Patent Description:
The human heart relies on a series of one-way valves to help control the flow of blood through the chambers of the heart. Deoxygenated blood returns to the heart, via the superior vena cava and the inferior vena cava, entering the right atrium. The heart muscle tissue contracts in a rhythmic, coordinated heartbeat, first with an atrial contraction which aids blood in the right atrium to pass through the tricuspid valve and into the right ventricle. Following atrial contraction, ventricular contraction occurs and the tricuspid valve closes. Ventricular contraction is stronger than atrial contraction, assisting blood flow through the pulmonic valve, out of the heart via the pulmonary artery, and to the lungs for oxygenation. Following the ventricular contraction, the pulmonic valve closes, preventing the backwards flow of blood from the pulmonary artery into the heart.

Oxygenated blood returns to the heart, via the pulmonary veins, entering the left atrium. Left atrial contraction assists blood in the left atrium to pass through the mitral valve and into the left ventricle. Following the atrial contraction, ensuing ventricular contraction causes mitral valve closure, and pushes oxygenated blood from the left ventricle through the aortic valve and into the aorta where it then circulates throughout the body. Under nominal conditions, prolapse of the mitral valve is prevented during ventricular contraction by chordae attached between the mitral valve leaflets and papillary muscles located in the left ventricle. Following left ventricular contraction, the aortic valve closes, preventing the backwards flow of blood from the aorta into the heart.

Unfortunately, one or more of a person's heart valves can have or develop problems which adversely affect the valves' function and, consequently, negatively impact the person's health. Generally, problems with heart valves can be organized into two categories: regurgitation and/or stenosis. Regurgitation occurs if a heart valve does not seal tightly, thereby allowing blood to flow back into a chamber rather than advancing through and out of the heart. This can cause the heart to work harder to remain an effective pump. Regurgitation is frequently observed when the mitral valve fails to properly close during a ventricular contraction. Mitral regurgitation can be caused by chordae stretching, tearing, or rupturing, along with other structural changes within the heart.

Neochordal replacement for stretched or torn chordae is one option to reduce regurgitation. In such a procedure, chords to be replaced are identified and dissected as required. A papillary suture is placed in a papillary muscle corresponding to the dissected chord. The papillary suture may optionally be pledgeted on one or both sides of the papillary muscle. A leaflet suture is also placed in the corresponding mitral valve leaflet. The papillary suture and the leaflet suture may then be tied or otherwise fastened together to create a replacement chord to help support the mitral valve leaflet and prevent regurgitation.

Unfortunately, while the above techniques are proven methods of heart valve repair, technical challenges impede their widespread utilization, especially in minimally invasive cardiac surgery. While minimally invasive surgery can dramatically reduce patient recovery times by avoiding the need for full or partial sternotomy, it is difficult and time consuming to manipulate a suture needle with forceps through a minimally invasive opening between adjacent ribs to place the sutures for neochordal replacement. An innovative system that remotely delivers and reliably places suture for minimally invasive neochordal replacement would be highly desirable.

<CIT> discloses a minimally invasive surgical suturing device comprising a flywheel portion, and a curved arm extending from the flywheel portion. The curved arm comprises a ferrule engaging tip at an end of the curved arm away from the flywheel portion. The device includes further a ferrule release feature having either a manual button, which has to be pushed in to engage with the curved arm or which has to be removed before a second stitch can be conducted.

Advantageous embodiments are defined by claims <NUM> to <NUM>.

A suturing device for minimally invasive surgery is disclosed. The device has at least one ferrule holder. The device also has a latch spring comprising at least one latch biased to cover the at least one ferrule holder. The device further has a needle comprising one or more curved needle arms. The device also has a needle control wire coupled to the needle for moving the one or more curved needle arms on an arcuate path through a tissue gap. The device further has a cam coupled to the needle control wire for selective engagement with a follower region on the latch spring.

It will be appreciated that for purposes of clarity and where deemed appropriate, reference numerals have been repeated in the figures to indicate corresponding features, and that the various elements in the drawings have not necessarily been drawn to scale in order to better show the features.

<FIG> is a perspective view of one embodiment of a minimally invasive surgical suturing device <NUM>. The device <NUM> has a housing <NUM> which extends down to form a handle <NUM>. The device <NUM> also has a shaft <NUM> which is coupled to the housing <NUM> by a rotational adapter which is not completely visible in this view. An indicator fin <NUM> of the rotational adapter can be seen in this view, however.

The device <NUM> has a distal tip <NUM> which is pivotably coupled to the shaft <NUM> by first and second articulation joints <NUM>, <NUM>. The first articulation joint <NUM> is operationally coupled to a first articulation knob <NUM> such that rotation of the first articulation knob <NUM> causes the first articulation joint <NUM> to articulate the distal tip <NUM> in a first plane <NUM>. The second articulation joint <NUM> is operationally coupled to a second articulation knob <NUM> such that rotation of the second articulation knob <NUM> causes the second articulation joint to articulate the distal tip <NUM> in a second plane <NUM>. In this example, the first plane <NUM> is substantially perpendicular to the second plane <NUM>. In other embodiments having two articulation joints, the two articulation planes may not be substantially parallel. Other embodiments may have more or fewer, including none, articulation joints. The articulation joints in other embodiments may be capable of movement in more than one plane.

<FIG> is a partially exposed view of the device <NUM> from <FIG>. In particular, part of the housing <NUM> has been removed so that the components inside may be more clearly seen. The distal tip <NUM> defines a tissue gap <NUM>. As will be explained in more detail later in this specification, the device <NUM> may be positioned so that tissue is in the tissue gap <NUM>. Curved needle arms (not visible in this view) are configured to be movable through the tissue gap <NUM> from the distal end of the gap 72D to the proximal end of the gap 72P. The needle arms (not visible in this view) are coupled to an actuation lever <NUM> which is pivotable around pivot point <NUM>. A biasing element, such as spring <NUM> is coupled between the actuation lever <NUM> and the inside of the handle <NUM> in order to keep the lever <NUM> biased away from the handle <NUM> as illustrated in the retracted position of <FIG>. In this retracted position, the needle arms (not visible in this view) remain retracted in the distal tip <NUM>.

The needles are coupled to the lever <NUM> by a needle control wire (not visible in this view) which runs through the second and first articulation joints <NUM>, <NUM>, the shaft <NUM>, and a rotation adapter <NUM>. Embodiments of rotation adapters <NUM> are known to those skilled in the art, for example, see <CIT>. The needle control wire (not visible in this view) also passes through, but is coupled to a twisting barrel <NUM>. The proximal end of the needle control wire (not visible in this view) has a ball which is coupled to a ball receiver <NUM> on the actuator lever <NUM>. Thus, the needle control wire (not visible in this view) is free to be rotated on its longitudinal axis while still being capable of movement substantially along that longitudinal axis when the actuation lever <NUM> is squeezed towards the handle <NUM>.

<FIG> are exploded views illustrating assembly of the minimally invasive surgical suturing device <NUM> of <FIG> and <FIG>. Referring to <FIG>, the shaft <NUM> is a hollow tube. As currently illustrated in <FIG>, the proximal end 54P of the shaft is attached to the rotation adapter. These two parts <NUM>, <NUM> are not shown exploded, but the proximal end of the shaft 54P inside of the rotation adapter <NUM> has textured features around which the rotation adapter <NUM> is molded. The shaft <NUM> has first and second slots <NUM>, <NUM> formed near the proximal end of the shaft 54P. A first articulation rack <NUM> is placed in the first slot <NUM> and a proximal end 92P of a first articulation control wire <NUM> is placed into a distal opening <NUM> in the shaft <NUM>. The proximal end 92P of the first articulation control wire <NUM> is configured to mate with a corresponding feature <NUM> on the first articulation rack. The first articulation rack <NUM> is shorter than the first slot <NUM>, so it is able to be moved back and forth within the first slot <NUM> in a direction that is substantially parallel to the longitudinal axis <NUM> of the shaft <NUM>.

The first articulation knob <NUM> has threads 64T which are pitched to engage gear threads 90T on the first articulation rack <NUM>. The first articulation knob <NUM> is passed over the shaft <NUM> and threaded onto the first articulation rack <NUM>. A connector 92C on the distal end of the first articulation control wire <NUM> extends out of the shaft <NUM> and can be moved towards the distal opening of the shaft <NUM> or away from the distal opening of the shaft <NUM> to the extent that twisting the first articulation knob <NUM> is able to move the first articulation rack <NUM> within the first slot <NUM>.

As shown in <FIG>, a second articulation rack <NUM> is placed in the second slot <NUM> and a proximal end 102P of a second articulation control wire <NUM> is placed into the distal opening <NUM> in the shaft <NUM>. The proximal end 102P of the second articulation control wire <NUM> is configured to mate with a corresponding feature <NUM> on the second articulation rack <NUM>. The second articulation rack <NUM> is shorter than the second slot <NUM>, so it is able to be moved back and forth within the second slot <NUM> in a direction that is substantially parallel to the longitudinal axis <NUM> of the shaft <NUM>.

The second articulation knob <NUM> has threads 66T which are pitched to engage gear threads 100T on the second articulation rack <NUM>. The second articulation knob <NUM> is passed over the shaft <NUM> and threaded onto the second articulation rack <NUM>. A connector 102C on the distal end of the second articulation control wire <NUM> extends out of the shaft <NUM>, farther than the first connector 92C, and can be moved towards the distal opening <NUM> of the shaft <NUM> or away from the distal opening <NUM> of the shaft <NUM> to the extent that twisting the second articulation knob <NUM> is able to move the second articulation rack <NUM> within the second slot <NUM>.

As shown in <FIG>, a collar <NUM> is placed over the distal end 108D of a needle control wire <NUM>. In this embodiment, the collar <NUM> has two cams <NUM>. As will be discussed in more detail later in this specification, the cams <NUM> will be moved into and out of phase with a follower surface of a ferrule latch (not shown in this view). The exact position of the collar <NUM> on the a proximal end 108P of the needle control wire <NUM> can be determined by those skilled in the art to effect the cam behavior discussed later in this specification. A distal ball end <NUM> is attached to the distal end 108D of the needle control wire <NUM>. The proximal end 108P of the needle control wire is inserted into the distal opening <NUM> of the shaft <NUM> and passed all the way through the shaft <NUM>, through the rotational adapter <NUM>, and out the actuator input <NUM> of the rotational adapter.

As illustrated in <FIG>, the proximal end 108P of the needle control wire <NUM> is passed through the twisting barrel <NUM> so that it protrudes out the proximal end 82P of the barrel <NUM>. The barrel <NUM> is then fixed to the needle control wire <NUM> such that it enters the actuator input <NUM> of the rotational adapter <NUM>. The barrel <NUM> has cam paths <NUM> which are engaged by a cam pin <NUM> biased against the barrel <NUM> by a cam spring <NUM> that is coupled to the rotation adapter <NUM>. A proximal ball end <NUM> is attached to the proximal end 108P of the needle control wire <NUM>. The proximal ball end <NUM> is coupled to the ball receiver <NUM> of actuation lever <NUM> as shown in <FIG>. The housing <NUM> and one or more rotation adapter receivers <NUM> stabilize the rotation adapter <NUM>.

For simplicity, <FIG> does not show the housing <NUM>, actuation lever <NUM>, spring <NUM>, or the rotation adapter receiver <NUM> so that the assembly of the distal end of the device may be seen more clearly. Recall that the first articulation control wire <NUM> and the connector 92C at its distal end protrude from the distal opening <NUM> of the shaft <NUM>. Similarly, the second articulation control wire <NUM> and the connector 102C at its distal end protrude farther from the distal opening <NUM> of the shaft <NUM>. Furthermore, the needle control wire <NUM> and the collar <NUM> and distal ball end <NUM> protrude even father from the distal opening <NUM> of the shaft <NUM>. As illustrated in <FIG>, a first pivotable arm <NUM> has a first connector receiver 124R and a pass-through channel 124PT. The needle control wire <NUM> and the second articulation control wire <NUM> are fed through the pass-through channel 124PT in the arm <NUM>, and then the arm <NUM> is positioned so the first connector receiver 124R receives the connector 92C from the first articulation control wire <NUM>. The first pivotable arm <NUM> also has an axle receiving opening <NUM>. Two fixed arm halves 128A, 128B are inserted into the distal end <NUM> of the shaft <NUM> while being brought together around the first pivotable arm <NUM>. The fixed arm halves 128A, 128B each have an axle <NUM> (only one of which is visible in <FIG>). The axles <NUM> are aligned with the axle receiving opening <NUM> on the first pivotable arm <NUM>. Together, the first pivotable arm <NUM> and the fixed arm halves 128A, 128B which support and provide an axle for the first pivotable arm <NUM> make up the first articulation joint <NUM> first discussed in <FIG>. Movement of the first articulation control wire <NUM> caused by rotation of the first articulation control knob <NUM> will cause the first pivotable arm <NUM> to pivot or articulate with respect to the fixed arm halves 128A, 128B.

As illustrated in <FIG>, the distal tip has two casing halves 130A, 130B. Each casing half 130A, 130B has an axle receiver <NUM> (only one of which is visible in <FIG>). The first pivotable arm <NUM> has a corresponding pair of axles <NUM>. Each casing half 130A, 130B also has a connector receiver <NUM> (only one of which is visible in <FIG>). The connector receivers <NUM> are sized to receive part of the connector 102C. The casing half 130A defines needle arm exit holes <NUM> and ferrule holders <NUM>. Although not visible in this view, the casing halves 130A, 130B also define receivers for the axles <NUM> of the needle <NUM>. When the axles <NUM> are held by the axle receivers (not visible in this view), the needle <NUM> may be pivoted so that the needle arms <NUM> will protrude from the needle arm exit holes <NUM>. The needle <NUM> also has a receiver <NUM> for receiving the distal ball end <NUM> and allowing clearance for the needle control wire <NUM>.

A latch spring <NUM> is also involved. The casing halves 130A, 130B each define a spring pivot receiver <NUM> (only one if which is visible in <FIG>). The spring pivot receivers <NUM> are sized to receive corresponding pivot points <NUM> from the latch spring <NUM>. Further details of the latch spring <NUM> will be discussed later in this specification, but it should be noted here that the latch spring has a channel which allows the needle control wire <NUM> to pass freely therethrough.

To complete the assembly of <FIG>, the casing halves 130A, 130B must be brought together so that <NUM>) the axles <NUM> are aligned with the corresponding axle receivers <NUM>, <NUM>) the connector 102C is aligned with the corresponding connector receivers <NUM>, <NUM>) the distal ball end <NUM> is coupled to the receiver <NUM> on the needle <NUM>, <NUM>) the needle axles <NUM> are aligned with the axle receivers (not visible in this view) of the casing halves 130A, 130B, and <NUM>) the pivot points <NUM> of the latch spring <NUM> are aligned with the spring pivot receivers <NUM> while <NUM>) biasing elements <NUM> of the latch spring <NUM> ride up on portions of the needle <NUM>, <NUM>) a manual latch defeat <NUM> of the latch spring <NUM> is aligned within a defeat opening <NUM> of the casing half 130A, and <NUM>) the needle control wire passes through the pivot points <NUM> of the latch spring <NUM> as the casing halves 130A, 130B are coupled and affixed to each other. Together, the proximal end of the device tip <NUM> (made from the casing halves 130A, 130B) and the distal end of the first pivotable arm <NUM> make up the second articulation joint <NUM> discussed in <FIG>. Movement of the second articulation control wire <NUM> caused by rotation of the second articulation control knob <NUM> will cause the distal tip casing 130A, 130B to pivot or articulate with respect to the arm <NUM>.

<FIG> and <FIG> are partial cross-sectional perspective views of the distal tip <NUM> which offer more clarity on the orientation of the collar <NUM> and the cams <NUM> with respect to the latch spring <NUM>. For the sake of explanation, a ferrule <NUM> has been loaded into one of the ferrule holders <NUM>. The latch spring <NUM> has two latch arms <NUM>, one corresponding to each ferrule holder <NUM>. The latch arms <NUM> are coupled to the pivot point <NUM>, but are biased towards the ferrule holders <NUM> by biasing elements <NUM>. Without any other forces interacting with the latch arms <NUM>, the biasing elements <NUM> cause the latch arms <NUM> to pivot about the pivot points <NUM> towards the ferrule holders <NUM> so that the latch <NUM> at the end of each latch arm <NUM> holds its corresponding ferrule <NUM> in the ferrule holder <NUM>.

The needle control wire <NUM> will move distally <NUM> when the actuation lever <NUM> is squeezed. As will be discussed later in this specification, this will cause the arms <NUM> of needle <NUM> to rotate out of the device tip <NUM> from the needle arm exit holes <NUM>, moving proximally on a curved or arcuate path towards the ferrules <NUM> held in the ferrule holders <NUM>. However, while the latch <NUM> is holding the ferrule <NUM>, the needle tips <NUM> will not be able to remove the ferrules <NUM> from the ferrule holders <NUM>. Fortunately, with this design embodiment, and its equivalents, the cams <NUM> are oriented such that they will contact follower regions <NUM> on the latch spring <NUM> as the needle control wire <NUM> moves distally. This contact of the cams <NUM> with the follower regions of the latch spring <NUM> overcomes the bias from the biasing elements <NUM> and pushes the latch arms <NUM> away from the ferrule holders <NUM> such that the latches <NUM> are no longer preventing the ferrules <NUM> from being removed by the needle tips <NUM> as will be discussed later on with regard to <FIG> ,<FIG>, <FIG>, <FIG>, <FIG>, <FIG>, and <FIG>.

The design of the rotating barrel <NUM> which engages with the cam pin <NUM> is such that as the actuator lever is released the cam paths <NUM> on the barrel <NUM> cause the needle control wire <NUM> to rotate ninety degrees while the needle control wire <NUM> moves in a proximal direction to retract the needle arms <NUM>. This will effectively align the cams <NUM> at ninety degrees from the <FIG> position, as shown in <FIG>. When the cams are aligned as shown in <FIG>, a subsequent squeeze of the actuation lever <NUM> will again cause the needle control wire to move in a distal direction, causing the arms <NUM> of needle <NUM> to rotate out of the device tip <NUM> from the needle arm exit holes <NUM>, moving proximally on a curved or arcuate path towards the ferrules <NUM> held in the ferrule holders <NUM>. This time, however, with the cams <NUM> ninety degrees out of phase, the cams <NUM> will not contact the follower regions <NUM> on the latch spring <NUM>. Instead, the cams <NUM> will simply pass through the clearance gap <NUM> defined by the latch spring <NUM> between the follower regions <NUM>. This clearance gap <NUM> cannot be seen in the following side views, so <FIG> can be consulted as desired to visualize the clearance gap <NUM>. When the cams <NUM> pass through the clearance gap <NUM> without contacting the follower regions <NUM>, then the latches <NUM> remain engaged with the ferrule holders <NUM>.

<FIG>, <FIG>, <FIG>, <FIG>, <FIG>, <FIG>, and <FIG> are partial cross-sectional side views illustrating a suturing sequence using the minimally invasive suturing device <NUM> discussed herein. Each of <FIG>, <FIG>, <FIG>, <FIG>, <FIG>, <FIG>, and <FIG> has a corresponding enlarged view, <FIG>, <FIG>, <FIG>, <FIG>, <FIG>, <FIG>, and <FIG>, respectively. The enlarged views show the distal tip in more detail. For convenience, only <FIG>, <FIG>, <FIG>, <FIG>, <FIG>, <FIG>, and <FIG> will be discussed, but it should be understood that the enlarged views of <FIG>, <FIG>, <FIG>, <FIG>, <FIG>, <FIG>, and <FIG> may also be consulted for more detail. Also, since 4A, 5A, 6A, 7A, 8A, 9A, and 10A are from a side view, only one needle arm, ferrule holder, ferrule, needle tip, latch, etc may be seen in these views. For convenience, therefore, only the one visible version of each component will be discussed, however, it is understood that there is a corresponding other component behind the visible component.

In <FIG>, at the start of the sequence, a ferrule <NUM> has been loaded into the ferrule holder <NUM>. The latch <NUM> is positioned over the ferrule holder <NUM>. The actuation lever <NUM> is in the unsqueezed position and the needle arm <NUM> is retracted inside of the distal tip <NUM>. The cam <NUM> is oriented in an unlatching phase, whereby the cam <NUM> will contact the follower region <NUM> of the latch spring <NUM> when the lever <NUM> is eventually squeezed. The tissue gap <NUM> of the device has been placed around tissue <NUM> through which it is desired to place the suture <NUM> which is coupled to the ferrule <NUM>.

As shown in <FIG>, the lever <NUM> is squeezed <NUM> towards the handle <NUM>. The needle control wire <NUM> moves distally <NUM>, causing the cam <NUM> to contact the follower region <NUM> and pivoting the latch <NUM> away from the ferrule holder <NUM>. The distal movement <NUM> of the needle control wire <NUM> also rotates the needle <NUM> so the needle arm <NUM> penetrates the tissue <NUM> and the needle tip <NUM> engages the ferrule <NUM>.

As shown in <FIG>, the lever <NUM> is starting to be released <NUM>. The needle control wire <NUM> starts to move proximally <NUM>, but the cam <NUM> is still in contact with the follower region <NUM> of the latch spring <NUM>. This keeps the latch <NUM> clear of the ferrule holder <NUM> while the needle arm <NUM> rotates <NUM> distally back along its curved path, allowing the ferrule <NUM> to be removed from the ferrule holder <NUM> by the needle tip <NUM>.

As the lever <NUM> is fully released, as shown in <FIG>, the cam <NUM> disengages the follower region <NUM> and the needle control wire <NUM> is rotated ninety degrees as discussed above. The biasing element <NUM> of the latch spring <NUM> has again pushed the latch <NUM> over the ferrule holder <NUM>. The needle arm <NUM> is fully retracted, and the needle tip <NUM> has pulled the ferrule <NUM> and its suture <NUM> back through the tissue <NUM>.

As shown in <FIG>, the tissue gap <NUM> is removed from the tissue <NUM>. It may be desirable to reset the suturing device so that a subsequent stitch may be placed. While there is no tissue <NUM> in the tissue gap <NUM>, as shown in <FIG>, the lever <NUM> may be squeezed <NUM> again. The needle tip <NUM> with its engaged ferrule <NUM> moves across the tissue gap <NUM>, returning the ferrule <NUM> to the ferrule holder <NUM>. Since the cam <NUM> is oriented to pass through the clearance gap <NUM> (not visible in this view), the latch <NUM> rides over the ferrule <NUM> and then comes to rest on the needle arm <NUM> just above the ferrule <NUM>. When the lever <NUM> is released <NUM> as shown in <FIG>, the latch <NUM> pulls the ferrule <NUM> off of the needle tip <NUM> as the needle arm <NUM> retracts. The needle control wire <NUM> rotates ninety degrees as it moves proximally <NUM>, as discussed above. This resets the cam <NUM> to the position of <FIG>. The ferrule <NUM> is also reset in the ferrule holder <NUM>, and the device is ready to place a second stitch.

By being able to reset the ferrule by squeezing the lever after taking a first stitch, the device can be called a "running-stitch" device, capable of making multiple suture stitches in vivo, through a minimally invasive access opening, without the need to remove the device and manually reset between stitches. This may be especially helpful in the replacement of chordae tendinae of a mitral valve leaflet, as a first stitch may be placed in a leaflet, the device reset, and then a second stitch placed in a papillary muscle. The second stitch may be secured after adjusting the length of the suture between the leaflet and the papillary muscle to a desired distance to reduce or eliminate leaflet prolapse.

When the desired stitches have been placed, it is still necessary to remove the ferrules from the suturing device. While the ferrules could simply be cut from the suture, this may make the suturing device unusable with other sutures because the ferrules will either be attached to the needle tips or kept housed in the ferrule holders. Accordingly, a manual latch defeat <NUM> may be incorporated into the latch spring <NUM>. To remove the suture <NUM> and ferrules <NUM> from the device, the ferrules <NUM> should be returned to the ferrule holders <NUM> as shown above. This is the situation shown in <FIG>. As can be seen in <FIG>, the latch <NUM> is positioned to retain the ferrule <NUM> in the ferrule holder <NUM>. As shown in <FIG>, the manual latch defeat <NUM> may be pressed <NUM> to push the latch <NUM> away from the ferrule holder <NUM>. This allows the ferrule <NUM> to be taken out of the ferrule holder <NUM>, thereby keeping the device in good order to be loaded with more suture having ferrules and used again if so desired.

Various advantages of a suturing device for minimally invasive surgery have been discussed above. Various alterations, improvements, and modifications will occur and are intended to those skilled in the art, though not expressly stated herein. These alterations, improvements, and modifications are intended to be suggested hereby. As just some examples, a similar latch spring could be used with a curved needle suturing device whose needles extend across the tissue gap in an opposite direction from the device discussed herein. Also, the latch spring could be configured to work with multiple more or fewer needles.

Claim 1:
A suturing device (<NUM>) for minimally invasive surgery, comprising:
at least one ferrule holder (<NUM>);
a latch spring (<NUM>) comprising at least one latch (<NUM>) having at least one latch arm (<NUM>) biased towards the at least one ferrule holder (<NUM>);
a needle (<NUM>) comprising one or more curved needle arms (<NUM>); and
a needle control wire (<NUM>) coupled to the needle (<NUM>) for moving the one or more curved needle arms (<NUM>) on an arcuate path through a tissue gap (<NUM>) towards the at least one ferrule holder (<NUM>);
a cam (<NUM>) coupled to the needle control wire (<NUM>) for selective engagement with a follower region (<NUM>) on the latch spring (<NUM>);
wherein the selective engagement comprises alternately contacting the follower region (<NUM>) with the cam (<NUM>) on every other movement of the needle control wire (<NUM>) in a first direction; and
wherein the at least one latch arm (<NUM>) is pushed away from the at least one ferrule holder (<NUM>) when the cam (<NUM>) contacts the follower region (<NUM>) such that the at least one latch (<NUM>) no longer prevents the ferrule from being removed by a needle tip of the needle.