comes about naturally because the strand that is trapped lies at 90 degrees from the strand that rotates. 
     Rotation is provided by a hand operated slider-crank mechanism that converts the linear motion of a finger pull into a rotational motion, which is then transmitted through the two spur gears to a rotator. The rotator  15  is bonded to the slotted driven spur gear  17 , and both have a hollow center and an open slot, like the slotted hollow axle. Both rotate as a unit upon the stationary slotted hollow axle  20 , and the minigrasper also rotates with them. The slider-crank mechanism uses an L-shaped connecting rod  21 , with two deflecting pillars  134  and  135 , to overcome dead centers, which is simpler than using other means such as auxiliary rods. For a description and an explanation of the L-shaped connecting rod, reference is made to U.S. Pat. No. 9,194,468, by the author. The slider-crank first rotates a driving spur gear  18 , then a slotted driven spur gear  17 , then a slotted rotator  15 , which carries the mini-grasper 
     The source of energy used for the rotation is a manual pull, with the return being performed automatically by a compression spring. The use of this simple mechanism avoids the use of complicated mechanisms or the use of electricity or the battery. 
     The mini-grasper sub-assembly,  FIG. 35, 36, 37 , is essentially a very short laparoscopic grasper, with one movable jaw, but no handle, and no shaft. The minigrasper is spring loaded, and is housed inside the rotator, which rotates on the slotted hollow axle. The mini-grasper is uniquely small and short, but fully functional. In order for it to rotate, its shaft needs to be separated from the long control rod, and it needs to be small enough to fit inside the rotator. The mini-grasper has only a movable upper jaw  16 , which is normally held in a closed position by a compression spring,  32 . 
     To grasp a suture the upper jaw  16  needs to be opened by external pressure on the compression spring  32 , exerted from the separated control rod, which is initiated by pushing the thumb knob  9 , with the thumb at the handle. A special inter-connecting ball and socket joint,  FIG. 48, 49, 50, 51 , in the control rod allows the rotator with the mini-grasper, to undergo 360 degree rotation in the sagittal plane of the long axis of the instrument, whilst also permitting the jaws to be remotely controlled from the handle with the push or pull, when the rotator is in the resting neutral position. 
     After the head end of the suture has been grasped by the mini-grasper, the rotation is activated by the index finger pulling on the trigger  4 , which causes the slider-crank mechanism to generate the first half of a rotation. The second half of the rotation is generated by a compression spring, when the trigger  4  is released, and is thus automatic. 
     After the rotator has completed a full rotation, it may be necessary to pull the suture ends apart to tighten the knot. At this point, because the force of the spring in the mini-grasper holding the suture is of limited strength, additional pressure will need to be applied to the upper jaw to hold on to the suture. This is provided by the trigger  3 , also operated by the index finger, whose additional pull will help to provide additional pressure keeping the jaw tightly closed holding on to the suture. The separated grasper rod is therefore provided with both a push as well as a pull activation. The push activation is provided by the thumb, whilst the pull activation is provided by the compression spring as well as by the index finger. There is no problem in using the index finger for two different activations since the two are not used simultaneously. 
     Referring to  FIG. 7 , the exploded view of the handle sub-assembly, part  1  is a pistol shaped handle which is gripped by the palm and by the middle, ring and little fingers through the loop, whilst freeing the index finger and the thumb for actuation. 
     The lower trigger is primarily pulled by the index finger. The upper trigger is primarily pushed by the thumb. The return movement on both triggers is performed by compression springs, which are hidden inside the handle. The upper trigger may in addition be pulled by the index finger. The connectors connecting the triggers to the actuating rods are located inside a cavity in the rear of the upper part of the handle. 
     Part  2  is the proximal spacer, which contains two holes for holding the two rods in place and allows their free passage, and contains a flange to prevent its accidental migration inside the sheath. There is no separate distal spacer which does exist in the rear of the base of the tip. Part  3  is the upper trigger, which is to be pushed forward by the thumb through the push knob, but can also be actively pulled back by the index finger. Part  4  is the lower trigger, which is pulled by the index finger to activate the rotation. 
     Both part  3  and part  4  triggers consist of a 9.5 mm diameter button at the outer end, an intermediate 5 mm diameter rod, and an inner 3 mm diameter rod, which screws into the lower end of the respective connectors further described below. Part  5  is the short connector whose upper end receives the flat neck of the proximal end of the push rod, and its lower end receives the upper trigger. Part  6  is the longer connector whose upper end receives the circular neck of the proximal end of the pull rod, and its lower end receives the lower trigger. Part  7  is a short compression spring used with the upper trigger. Part  8  is a long compression spring used with the lower trigger. Part  9  is the thumb push knob which screws into the upper (push/pull) trigger rod used for opening and closing the movable upper jaw of the mini-grasper. Part  10  is the lid for covering up the cavity on the left side of the handle, containing the connectors.  FIG. 8  illustrates  101  which refers to the finger loop,  102  refers to the space inside the finger loop.  103  refers to the seating for trigger for the rotary system, whilst  104  refers to the seating of the trigger for the grasper system.  105  is an empty space, to lighten the weight of the handle.  FIG. 9  illustrates the handle from the left side, showing different features  106  and  107 . 
       FIG. 10  is a perspective view of the long connector to the trigger of the rotating system and  FIG. 11  is a perspective view of the trigger of this system.  108  shows the seating for the head end of the rod,  109  shows the seating for the flat neck of the rod.  111  is the male threaded end which screws into the hole  110 .  112  is the 3 mm diameter portion of the shaft of the trigger, over which the compression spring is installed.  113  is a shoulder stop.  114  is the external button.  FIG. 12  is a perspective view of the short connector of the grasper rod system, which is similar to  FIG. 10 .  109  is the slot that receives the flat neck of the rod.  FIG. 13  is a perspective view of the trigger of the grasper rod system, showing  115  which is a female threaded hole, receiving  117  of part  9 .  FIG. 14  is a view of the thumb lush knob  116  of the grasper rod system.  FIG. 15  shows the long compression spring of the trigger of the rotation system;  FIG. 16  shows the short compression spring of the trigger of the grasper rod system; and  FIG. 17  shows the lid that covers the cavity on the left side the handle.  FIG. 18  shows the external sheath that covers the two rods.  FIG. 19  shows the proximal spacer, which bears two channels,  118  and  119 , for supporting the two rods and keeping them aligned. Its rear flange  120  is to prevent accidental migration into the rear of the sheath. 
       FIG. 20  shows part  12 , the 2.5 mm push rod of the grasper system, whose proximal end,  122  bears a narrow flat sided neck which mates into the top of the short connector, and helps to prevent accidental rotation of the rod. Its distal end  121  is mated to the socket holding the ball, which is part of a ball and socket joint, which in turn is part of the actuator that moves the upper jaw. 
       FIG. 21  shows part  13 , the 3 mm pull rod extension of the rotation system with the narrow flat neck,  124 , whose distal end  123 , screws into the proximal end of the “gear rod” part  9 , and whose proximal end has a round cut out to create a narrow round neck, to mate with the top of the long connector. 
       FIG. 22  is a perspective view of the tip sub-assembly, whilst  FIG. 23  is an exploded view of the same, showing the numerous components. Part  14  is the tip-base, without the rotator, and houses the components of the rotational mechanism, which include the crank-slider, the L-shaped connecting rod, the deflecting pillars, the driving spur gear, and the driven spur sear, and provides the base for fixation of the slotted hollow axle. It also bears a V-shaped slot on its side for guiding the tail end of the suture into the trap. This slot may be located alternately at the very tip of the base. Part  15  is the rotator, which is a complex and crucial body, representing a short sagittal portion of the tip, and participates in each of the trapping, grasping and rotating mechanisms. Part  16  is the movable upper jaw. Part  18  is the driving spur gear, which bears a counter sunk hole in the center for mounting a shoulder screw, and a smaller screw in its periphery for mounting the distal end of the L-shaped connecting rod. It origin is identical to the slotted driven gear, so their teeth can match. Part  17  is the slotted driven spur gear, which is similar to part  18 , but has an open slot between two adjacent teeth, allowing access to the hollow space in the center. This is part of the trapping mechanism. Its upper surface is fixed to the underside of the rotator, either by adhesives or by 3 tiny pins, through 3 tiny counter-sunk holes. It is designed intentionally with a small number of teeth, in order to create a wide enough slot between two adjacent teeth, for the suture to pass through. The gap created between two adjacent teeth on the other hand must not damage the teeth. Part  19  is the shoulder screw for mounting the driving spur gear. Part  20  is the slotted hollow axle, which bears a male thread at one end, a retaining flange at the other end, a hollow center throughout its length, and an open ended slot on the entire length of its side. Part  20  is the slotted hollow axle, which screws into the base of the tip,  126 . Part  15  is the rotator that rotates upon the flat platform  125  of the tip base. Part  16  is the upper jaw. The lower jaw is an integral part of the rotator. The hollow center is for temporary trapping of a portion of the suture, and the slot of the side is provide entry and exit for the suture. Part  21  is the L-shaped connecting rod which is a flat structure, with its side arm installed proximally, and connected to the round gear rod  25 . Part  22  is the screw that attaches the distal end of the connecting rod to the periphery of the driving spur gear. Part  23  is the screw that attaches the proximal end of the L-connecting rod to the gear rod. Part  24  is the socket that houses the ball attached to the rotator. Part  25  is the push/pull rod whose distal end is attached to the upper end of the socket, and whose proximal end is attached to the short connector. Part  14  is the large base of the tip. 
     Referring to  FIG. 24  and  FIG. 25 , concerning the tip base,  126  is a female threaded hole that receives the male thread of the slotted hollow axle,  20  and illustrates element  130 .  127  receives the mounting shoulder screw of the driving spur gear.  128  is a shoulder stop for the distal end of the sheath.  129  is the channel in which the gear rod  25  travels.  131  is the seat for the slotted driven spur gear.  132  is the v-shaped slot for the tail strand to slide in and out.  133  is the seat for the driving spur gear.  134  and  135  are the deflecting pillars, which are strategically located, so that they will deflect the distal end of the connecting rod off the dead center positions, just before the end of the travel of the side arm in either direction.  136  is the end of channel  129 , for the gear rod to slide up and down.  137  and  138  are channels which guide the grasper rod.  139  is the end of an elliptical cut out which extends from the upper edge of the platform  125  to the upper end of the tip base. This space allows the L-shaped connecting rod to operate. 
       FIG. 26  is a perspective view of the slotted hollow axle, part  20  and illustrates element  140 .  141  is the retaining flange.  142  is the hollow center.  143  is the open slot that extends through the entire length of the axle.  144  is the male thread.  FIG. 27  shows one of the 3 pins that holds the slotted driven spur gear through  148  to underside of the rotator.  FIG. 28  is a picture of the driven slotted spur gear.  145  shows the width of the gap between two adjacent teeth, which is vital for creating the slot  147 .  146  is the central hole for mounting the part  20 .  FIG. 29  is a picture of the shoulder screw that holds the driving spur gear.  FIG. 30  is a picture of the driving spur gear, showing the holes  149  and  150  for the mounting screw with counter-sunk head.  151  is a hole for a miniature screw that joins the driving spur gear to the hole  154  of the L-rod.  FIG. 31  is a perspective view of the gear rod, which bears a female hole  152 , on the side near its distal end, for attachment to  158  of the L-rod, and bears a female hole  153  on its proximal end for joining to the rod extension.  FIG. 32  is a perspective view of the L-shaped connecting rod, whose proximal end  158  is attached to  152  of the gear rod, and whose distal end  154  is attached to  151  of the driving spur gear.  156  is the side arm, whose edges  155  and  157 , make contact with the pillars  134  and  135 . 
       FIG. 37  is an exploded view of the rotator sub-assembly, showing the numerous components. Part  15  is the rotator. Part  16  is the upper jaw. Part  26  is the adaptor with an oval slot on its side for the pin  27  to move up and down, thereby converting vertical motion into horizontal, in moving the upper jaw. Part  27  is the pin that moves the upper jaw. Part  28  is the pin that acts as the fulcrum for moving the upper jaw. Part  29  is the screw that joins the oval plate to the plunger. Part  30  is the oval plate, which acts an adaptor which changes the line of action of the push/pull rod from the midline to the side of the rotator. Part  31  is the plunger, being part of the actuating system of the upper jaw. Part  32  is the compression spring. Part  33  is the stem of the ball. Part  34  is the ball. Part  35  is the socket. Part  36  are the 3 tiny pins for attaching the driven spur gear to the underside of the rotator. 
     Referring to  FIGS. 38 and 39 , concerning the rotator itself, it is a complex and crucial structure.  160  is for the hollow axle, and  159  is for its counter-sunken flange.  161  is for the swinging arm of the upper jaw  173 .  162  is for the fulcrum pin  28 .  163  is the housing for the adaptor  26 .  164  is an intentional groove on the lower jaw.  165  is the fixed lower jaw.  166  is the V-shaped slot for entry/exit of the tail strand of the suture.  167  is for installing the plunger and compression spring. The combination of  167  and  168  is for the oval plate. 
       FIG. 40  is a perspective view of the upper jaw, part  16 .  169  is the hole for mounting the actuating pin  27 , which moves the jaw.  170  is for mounting the screw  28  acting as fulcrum for the jaw.  171  is the gripping surface.  172  is the rounded upper surface. 
     Referring to  FIGS. 43 and 44 , the top of the plunger has a female threaded hole  174  for the screw  29  that secures it to the oval plate.  175  is the head of plunger, and  176  is the shaft over which the compression spring rests.  177  is the male threaded end which mates into the female hole  178  on the adaptor  26 .  179  is an oval slot transversely placed on the adaptor which is necessary to compensate for circular path of travel of pin  27  on the upper jaw. 
       FIGS. 43, 44 and 45  show 3 of the components of the jaw sub-assembly that moves the upper jaw, including the plunger  31 , the adaptor  26 , and the compression spring  32 . 
       FIGS. 46 and 47  show the entire jaw sub-assembly. Part  26  is the adaptor with an oval slot placed horizontally on its side. Part  31  is the plunger which screws into the top of the adaptor  26 , with a compression spring  32  mounted on its shaft. On its upper end is mounted the oval adaptor, secured with the screw  29 . On the other end of the oval adaptor is mounted the stem of the ball, in the midline of the rotator, and in line with the socket. 
       FIG. 48  is a picture of the ball  34  with the stem  33 .  FIG. 49  is a perspective view of the oval plate located at the top of the rotator that is responsible for diverting the forces of actuation from the midline to the side of the rotator.  181  and  182  receives the counter-sunk screw.  180  receives the stem of the ball. 
       FIG. 50  and  FIG. 51  are perspective views of the socket that contains the ball, illustrated by elements  183 ,  184 . Note the socket is open at the lateral sides allowing the ball to escape and enter at the sides. 
     Referring to  FIGS. 55, 57, and 58 , the order of assembly is explained. First the sub-assemblies are constructed, which include the rotator sub-assembly, the tip-base sub-assembly, and the handle sub-assembly. Next the rotator sub-assembly is mounted on the tip-base sub-assembly. Then the two long operating rods are mounted followed by the outer sheath, and the proximal spacer. Next the rear end of this large sub-assembly is carefully inserted into the front of the handle, secured in place, followed by installation of the long and short connectors into the cavity in the handle, followed by installation of the triggers and compression springs. 
       FIG. 59  is diagram indicating the names of the different parts of a suture ligature,  1  for the head end,  2  the tail end,  3  the leading strand, and  4  the tail strand. 
       FIG. 61  shows how a knot is made using the present instrument. The tail end of the suture is grasped with a regular grasper, and is pulled taut so that the tail strand becomes relatively taut. The jaw of the mini-grasper then grasps the head end of the suture, and the instrument is pulled back over the tail strand, crossing it. The tail strand is then engaged in the V-slot on the upper surface of the tip of the present instrument, and seated firmly in the central space of the hollow axle. The rotation trigger  4 , is then fired. The rotator will rotate through 180 degrees. Upon release of the rotation trigger, the compression spring will make the rotator rotate through the second 180 degrees, carrying the head end of the suture with it, producing the throw. Pulling the two ends apart will result in a knot. The process may be repeated.