Patent Description:
Suturing apparatus in the past have had an elongate shaft and a low profile distal clamping mechanism to facilitate their use through cannulas <NUM> in less invasive surgery. These devices have typically included opposing jaws which clamp onto the tissue to be sutured. The end segment of the suture is pre-positioned and secured at the distal end of one jaw member. Beyond the clamping motion, the mechanism for passing a suture between the jaws and through the tissue incorporates a bendable needle. The bendable needle advances distally within the jaw member, bringing it in contact with a segment of the suture.

The needle engages and secures the suture to carry it forward. This distal advancement of the bendable needle also results in the leading end of the needle to approach and engage a ramp <NUM> in the jaw member, deflecting the bendable needle in a direction toward the opposing jaw. The bending of the needle requires a high force and results in excess strain on the needle component. Fracture and failure of the bendable needle is a concern.

Additionally, the bendable needle is further advanced after being deflected in a direction extending away from the jaws, and potentially into unintended anatomy. Extension of the needle in this manner is a safety concern. Even after the apparatus has completed passing the suture through the tissue, the end segment of the suture must be retrieved by retracting the entire apparatus out of the cannula. Suture manipulating devices of the prior art are known from, e.g., <CIT>, <CIT> and <CIT>, wherein <CIT> discloses a sort of pair of tweezers connected to a holding pipe received in a guiding pipe so that the tweezers may be opened and closed by means of displacing the guiding pipe.

<CIT> discloses suture passers for suturing tissue in a continuous manner by passing a suture attached to a suture shuttle through. A suture passer may include a first jaw, a second jaw, and a tissue perpetrator that is retractable and extendable from the first jaw. The tissue penetrator may have a suture shuttle engagement region, and the second jaw may include a shuttle dock. The suture shuttle may be transferred between the first and second jaws as the tissue penetrator is extended from the first jaw and engages the second jaw.

It would be advantageous to have an apparatus that could load and unload suture without the need to remove the apparatus from the surgical site.

It would be advantageous to have an apparatus that could pass (not load and unload) suture repeatedly through tissue without the need to remove the apparatus from the surgical site. It would also be advantageous for the suture shuttling mechanism (either needle or shuttle) to be entirely contained within the apparatus during operation to improve accuracy of suture placement and improve safety of needle or shuttle position during operation.

The present invention provides for a suture manipulating device as defined by claim <NUM>. Preferred embodiments of the invention are laid down in the dependent claims.

The suture passing device can be made to have no mechanical pivoting links. The suture passing device can have no hinges in the jaw structure. The jaw structure can open and close with hinge-less action.

The suture can be mounted on the lateral side of the jaw structure.

A shuttle for holding and moving the suture can be captured and held within the jaws, for example creating a design of the device that has no loose parts capable of being separated from the device during use.

The jaws and/or the shaft or compression cover of the device can be made from a resilient metal such as Nitinol or any other material disclosed herein.

The device can pass suture repeatedly through tissue without the need to remove the apparatus from the surgical site or to load and unload the suture from the device. The suture shuttling mechanism (e.g., the needle and/or the shuttle) can be partially or entirely contained within the apparatus during operation to improve accuracy of suture placement and improve safety of needle or shuttle position during operation.

<FIG> through to illustrate a suture passing device I <NUM> that can be used to pass suture <NUM> through soft or hard tissue <NUM> without removing the device <NUM> or the suture <NUM> from the target site while creating one or more complete stitches.

The suture passing device <NUM> can have an ergonomic handle <NUM>, a sliding tube actuator <NUM>, and a distal end <NUM>. The ergonomic handle <NUM> can be used to control the distal end <NUM>. The ergonomic handle <NUM> can have a side knob <NUM>. The ergonomic handle <NUM> can have a top knob <NUM>. The top knob <NUM> and/or the side knob <NUM> can individually or in concert, advance and/or retract the upper <NUM> and/or lower pusher <NUM>.

The sliding tube actuator <NUM> can have an outer compression cover <NUM> and an inner rod (not shown due to obstruction by the outer compression cover <NUM>). The inner rod can be fixedly attached to the handle <NUM> and the proximal end of the jaw structure <NUM>. The outer compression cover <NUM> can be radially outside of the inner rod. The outer compression cover <NUM> can be actuated by the handle <NUM>, for example be distally and proximally translated with respect to the handle <NUM> when the trigger <NUM> is squeezed or released.

<FIG> and <FIG> illustrate that the device <NUM> can have a sliding ribbon shuttle <NUM> or needle held within the device <NUM>. The shuttle <NUM> can have an elongated shuttle rail <NUM>. The shuttle rail <NUM> can have numerous slits <NUM> along one or both sides of the shuttle rail <NUM>. The slits <NUM> can be positioned at regular or irregular length intervals along the rail <NUM>.

The shuttle <NUM> can have a suture holder <NUM> extending laterally from the rail <NUM>. The shuttle <NUM>, for example the suture holder <NUM><NUM>, can extend out of the lateral side slot <NUM> of the arm structure. The suture holder <NUM> can extend from the left and/or right side of the device <NUM>. The distal end <NUM> of the device <NUM> can be reversible so the suture holder <NUM> can be switched from one side of the device <NUM> to the other side of the device <NUM>. The suture holder <NUM> can have a generally flat, isosceles trapezoid configuration. The suture holder <NUM> can have a suture holding notch <NUM>. The notch <NUM> can have an inner hole 17a, an outer hole 17b contiguous with the inner hole 17a, and a first cleat 97a positioned between the inner hole 17a and the outer hole 17b. The notch <NUM><NUM> can have a second cleat 97b on the side of the outer hole away from the inner hole. The notch <NUM> can be configured to secure to suture <NUM>. For example, the suture <NUM> can be compressed and friction fit in the inner cleat 97a.

The suture holder <NUM> can have a front leading edge and a rear leading edge. The edges can be slanted at a right or non-right angle with respect to the longitudinal axis of the rail <NUM>. One or both of the edges can be sharpened to be traumatic to tissue <NUM>, for example to cut through soft tissue <NUM>. The edges can cut through tissue <NUM>, allowing the suture holder <NUM> to pull the suture <NUM> through the tissue <NUM> immediately behind the respective edge.

The shuttle <NUM> can be made from a flexible polymer, such as PEEK, a resilient metal such as Nitinol, any material disclosed herein or combinations thereof. The shuttle <NUM> can be made from a molded polymer. The shuttle <NUM> can be pre-curved, for example to reduce resistance when going around curves in the tracks.

<FIG> illustrates that the rail <NUM> can curve at the locations of the slits <NUM>, and/or the rail <NUM> can be pre-curved.

<FIG> illustrate that the suture passing device <NUM> can capture or releasably attach to the suture <NUM> in the inner and/or outer cleats 97a and/or 97b of the suture holder <NUM>. The suture <NUM> can be loaded or held laterally of the jaw structure <NUM>, out of plane with the rotation of the jaws. The device <NUM> can make multiple passes of the suture <NUM> through the tissue <NUM> without extracting or reloading the suture passing device <NUM>. The jaw structure <NUM> can resiliently deform open at the proximal end of the jaw structure <NUM>, having no hinge. The jaws can be opened and/or closed with no mechanical pivots or linkages in the jaw structure <NUM>.

<FIG> illustrates that the suture passer device <NUM> has a jaw structure <NUM> with a top jaw <NUM> and a bottom jaw <NUM>. The entire jaw structure <NUM> can be an integral piece of material, such as a single molded, cast, or cut element of Nitinol, other resilient metal or polymer, any other material listed herein, or combinations thereof. The jaw structure <NUM> can be configured to be in an opened configuration (as shown in <FIG>) when in an unbiased configuration (i.e., when no external forces are applied).

The jaw structure <NUM> has a jaw structure longitudinal axis <NUM>. Each jaw can also have a respective jaw longitudinal axis along the jaw.

The inside channel of the compression cover <NUM> can be sized and shaped to fit over the jaw structure <NUM> with minimum clearance when the jaw structure <NUM> is in a closed configuration. When the compression cover is translated distally <NUM> with respect to the jaw structure <NUM>, as shown by arrow, the compression cover <NUM> can press the top and bottom jaws <NUM> toward the jaw structure : longitudinal axis <NUM>. The jaw structure <NUM> can be fully compressed into a closed configuration, as shown in <FIG>. In this way, when an actuation lever such as the trigger <NUM> is actuated, the channel or compression cover <NUM> can advance to cam closed the jaws. The jaws can pre-pierce the tissue and establish a continuous track for the shuttle to pass through the tissue.

The compression cover <NUM> can be attached to an opening ball <NUM> positioned between the first and second jaws.

<FIG> illustrates that the opening ball <NUM> can be rotatably or fixedly attached to a ball axle <NUM> passing laterally through the opening ball <NUM>. The ball axle <NUM> can extend out from the lateral sides of the ball <NUM>. The ball axle <NUM> can be slidably received by axle slots <NUM> formed through distal arms <NUM> or extensions <NUM> of the compression cover <NUM>. When the jaw structure <NUM> is in a closed configuration, the ball axle <NUM> can abut and interference fit against the proximal end of the axle slot <NUM>, for example to prevent overextension of the compression cover <NUM> over the jaw structure <NUM>. When the jaw structure <NUM> is in an opened configuration, the ball axle <NUM> can abut and interference fit against the distal end <NUM> of the axle slot <NUM>, for example to prevent overrotation of the jaws and/or pulling the ball <NUM> past the ramps <NUM> on the inside of the jaw structure <NUM>.

<FIG> illustrates that the bottom track distally terminates in a bottom track port <NUM>. The top track <NUM> distally terminates at a top track port <NUM>. The top track port <NUM> aligns with and is adjacent to (as shown) or in contact with the bottom track port <NUM> when the jaw structure <NUM> is in a closed configuration with the first jaw tip <NUM> interdigitating with the second jaw tip <NUM>. The tracks of the upper jaw <NUM> and bottom jaw <NUM> can form a continuous path when the jaw structure <NUM> is in a closed configuration. The first jaw tip <NUM> can interdigitate with and be adjacent or in contact with the second jaw tip <NUM> when the jaw structure <NUM> is in a closed configuration.

<FIG> illustrates that that compression cover <NUM> can be translated proximally <NUM>, as shown by arrow, with respect to the jaw structure <NUM>. The ball axle <NUM> can slide to the distal end <NUM> of the axle slot <NUM>. The axle slot <NUM> can then pull the ball axle <NUM>, and therefore the opening ball <NUM>, proximally. The opening bill. <NUM> can then press against the inside surface ramp <NUM> of the first jaw and/or second jaw. The first jaw tip <NUM> and/or second jaw tip <NUM> can then rotate away from the opposing jaw tip. The jaw structure <NUM> can then be in an opened configuration, as shown.

The proximal ends of the jaws can be rigid or flexible, for example to bend around the opening of the compression cover <NUM> when the jaws are in an opened configuration. The entire jaws or just the proximal ends of the jaws can be made from Nitinol, for example with the distal ends of the jaws made from stainless steel.

<FIG> illustrates that the side slot <NUM> can extend laterally from one side of the tracks. The rail <NUM> of the shuttle <NUM> can be taller than the height of the side slot <NUM>. The rail <NUM> can be too large to pass through the side slot <NUM>. The suture holder <NUM> can extend laterally from the rail <NUM> through the side slot <NUM>. The suture holder <NUM> can hold the suture <NUM> laterally spaced away from the jaw.

<FIG> illustrates that the upper jaw <NUM> and the lower jaw <NUM> can be closed, as shown by arrows, and compressed through tissue <NUM>, such as soft tissue <NUM> in the rotator cuff or other joint. The upper jaw tip <NUM> and/or the lower jaw tip <NUM> can pierce the tissue <NUM>. The upper jaw tip <NUM> and the lower jaw tip <NUM> can interdigitate in or adjacent to the tissue <NUM>. The hole created by the touching or interdigitating of the upper jaw tip <NUM> and/or the lower jaw tip <NUM> can be a hole in the tissue <NUM> through which the shuttle <NUM> and/or suture <NUM> can pass. The compression cover can be pushed distally <NUM> to further compress the first jaw toward the second jaw, for example to force the jaw tips to pierce the tissue <NUM>.

The lower pusher <NUM> can be advanced distally, as shown by arrow, as controlled by the handle <NUM>. The lower pusher <NUM> can force or push the shuttle <NUM> through the track to move distally and to carry the suture <NUM> with the shuttle <NUM>.

<FIG> illustrates that the lower pusher <NUM> can continue to be pushed by the handle <NUM>. The lower pusher <NUM> can push the shuttle <NUM> through the tissue <NUM>. The front edge <NUM> of the suture holder <NUM> can cut through the tissue <NUM> and the suture holder <NUM> can pull the suture through the cut created in the tissue <NUM> by the front edge <NUM> and/or through the piercing created in the tissue <NUM> by the tips of the jaw. The pusher and the shuttle <NUM> can move along the longitudinal axis of the jaws.

The shuttle <NUM> can then be positioned entirely in the track of the upper jaw <NUM>. The lower pusher <NUM> can then be withdrawn from the track of the upper and/or lower jaw <NUM>, and/or the lower pusher <NUM> can be left in place but the resistive force can be removed, allowing the lower pusher <NUM> to slide freely in the tracks.

<FIG> illustrates that the compression cover can then be translated proximally <NUM> (e.g., by releasing or squeezing the trigger <NUM>), as shown by arrow, <NUM>. The ball axle <NUM> can be pulled proximally, forcing the opening ball <NUM> against the inner surface of the top and/or bottom jaws <NUM>. The opening ball <NUM> can thus resiliently force open the top and/or bottom jaw <NUM>. The jaws can then be unclamped (i.e., rotated open, as shown by arrows <NUM>), and be cleared from the tissue <NUM>.

The device <NUM> can then be shifted to a position where the distal end <NUM> of the device <NUM> is adjacent (e.g., lateral) to where the suture initially passed through the tissue <NUM>.

<FIG> illustrates that the jaw can then be closed, piercing the tissue <NUM> adjacent to the first passage of the suture <NUM> through the tissue <NUM>. The upper pusher <NUM> can then be forced distally, as shown by arrow, by the handle <NUM>. The upper pusher <NUM> can force or push the shuttle <NUM> along the track in the reverse direction from shown in <FIG>. The rear edge <NUM> of the suture holder <NUM> can then cut the tissue <NUM> as the suture holder <NUM> passes through the tissue <NUM>, carrying the suture <NUM> through the tissue <NUM>. Thus a mattress stitch of the suture <NUM> through the tissue <NUM> can be created.

The shuttle <NUM> can then be in the home position, as shown in <FIG>. The upper pusher <NUM> can then be withdrawn from the track of the upper and/or lower jaw <NUM>, and/or the upper pusher <NUM> can be left in place but the resistive force can be removed, allowing the upper pusher <NUM> to slide freely in the tracks. The jaws can be reopened and repositioned, and the device <NUM> can create another stitch repeating the method shown in <FIG>. The jaws can be reopened and removed from the target site when the stitching is complete or to deliver a second stitch.

<FIG> illustrate that the device <NUM> can have a base <NUM> and a handle <NUM> extending from the base <NUM>. The device <NUM> can have a rotatable lever <NUM> rotatably attached to the base <NUM> or handle <NUM>. The device <NUM> can have a compression cover <NUM> translatably attached to and extending distally from the base <NUM>.

The distal end <NUM> of the device <NUM> can have the upper and lower jaws <NUM>. The upper jaw <NUM> can be rotatable with respect to the lower jaw <NUM> and vice versa.

The compression cover <NUM> can be slidably attached to one or both jaws. The rotatable lever <NUM> can be attached to the compression cover <NUM>. For example, squeezing and rotating the lever <NUM> toward the handle <NUM> can push the compression cover distally <NUM> with respect to the jaws. The compression cover can distally slide over the jaws, rotating the upper jaw <NUM> toward the lower jaw <NUM> and closing the jaws. The lever <NUM> can be spring loaded to rotate away from the handle <NUM>, proximally retract the compression cover <NUM>, and return the jaws to an open configuration when external pressure or squeezing is no longer applied to the lever <NUM>,.

<FIG> illustrates that a pusher shaft or button can extend distally from the base <NUM> or handle <NUM>. The pusher shaft or button can be translated with respect to the base <NUM> and/or handle <NUM>, as shown by arrows. The pusher shaft can be configured to push and/or pull one or both pushers. Pressing or pulling on the pusher shaft can translate the pusher. A single pusher shaft or button can be toggled between both pushers.

A pusher toggle, such as a side paddle <NUM> can extend from the lateral side of the base <NUM>. The side paddle <NUM> can be positioned on the top or bottom of the base <NUM> or the handle <NUM>. The side paddle <NUM> can rotate <NUM> with respect to the base <NUM>, as shown by arrow. The side paddle <NUM> can be configured to orient the pusher shaft or button to translate the upper pusher <NUM> or lower pusher <NUM> depending on the position of the side paddle <NUM>.

The device <NUM> can have a lever <NUM> lock <NUM>. The lever <NUM> lock <NUM> can extend laterally from the base <NUM>. The lock <NUM> can rotate <NUM>, as shown by arrows, with respect to the base <NUM>. The lock <NUM> can be configured to fix or secure the lever <NUM> closed or in a particular angular position with respect to the base <NUM>. For example, the lever <NUM> lock can fix the lever <NUM> closed, in turn fixing the jaws in a closed configuration.

<FIG> illustrates that the shuttle <NUM> can have a rail <NUM> that can be a cylindrical tube or sleeve. The rail <NUM> can be made from Nylon, other materials disclosed herein, or combinations thereof. The rail <NUM> can have rounded (e.g., hemi-spherical) or flat terminal longitudinal ends.

The shuttle <NUM> can have a suture holder <NUM> that can be a wire loop <NUM> extending laterally from the rail <NUM>. The wire loop <NUM> can have a wire. The wire loop <NUM> can extend in a flat plane. The terminal ends of the wire can be anchored - e.g., removably or fixedly attached to the rail <NUM>, for example through a port or slot in the lateral side of the rail <NUM>. The suture <NUM> can extend through and remain within the area defined by the perimeter of the wire loop <NUM> while the suture <NUM> is retained by the suture <NUM> passer.

<FIG> illustrates that the lower jaw <NUM> (as shown) and/or upper jaw <NUM> can have one or more loading notches or docks <NUM>. The loading dock <NUM> can expose the suture holder <NUM>, such as the wire loop <NUM>, for suture <NUM> loading/unloading. The suture holder <NUM> can extend into the loading notch. For example the wire loop <NUM> can extend through the side slot <NUM> and into the holding notch <NUM> with the shuttle <NUM> is in a position for loading and/or unloading the suture <NUM> to and/or from the shuttle <NUM>. For example, the shuttle <NUM> can be at the proximal-most position for the shuttle <NUM> on the bottom track <NUM> when the suture holder <NUM> is aligned with the loading dock <NUM>. The side slot <NUM> can terminate at the loading dock <NUM>, for example, interference fitting the wall of the loading dock <NUM> against the shuttle <NUM> and/or suture holder <NUM> to prevent further translation of the shuttle <NUM> proximally along the jaw.

The lower <NUM> and/or upper jaws <NUM> can have a septum <NUM> can cover a medial terminal face at the distal end <NUM> of the lower jaw <NUM> (as shown) and/or upper jaw <NUM>. The septum <NUM> can be a flexible material that can be configured to seal around all or part of the shuttle <NUM> as the shuttle <NUM> passes through the septum <NUM>, For example, the septum <NUM> can be made from a fabric, or a solid panel of polymer such as polyurethane or polyester.

The septum <NUM> can have a septum rail port <NUM>. The septum rail port <NUM> can be aligned with the terminal end of the bottom track <NUM> and/or top track <NUM>.

The septum <NUM> can have a septum slot <NUM>. The septum slot <NUM> can be aligned with the side slot <NUM> of the bottom track <NUM>, and/or the upper track <NUM>.

The septum <NUM> can be configured to wipe or squeegee debris, such as tissue <NUM> and biological fluids, from the shuttle <NUM> as the shuttle <NUM> passes through the septum <NUM>, for example to prevent or minimize debris and fluids entering the top and/or bottom tracks <NUM>,.

<FIG> illustrates that the shuttle <NUM> can have a rail <NUM> that can have a cylinder and suture holder <NUM> can be as described in <FIG>. The holding notch <NUM> can have angular cleats <NUM>. The holding notch <NUM><NUM> can extend to side of the rail <NUM>,.

<FIG> illustrates that the shuttle <NUM> can be positioned so the holding notch <NUM> of the suture holder <NUM> can be in the loading dock <NUM> when the suture <NUM> is attached to or removed from the holding notch <NUM>, The suture <NUM> can be pressed into (e.g., for attaching) or pulled from (e.g., for removing, detaching or repositioning) the holding notch <NUM>. A longitudinally opposing pair of first cleats <NUM> can laterally friction fit or interference fit the suture <NUM> in the holding notch <NUM>. A longitudinally opposing pair of second cleats <NUM> can medially friction fit or interference fit the suture <NUM> in the holding notch <NUM> (i.e., the suture <NUM> can be radially fixed between the pair of first cleats <NUM> on a lateral side of the suture <NUM> and the pair of second cleats <NUM> on a medial side of the suture <NUM>).

The suture <NUM> can be radially fixed between a pair of longitudinally opposed cleats <NUM> that can dig into and compress or puncture the external surface of the suture <NUM>.

The shuttle <NUM> can interference fit or otherwise be stopped by the lower jaw <NUM> from moving proximal to a position where the holding notch <NUM> is exposed in the loading dock <NUM>.

<FIG>, <FIG> illustrate that the device <NUM> can be in an open configuration with the upper jaw <NUM> positioned rotated away from the lower jaw <NUM>. The upper jaw <NUM> can have an upper jaw longitudinal axis. The lower jaw <NUM> can have a lower jaw longitudinal axis <NUM>. The lower jaw longitudinal axis <NUM> (as shown) or the upper jaw longitudinal axis <NUM> can be parallel and/or collinear with the compression cover longitudinal axis. The upper law longitudinal axis <NUM> and the lower jaw longitudinal axis <NUM> can intersect at a jaw angle <NUM>. When the jaws are in an open configuration, the jaw angle <NUM> can be from about <NUM>° to about <NUM>°, more narrowly from about <NUM>° to about <NUM>°.

The compression cover <NUM> can be translated and retracted proximally, as shown by arrow <NUM>, away from the jaws. The upper jaw <NUM> can have a slot slide pin <NUM> that can extend laterally from one or both lateral sides of the proximal end of the upper jaw <NUM>,.

The distal end <NUM> of the compression cover <NUM> can have one or more ramp slots <NUM> on one or both lateral sides of the compression cover <NUM>. The ramp slot <NUM> can narrow as the ramp slot <NUM> extends proximally (i.e., widen as the ramp slot <NUM> extends distally). The ramp slot <NUM> can be at a non-zero angle (i.e., non-aligned) to the longitudinal axis of the compression cover <NUM>.

The slot slide pin <NUM> can be configured to extend through the ramp slot <NUM>. The slot slide pin <NUM> can slide within the ramp slot <NUM>. The slot slide pin <NUM><NUM> can friction fit into the narrower, proximal end of the ramp slot <NUM>, for example friction-fitting the jaws in a closed configuration and providing tactile feedback to the user of the jaw angle <NUM>.

<FIG> illustrates that the upper track can pass through a hinge tube <NUM> where is extends past the distal opening of the compression cover <NUM> and into the upper jaw. The hinge tube <NUM> can be made from nitinol, for example, The hinge tube <NUM> can flex when the upper jaw is rotated. The hinge tube <NUM> can be an integrated length of the entire upper track, or can be a separate length of tube attached on one or each end to the remainder of the upper track.

<FIG> and <FIG> illustrate that the compression cover <NUM> can be distally extended or advanced, as shown by arrow <NUM>, with respect to the jaws. The compression cover <NUM> can force the jaws to rotate toward each other to a closed configuration. For example, the upper jaw <NUM> can rotate, as shown by arrow <NUM>, while the lower jaw <NUM> remains in a rotationally fixed position with respect to the compression cover <NUM>, or vice versa, or the jaws can both rotate with respect to the compression cover <NUM>. Thus, a lever, such as the trigger <NUM>, can be actuated to advance the outer tube or compression cover <NUM> to cam closed the jaws.

When the jaws are in a closed configuration, the jaw angle <NUM> can be from about <NUM>° to about <NUM>°, more narrowly from about <NUM>° to about <NUM>°, for example about <NUM>°.

<FIG> and <FIG> illustrate that the upper jaw tip <NUM> can be pressed into and through the septum rail port <NUM>. The top or upper track <NUM> can form a continuous lumen <NUM> with the bottom or lower track <NUM>, for example, that the shuttle <NUM> can slide through.

A side slot <NUM> of upper jaw <NUM> can align with a side slot <NUM> of lower jaw <NUM>. The suture holder <NUM> can extend through the side slot <NUM> and hold the suture <NUM> in the side slot <NUM>. The suture holder <NUM> can translate suture <NUM> back and forth between the upper <NUM> and lower jaws <NUM> in the side slot <NUM> as the shuttle <NUM> is translated back and forth between the upper <NUM> and lower jaws <NUM>.

<FIG> illustrate that the shuttle <NUM><NUM> can a rail <NUM>, for example a shuttle spine <NUM>, and shuttle <NUM> lateral arms or fingers extending laterally and/or inwardly from the shuttle spine <NUM>. The shuttle fingers <NUM> can extend laterally, downwardly, and medially with respect to the shuttle spine <NUM>, as shown. The shuttles <NUM> can have slits <NUM> or shuttle lateral slots <NUM> between the shuttle fingers <NUM>. The shuttle lingers <NUM> can be flexible or rigid.

The shuttle <NUM> can have a shuttle longitudinal axis <NUM>. The shuttle longitudinal axis <NUM> can be flat or curved, for example have a shuttle radius of curvature <NUM> from about <NUM> to about <NUM>, more narrowly from about <NUM> to about <NUM>, for example about <NUM>.

The shuttle spine <NUM> can be flexible or rigid. The shuttle <NUM> can be made from a single panel of material (e.g., metal), for example by bending and laser cutting the panel.

The suture holders <NUM> can be one, two or more circular, oval, or otherwise elongated, longitudinal slots in the shuttle spine <NUM>. For example, the suture <NUM> can extend through one or both suture holders <NUM>. The suture <NUM> can be fused to the shuttle <NUM> adjacent to the suture holders <NUM>. A detachable or fixed frame can be attached to the slots in the shuttle <NUM> and the suture <NUM> can be attached to the detachable frame. For example, the detachable frame can be an arc-shaped wire attached at a first end to a first slot in the shuttle spine <NUM> and at a second end to the adjacent second slot in the shuttle spine <NUM>.

<FIG> illustrates that the suture holder <NUM> can be an are integral with the shuttle spine <NUM><NUM>. For example, the shuttle <NUM> can be made from a single panel of material (e.g., metal). The lateral sides of the suture holder <NUM> can be cut, and the longitudinal ends can remain integrated with the shuttle spine <NUM>. The suture holder <NUM> can then be bent or otherwise deformed away from the plane of the shuttle spine <NUM>, for example forming an arc away from the plane of the shuttle spine <NUM>.

The suture <NUM> can have a suture loop <NUM> at the terminal end of the suture <NUM>. The suture loop <NUM> can extend around and completely or partially circumscribe the suture holder <NUM>. The remainder of the suture <NUM> can be integral with the suture loop <NUM>, or can removably attached to the suture loop <NUM>. The suture loop <NUM> can be circular or oval.

<FIG> illustrates that the shuttle <NUM> can have one or more shuttle notches <NUM> or cut-outs. For example, the shuttle <NUM> can have two shuttle notches <NUM> on each lateral site of the shuttle. The shuttle notches <NUM> can be even longitudinally spaced and distributed along the shuttle <NUM>. The shuttle notches <NUM> can be curved. The sides of the shuttle <NUM>, other than at the notches, can be straight.

A radius of curvature of the shuttle notch <NUM> can be from about <NUM> to about <NUM>.

<FIG> illustrate that one or both of the longitudinally terminal ends of the shuttle <NUM> can be curved or sharpened shuttle tips <NUM>. For example, the shuttle tip <NUM> can have an angled chisel tip or needle tip.

The shuttle holder can have a holder leader <NUM> extending away from the shuttle spine <NUM>. The end of the holder leader <NUM> away from the shuttle spine <NUM><NUM> can be a closed wire loop <NUM> configured to attach to the suture <NUM>. A loop neck <NUM>, such as a dual clamp, can fix a first terminal end of the leader wire to an intermediate point on the holder leader <NUM>, as shown. A second terminal end of the holder leader <NUM> can extend through the shuttle longitudinal slot <NUM> and terminate at a leader anchor <NUM> such as a crimp or swaged ball or disc having a larger diameter than the width of the shuttle longitudinal slot <NUM>, for example to slidably attach the suture holder <NUM> to the shuttle longitudinal slot <NUM>. The suture holder <NUM> can be slidably captured in the shuttle longitudinal slot <NUM> by the leader anchor <NUM>.

The holder leader <NUM> can be translatably and/or rotationally fixed in the shuttle longitudinal slot <NUM> or can slide and/or rotate in the shuttle longitudinal slot <NUM>. For example, the wire loop <NUM> can extend past a first end of the shuttle spine <NUM> when the shuttle <NUM> is being translated in a first direction (e.g., toward the lower jaw <NUM> from the upper jaw <NUM>), and the holder leader <NUM> can passively rotate and translate when the shuttle <NUM> is then translated in a second direction (e.g., toward the upper jaw <NUM> from the lower jaw <NUM>).

The holder leader <NUM> can be rigid or flexible. For example, the holder leader <NUM> can be made from stainless steel, other material disclosed herein, or combinations thereof.

The suture <NUM> can be passed through and/or tied to the wire loop <NUM>. The wire loop <NUM> can be at a height away from the shuttle spine <NUM>. The wire loop. <NUM> can extend proximally or distally past the end of the shuttle tip <NUM>. For example, the suture <NUM> can be attached to the wire loop <NUM> away from sharp edge sharps to minimize the risk of cutting or damaging the suture <NUM>.

<FIG> illustrate that suture <NUM> can be directly attached or fused to the shuttle spine <NUM> at a suture attachment <NUM> in the longitudinal and lateral middle of the shuttle <NUM>. The suture <NUM> can be braided.

For example, the entire shuttle <NUM> can be made from plastic and can be molded, overmolded, or otherwise joined to a plastic suture. The suture can be thermally formed to the shuttle <NUM>. The suture <NUM> can extend through the shuttle <NUM>, for example at a suture anchor <NUM>. The suture anchor <NUM> can be the terminal end of the suture <NUM> extending through and attached to the shuttle <NUM>.

<FIG> illustrate that the leader or wire loop <NUM> can extend partially or entirely in a plane perpendicular to the plane of the shuttle spine <NUM>. A first terminal end of the wire loop <NUM> can have a leader first anchor <NUM>. A second terminal end of the wire loop <NUM> can have a leader second anchor <NUM>. The shuttle spine <NUM> can have a shuttle longitudinal first slot <NUM> and a shuttle longitudinal second slot <NUM>. The shuttle longitudinal slots <NUM> can be elongated or circular. The wire loop <NUM> can be made from Nitinol and/or steel, for example, and can be tied to the suture.

The wire loop <NUM> can extend through the shuttle longitudinal slots <NUM>. The leader first and second anchors can be on the underside (e.g., the concave side or radially interior side) of the shuttle spine <NUM>. The wire loop <NUM> can be on the otitersicle (e.g., the convex side or radially exterior side) of the shuttle spine <NUM>. Neither, one, or both of the leader anchors <NUM> can be fixed or integrated (e.g., melted or welded) to the shuttle spine <NUM>. Neither, one or both of the leader anchors <NUM> can be slidably attached to the longitudinal slots. The wire loop <NUM> can be fixed or slide longitudinally with respect to the shuttle spine <NUM>.

The wire loop <NUM> can have a longitudinally symmetric or assymetric (as shown) shape. For example, the wire loop <NUM> can be an arc (similar to the shape shown by the suture holder <NUM> in <FIG>) or can assy metrically overhang (as shown) toward one of the ends of the longitudinal shuttle.

<FIG> illustrates that the device <NUM> can have the shuttle <NUM> in a position spanning across the upper jaw <NUM> and the lower jaw <NUM>. The jaws can have jaw lateral ridges <NUM>. The shuttle fingers <NUM> can wrap around the jaw lateral ridges <NUM>, for example, slidably attaching the shuttle to the jaws. The jaw lateral ridges <NUM> at the terminal ends of the upper <NUM> or top jaw <NUM> and the bottom or lower jaw <NUM> can align when the jaws are in a closed configuration, for example so the shuttle <NUM> can slide along a continuous ridge between the upper <NUM> and lower jaws <NUM>.

<FIG> illustrates that the device <NUM> can have a lower pusher <NUM> slidably attached to the jaw lateral ridge <NUM> on the lower jaw <NUM>. The lower pusher <NUM> can abut the shuttle <NUM>.

<FIG> illustrates that the device <NUM> can have an upper pusher <NUM> slidably attached to the jaw lateral ridge <NUM> on the upper jaw <NUM>. The upper <NUM> and/or lower pushers <NUM> can be shaped like the shuttle <NUM>. The slitittle <NUM> can be pushed onto a straight length of the lower jaw <NUM>. The shuttle <NUM> can deform to a straight configuration when on a straight length of the jaws and to a curved configuration when on a curved length of the jaws.

The pushers can be generally shaped similarly to the shuttles <NUM>, having fingers, longitudinal slots, spines, and lateral slots between the fingers. More than one pusher can be used concurrently on a single device <NUM> (e.g., if the pushers in <FIG> were shuttles <NUM> and if additional pushers were used), for example to deliver multiple sutures <NUM> to the same target site.

<FIG> illustrates that the shuttle <NUM> can be pushed, as shown, to the upper jaw <NUM> by the lower pusher <NUM>. The lower pusher <NUM> can then retreat onto the lower jaw <NUM>.

<FIG> illustrate that the upper and/or lower jaws <NUM> can each have jaw spines <NUM>. The jaw spines <NUM> can extend medially from the remainder of the jaws toward (as shown) or away from the jaw control extension longitudinal axis. For example, the jaws spines can extend from the remainder of the jaws distally until the terminal distal ends <NUM> of the jaws, distal to where the jaw s extend into a medially-curved jaw medial extension closer to and in the respective jaw tip from a jaw longitudinal extension <NUM>, <NUM>.

The jaws can have jaw lateral ridges <NUM> or rails <NUM>, as described elsewhere herein. The jawa can have a T-shaped cross-section.

The shuttle <NUM> can have shuttle fingers <NUM> that can each have a shuttle downward extension <NUM>. The shuttle finger <NUM> can each have a shuttle lateral extensions <NUM> extending laterally from the respective shuttle spine <NUM>. The shuttle fingers <NUM> can have shuttle downward extensions <NUM> that can each extend downward (e.g., toward the longitudinal axis of the iaw structure) from the laterally terminal ends of the lateral extensions. The shuttle fingers <NUM> can have shuttle inward extensions <NUM> that can extend inward from the shuttle downward extensions <NUM>. The shuttle spines <NUM> and/or lateral extensions, downward extensions, and inward extensions can slidably wrap around the jaw lateral ridges <NUM>,.

The upper jaw tip <NUM> and/or lower jaw tip <NUM> can have blunt, beveled (e.g., needle-tip), chisel (e.g., beveled on opposite sides, as shown in <FIG>), conical, Sprotte, diamond, Tuohy tips, or combinations thereof (e.g., the upper jaw tip <NUM> can have a first tip shape and the lower jaw tip <NUM> can have a second tip shape). The bevel on the distal side of the jaw tips can have the same angle and length, or a smaller angle and longer length than the bevel on the proximal side of the jaw tips.

The upper jaw tip <NUM> can have a tip gap <NUM> or touch the lower jaw tip <NUM> when the jaws are in a closed configuration,.

<FIG> illustrate that the jaw spines <NUM> in one or both jaws can terminate before the respective jaw tips or jaw medial extensions,.

The bevel on the proximal side of the jaw tips can have a smaller angle and longer length than the bevel on the distal side of the jaw tips.

<FIG> illustrate that the jaw spine <NUM> on the upper jaw <NUM> can extend along the straight length of the upper jaw <NUM> and can terminate at or proximal to the upper jaw medial extension <NUM> or upper jaw tip <NUM>. The jaw lateral ridge <NUM> on the upper jaw <NUM> can extend to the terminal distal tip of the upper jaw <NUM>.

The jaw spine <NUM> on the lower jaw <NUM> can extend to the terminal distal tip of the lower jaw <NUM>.

The jaw lateral ridge <NUM> on the lower jaw <NUM> can extend along the straight length of the lower jaw <NUM> and can terminate at or proximal to the lower jaw medial extension <NUM> or lower jaw tip <NUM>.

When the jaws are in a closed configuration, the lower jaw tip <NUM> can be positioned proximally to and overlap the upper jaw tip <NUM>. The upper jaw tip <NUM> and lower jaw tip <NUM> can overlap along a tip interface <NUM>. For example, the distal end <NUM> of the jaw spine <NUM> on the lower jaw <NUM> can overlap and slide against the proximal side of the upper jaw tip <NUM>. The upper jaw tip <NUM> can contact the lower jaw tip <NUM> at the tip interface <NUM> or there can be a gap between the upper jaw tip <NUM> and the lower jaw tip <NUM> at the tip interface <NUM>.

The tip interface <NUM> can have a tip interlace axis <NUM> with respect to the jaw. structure longitudinal axis <NUM>. The tip interface axis <NUM> can intersect the jaw structure longitudinal axis <NUM> at a tip interface angle <NUM> of about <NUM>°.

The upper jaw tip <NUM> can be distal to the lower jaw tip <NUM> at the tip interface <NUM>.

The distal terminal end of the jaw lateral ridge <NUM> of the upper jaw <NUM> can contact or not contact the distal terminal end of the jaw lateral ridge <NUM> of the lower jaw <NUM> when the jaws are in a closed configuration.

<FIG> illustrate that the tip interface <NUM> can have a tip interface axis <NUM> with respect to the jaw structure longitudinal axis <NUM>. The lower jaw tip <NUM> can be distal to the upper jaw tip <NUM> at the tip interface <NUM>, The tip interface angle <NUM> can be from about <NUM>° to about <NUM>°, more narrowly <NUM>° to about <NUM>°, for example about <NUM>°.

<FIG> illustrate that the distal end <NUM> of the lower jaw tip <NUM> (as shown) or upper jaw tip <NUM> can have a tip seat <NUM>. The tip seat <NUM><NUM> can be shaped to receive the shape of the opposite jaw tip. For example, the tip seat <NUM> can be triangular (e.g., A-shaped or V-sliaped).

The tip seat <NUM> can surround the lateral sides and distal side of the upper jaw tip <NUM> when the jaws are in a closed configuration. The tip seat <NUM> can contact or not contact (i.e., there can be a gap) the upper jaw tip <NUM> when the jaws are in a closed configuration.

The jaw lateral ridge <NUM> of the jaw with the tip seat <NUM> (the bottom jaw <NUM>, as shown) can extend to the terminal end of the lower jaw tip <NUM> and the tip seat <NUM>. The jaw lateral ridge <NUM><NUM> of the jaw opposite of the tip seat <NUM> (the upper jaw <NUM>, as shown) can narrow, for to a point at the terminal end of the respective jaw tip. The narrowed jaw lateral ridge <NUM> can be received within the tip seat <NUM>.

<FIG> illustrate that the upper <NUM> and/or lower jaws <NUM> can have circular or oval cross-sections. The upper <NUM> and/or lower jaws <NUM> can be made from solid or hollow rods, for example having a diameter of from about <NUM> in. to about <NUM> in. , for example about <NUM> in.

The terminal end of the upper and/or lower jaw tip <NUM> can have a conical shape. The terminal end of the lower jaw tip <NUM> can have an tip seat <NUM> that can be inverse or negative to a conical shape, for example sized and shaped to receive the upper jaw tip <NUM>.

The shuttle <NUM> can have a circular or oval cross-section.

The pushers can have pusher fingers <NUM> extending from the pusher spine <NUM>, similar to the shuttle fingers <NUM> and shuttle spine <NUM>. The pusher fingers <NUM> can be triangular.

<FIG> illustrate that the distal end <NUM> of the device <NUM> can be inserted into a cannula <NUM>, for example to be deployed percutaneously through a cannula <NUM> inserted in a patient at a target site. The cannula <NUM> can have a cannula inner diameter <NUM>. The cannula inner diameter <NUM> can be from about <NUM> to about <NUM>, for example <NUM>, or <NUM> (<NUM> in. ), or <NUM> French gauge (<NUM> (<NUM> in.

The shuttle <NUM> can have a shuttle height <NUM>. The shuttle height <NUM> can be from about <NUM> in. to <NUM> in. , for example about <NUM> in.

The compression cover <NUM> can be attached to or integral with one or more jaw control extensions <NUM>. For example the jaw control extensions <NUM> can extend from the lateral distal ends <NUM> of the compression cover <NUM>. The jaw control extension <NUM> can slidably attach to or contact the jaws directly or indirectly. The jaw control extension <NUM> can push the jaws apart from each other when the jaw control extension <NUM> is translated proximally with respect to the jaws, and toward each other when the jaw control extension <NUM> is translated distally with respect to the jaws.

One or more upper cam pins <NUM> can extend laterally from the one or both lateral sides of the proximal end of the upper jaw <NUM>. One or more lower cam pins <NUM> can extend laterally from the one or both lateral sides of the proximal end of the lower jaw <NUM> at the same or different longitudinal position as the upper cam pins <NUM>.

The jaw control extensions <NUM> can have one or more upper cam slots <NUM> and one or more lower cam slots <NUM>. The upper <NUM> and/or lower cam slots <NUM> can be straight, curved, angled (as shown) or a combination thereof. The cam pins can be positioned inside and through the respective cam slots. The cam pins can slide within the cam slots.

When the jaw control extension <NUM> is translated distally with respect to the jaws, the cam pins can slide proximally within the respective cam slots and rotate the jaws away from each other. When the jaw control extension <NUM> is translated proximally with respect to the jaws, the cam pins can slide distally within the cam slots and rotate the jaws toward each other.

The jaws can have a jaw extension length <NUM>. The jaw extension length <NUM> can be the length from the distal end <NUM> of the jaw control extension <NUM> to the proximal side of the jaw tips. The jaw extension length <NUM> when the jaws are in a closed configuration can be from about <NUM> to about <NUM>, for example about <NUM> and <NUM>.

The jaws can have a jaw straight gap <NUM> along the straight length of the jaws. The jaw straight gap <NUM> can be from about <NUM> to about <NUM>, for example about <NUM> or about <NUM>. For example, the cannula inner diameter <NUM> can be <NUM> and the jaw straight gap <NUM> can be about <NUM>.

The jaws can be separate or can be integrated at a jaw body. Jaws integrated in a jaw body can rotatably deform away from each other when moved into an open configuration.

<FIG> illustrate that the upper jaw tip <NUM> and/or lower jaw tip <NUM> can have suture holder slots <NUM>. The suture holder slots <NUM> can extend medially along the outer surface of the respective jaw tip. The suture holder slot <NUM> can extend from the outer surface of the jaw tip to the respective track. The suture holder <NUM> can be accessible through or extend out of the suture holder slot <NUM>. The suture <NUM> (not shown) can attach to or be integral with the suture holder <NUM> in or outside of the suture holder slot <NUM>.

The upper track <NUM> distally terminates at an upper jaw tip shuttle port <NUM>. The lower track <NUM> distally terminates at a lower jaw tip shuttle port <NUM>. The shuttle <NUM> can extend out of or into, and pass through each of the shuttle <NUM> ports. During use, the sharpened shuttle tip <NUM><NUM> extending out of the shuttle port can pierce, cut and dissect tissue <NUM> when the jaws are rotated to a closed configuration.

The upper jaw <NUM> and/or lower jaw <NUM> can have a jaw stop <NUM>. The jaw stop <NUM> can be a feature, shape or configuration that can abut and stop the distal translation of the compression cover <NUM> with respect to the jaws. For example, the distal terminal end of the compression cover <NUM> can abut the jaw stops <NUM> when the jaws are in a closed configuration.

The radially inner surface of the jaws can have radially inner slopes <NUM>.

The upper jaw <NUM> and/or lower jaw <NUM> can have a jaw slide <NUM>. The jaw slide <NUM> can be a radially outer surface of the jaws between the jaw stops <NUM> and the compression cover <NUM> when the compression cover <NUM> is in a proximally retracted <NUM> position with respect to the jaws and/or the jaws are in an opened configuration. The jaw slide <NUM> can increase in radius from the jaw structure longitudinal axis <NUM> in the distal longitudinal direction (e.g., the larger the longitudinal dimension of the jaw slide <NUM>, the larger the radial dimension of the jaw slide <NUM>). When the compression cover is translated distally <NUM> with respect to the jaws, the radially inner distal edge of the compression cover <NUM> can slide along the jaw slide <NUM>, and press the jaw slide <NUM> toward the jaw structure longitudinal axis <NUM>. A radially compressive force delivered from the compression cover <NUM> to the jaw slide <NUM> can create a torque in the respective jaw, rotating the respective jaw toward the jaw structure longitudinal axis <NUM> and the opposing jaw.

The device <NUM> can have a jaw control extension <NUM>. The jaw control extension <NUM> can extend along the jaw structure longitudinal axis <NUM>. The jaw control extension <NUM> can extend between the jaws proxima! to the jaw tips. The jaw control extensions <NUM> can terminate in a jaw control extension head.

The jaw control extension head <NUM> can have one or two lobes or cams. Each lobe can extend from the longitudinal axis of the jaw control extension <NUM> toward a jaw. The lobes can act similarly to the opening roller ball shown in <FIG>, and elsewhere herein. The upper jaw <NUM> and lower jaw <NUM> can have upper and inner jaw radially inner slopes <NUM>, respectively. The inner slopes can be the radially inner surfaces of the jaws proximal to the jaw tips and distal to the jaw control extension head <NUM> when the jaw control extension head <NUM> is in a proximally retracted position with respect to the jaws. The radially inner slope <NUM> can increase in radius from the jaw structure longitudinal axis <NUM> in the distal longitudinal direction (e.g., the larger the longitudinal dimension of the radially inner slope <NUM>. the larger the radial dimension of the radially inner slope <NUM>). When the jaw control extension <NUM> is proximally translated or retracted with respect to the jaws, the lobes can slide against the radially inner slopes <NUM> of the jaws and press the jaws away from each other into an open configuration.

When the jaws are in an open configuration, the compression cover <NUM> can be positioned at or proximally past the proximal end of the jaw slides <NUM>, and the jaw extension head can be positioned at or proximally past the proximal end of the radially inner slopes <NUM>.

The jaw control extension <NUM> can be attached to or integral with a control rail <NUM>. The control rail <NUM> can extend radially from one or both lateral sides of the jaw control extension <NUM>, for example in a plane at a right angle to a plane defined by the opposing jaws or the opposing extension head lobes <NUM>.

The compression cover <NUM> can have a control rail slot <NUM>. The control rail slot <NUM> can extend to the distal terminal end of the compression cover <NUM>. The control rail <NUM> can be fixed to or longitudinally translate within the control rail slot <NUM>. The control rail <NUM> can interference fit, abut or stop against the proximal end of the control rail slot <NUM>, for example when the control rail <NUM> is in a proximal or distal longitudinal position with respect to the jaws. The control rail <NUM> can move longitudinally in unison (i.e., coincidentally) with the compression cover <NUM> in the distal and/or longitudinal directions. The control rail <NUM> can move longitudinally in unison with the jaw control extension <NUM> in the distal and/or longitudinal directions.

The device <NUM> can have an upper socket arm <NUM> and a lower socket arm <NUM> radially inside of the compression cover <NUM>. The upper socket arm <NUM> and lower socket arm <NUM> can be a single integrated element (e.g., a hollow cylinder) or separate elements. The upper socket arm <NUM> can be opposite the lower socket arm <NUM>. The upper socket arm <NUM> can be translatably fixed (i.e., mechanically attached to translate in unison) to the lower socket arm <NUM>. The jaw control extension <NUM> can extend longitudinally between the upper <NUM> and lower socket arms <NUM> or within a hollow channel inside a unitary socket arm (comprising the upper <NUM> and lower socket arms <NUM> as an integrated element). The distal terminal ends of the socket arms can extend to or proximal to the distal terminal end of the compression cover <NUM> when the jaws are in an open configuration.

The proximal terminal end of the upper jaw <NUM> can have a laterally elongated upper jaw bearing <NUM>. The upper jaw bearing <NUM> can extend radially outward from the remainder for the proximal end of the upper jaw <NUM>.

The distal end <NUM> of the upper socket arm <NUM> can have a laterally elongated upper jaw socket <NUM>. The upper jaw socket <NUM> can open medially and have a diameter approximately equal to or slightly larger than the diameter of the upper jaw bearing <NUM>.

An upper jaw <NUM> hinge can have the upper jaw bearing <NUM> and the upper jaw socket <NUM>. The upper jaw <NUM> can rotate around the transverse axis of the upper jaw bearing <NUM>. The upper jaw bearing <NUM> can rotate in the upper jaw socket <NUM>.

The proximal terminal end of the lower jaw <NUM> can have a laterally elongated lower jaw bearing <NUM>. The lower jaw bearing <NUM> can extend radially outward from the remainder for the proximal end of the lower jaw <NUM>.

The distal end <NUM> of the lower socket arm <NUM> can have a laterally elongated lower jaw socket <NUM>. The lower jaw socket <NUM> can open medially and have a diameter approximately equal to or sliglitly larger than the diameter of the lower jaw bearing <NUM>.

A lower jaw <NUM> hinge can have the lower jaw bearing <NUM> and the lower jaw socket <NUM>. The lower jaw <NUM> can rotate around the transverse axis of the lower jaw bearing <NUM>. The lower jaw bearing <NUM> can rotate in the lower jaw socket <NUM>.

The upper <NUM> and/or lower pushers <NUM> can have entire lengths or only distal ends <NUM> that can have articulated segmentations <NUM>. The articulated segments <NUM> can rotate with respect to each other around an axis perpendicular to the longitudinal axis of the respective pusher. The articulated segmentations <NUM> can be connected by a discrete hinge (e.g., a pin or snap connection) or can be longitudinally coincidental or longitudinally alternating lateral slots cut into the sides of the pusher, similar to the shape of the shuttle lateral slots <NUM>. The proximal end of either or both upper <NUM> and lower pushers <NUM> can have a continuous, non-segmented, flat, uniform ribbon of material.

Each of the upper <NUM> and/or lower pushers <NUM> can have distal terminal ends that can have a shuttle seat <NUM>. The shuttle seat <NUM> can be an inverse shape to the shape of the shuttle tip <NUM>, For example, if the shuttle tip <NUM><NUM> has an angled end, the shuttle seat <NUM> can have the opposite angle. If the shuttle tip <NUM> has a convex curved end, the shuttle seat <NUM> can have a concave curved end with the same radius of curvature as the shuttle tip <NUM>.

<FIG> illustrate that the compression cover <NUM> can be distally translated, as shown by arrow, with respect to the jaws. The compression cover <NUM> can deliver translational force through the edges of the control rail slot <NUM> to the control rail <NUM>. The control rail <NUM> can deliver the translational force to the jaw control extension <NUM>. The jaw control extension <NUM> can translate distally, as shown by arrow, concurrently with the compression cover <NUM>. The compression cover <NUM> can translate <NUM> over the jaw slides <NUM>, pressing radially inward on the jaw slides <NUM>. The jaw control extension head <NUM> can move distally with respect to the jaws, as shown by arrow <NUM>, for example, allowing the closure of the jaws without interference fitting or abutting against the jaw control extension head <NUM>. The upper jaw <NUM> and/or lower jaw <NUM> can rotate radially inward, as shown by arrows.

When the jaws are in a closed configuration, the compression cover <NUM> can be positioned at or adjacent to the jaw stop <NUM>, and the jaw extension head can be positioned at or proximally past the proximal end of the radially inner slopes <NUM>.

When the jaws are in a closed configuration, if the shuttle <NUM> is in the upper track <NUM>, the upper pusher <NUM> can translate distally through the upper track <NUM>. The distal terminal end of the upper pusher <NUM> can abut the shuttle <NUM>. The upper pusher <NUM> can then push the shuttle <NUM> through the upper track <NUM>, out the upper jaw tip shuttle port <NUM> and into the lower jaw tip shuttle port <NUM>.

When the jaws are in a closed configuration, if the shuttle <NUM> is in the lower track <NUM>, the lower pusher <NUM> can translate distally through the lower track <NUM>. The distal terminal end of the lower pusher <NUM> can abut the shuttle <NUM>. The lower pusher <NUM> can then push the shuttle <NUM> through the lower track <NUM>, out the lower jaw tip shuttle port <NUM> and into the upper jaw tip shuttle port <NUM>.

When the shuttle <NUM> is pushed from the upper track <NUM> to the lower track <NUM> or vice versa, the shuttle <NUM> can be curvilinearly translated <NUM>, as shown by arrow, following the paths of the upper track <NUM> and the lower track <NUM>,.

When the jaws are in a closed configuration, the shuttle <NUM> can move from the upper jaw <NUM> to the lower jaw <NUM>, as shown by arrow, back to the upper jaw <NUM>, and can repeat the motion from the upper jaw <NUM> to the lower jaw <NUM>, and optionally from the lower jaw <NUM> to the upper jaw <NUM> one, two or more times.

The device <NUM> can have a pusher lockout that can prevent translation of the pushers and the shuttle <NUM> when the jaws are in an open configuration,.

The device <NUM> can have a jaw lockout preventing opening of the jaws when either of the pushers is extended out of the respective jaw tip shuttle port and/or when the shuttle <NUM> is concurrently in the upper jaw <NUM> and the lower jaw <NUM>.

<FIG> illustrates that the upper pusher <NUM> can be distally translated with respect to the jaws. The upper pusher <NUM> can curvilenearly translate, as shown by arrows <NUM> and <NUM>, along the upper track <NUM>. The distal terminal end of the upper pusher <NUM> can exit out of and extend from the upper jaw tip shuttle port <NUM>. The V-shaped (or A-shaped), or curved (e.g., U-shaped) shuttle seat <NUM> at the distal terminal end of the upper pusher <NUM> can abut the V-shaped (or A-shaped), or curved (e.g., U-shaped) shuttle tip <NUM> at the terminal end of the shuttle. The upper pusher <NUM> can push the shuttle <NUM> through the upper track <NUM>, across the gap between the upper jaw tip shuttle port <NUM> and the lower jaw tip shuttle port <NUM>, and into the lower track <NUM>, The shuttle <NUM> can have a curvilinear translation <NUM>, as shown by arrow, along the tracks.

The lower pusher <NUM> can have no or one lower pusher articulating segment (as shown), or can have a. number of articulating segments, similar to the upper pusher <NUM> in <FIG>.

<FIG> illustrates that the suture <NUM> can be tied or adhered directly to suture holder <NUM>, for example as shown in <FIG>. The suture <NUM> can have a suture loop <NUM>, The suture loop <NUM> can circumscribe the suture holder <NUM>.

<FIG> illustrates that when the jaws are in a closed configuration, the terminal end of the upper jaw tip <NUM> can be in contact with or have a tip gap <NUM> to the terminal end of the lower tip jaw. The tip gap <NUM> can be from about <NUM> in. to about <NUM> in. (about <NUM> to about <NUM>), for example about <NUM> in. (about <NUM>).

The slitittle <NUM> can have a shuttle width <NUM>. The shuttle width <NUM> can be from about <NUM> in. to about <NUM> in. (from about <NUM> to about <NUM>), for example about <NUM> in. (about <NUM>).

The shuttle <NUM> can be made from nickel titanium alloys (e.g., Nitinol), stainless steel, other materials disclosed herein, or combinations thereof.

<FIG> and <FIG> illustrate that the lever <NUM> or handle <NUM> can control the rotation, and opening and closing of the jaws.

The handle <NUM> can have a handle pivot <NUM>. The handle pivot <NUM> can be a rotatable pin joint where the handle <NUM> can rotatably attach to the base <NUM>. The handle <NUM> can rotate around the handle pivot <NUM> with respect to the base <NUM>.

The handle <NUM> can be attached to the socket arms and/or the compression cover <NUM> (as shown). For example, the compression cover <NUM> can have radially and/or laterally extending cover pins <NUM>. The cover pins <NUM> can attach to the jaw control extension <NUM>. The handle <NUM> can have one or two transmission ports <NUM> or loops <NUM> on opposing lateral sides of the compression cover <NUM>. The cover pins <NUM> can extend through the transmission loops <NUM>.

The other of the socket arms (as shown) and compression cover <NUM> not attached to the handle <NUM> can be attached to the base <NUM>.

Squeezing and rotating the handle <NUM> toward the base <NUM> can distally extend <NUM> the compression cover <NUM> and jaw control extension <NUM> with respect to the jaws, or proximally retract <NUM> the jaws with respect to the compression cover <NUM> and jaw control extension <NUM>. When the handle <NUM> is rotated, the jaws can move to an open configuration. For example, when the bottom of the handle <NUM><NUM> is rotated proximally toward the base <NUM>, the transmission loop <NUM> can rotate distally toward the jaws, pushing the cover pin <NUM> and the compression cover <NUM> distally. The transmission loop <NUM> can force the compression cover <NUM> and/or jaw control extension <NUM> to translate distally, for example, closing the jaws.

The proximal end of the upper socket arm <NUM> and the proximal end of the lower socket arm <NUM> can be an integral element or can be fixedly attached by a socket arm brace <NUM>.

The terminal proximal end of the upper pusher <NUM> can attach to or be integrated with an upper pusher <NUM> shaft and/or upper pusher button 210a. The terminal proximal end of the lower pusher <NUM> can attach to or be integrated with a lower pusher shaft and/or lower pusher button 210b. The proximal distal ends <NUM> of the upper pusher button 210a and lower pusher button 210b can be above and below each other or side-by-side (e.g., left and right, as shown). The device <NUM> can be configured so that pressing (e.g., distally translating) the upper pusher button 210a can distally advance the upper pusher <NUM>, and pressing (e.g., distally translating) the lower pusher button 210b can distally advance the upper pusher <NUM>. Pressing the upper pusher button <NUM> can proximally retract the lower pusher <NUM> and/or lower pusher button 210b. Pressing the lower pusher button 210b can proximally retract the upper pusher <NUM> and/or upper pusher button <NUM>,.

The medial sides of the distal ends <NUM> of the upper and lower pusher buttons 210b can have upper pusher button gears <NUM> and lower pusher button gears <NUM>, respectively. The upper pusher button gears <NUM> can face the lower pusher button gears <NUM>.

The pusher toggle knob <NUM> can be rotatably attached to the base <NUM>. The pusher toggle knob <NUM> can be integrated or rotationally fixed to a pusher toggle knob gear <NUM>. The pusher toggle knob gear <NUM> can rotatably interface and interdigitate with the upper pusher button gear <NUM> on a first side and with the lower pusher button gear <NUM> on the opposite side of the upper pusher button gear <NUM>.

When the upper pusher button translates distally <NUM>, the upper pusher button gear <NUM> can rotate the pusher toggle gear, for example also rotating the top of the pusher toggle knob <NUM> to a position indicating that the upper pusher button 210a has been translated distally <NUM>. The top surface or circumference of the top of the pusher toggle knob <NUM> can have an indicator, such as an arrow, that can indicate whether the upper pusher <NUM> or the lower pusher <NUM> has been translated and by how far, for example indicating the position of the shuttle <NUM> in the upper track <NUM>, lower track <NUM>, extending out of one track, or extending across both tracks simultaneously. The pusher toggle gear can simultaneously proximally translate the lower pusher button gear <NUM>. For example, when the upper pusher <NUM> is distally translated, the lower pusher <NUM> can be simultaneously proximally translated at the same speed.

When the tower pusher button 210b translates distally, the lower pusher button gear <NUM> can rotate the pusher toggle gear, for example also rotating the top of the pusher toggle knob <NUM> to a position indicating that the upper pusher button 210a has been translated distally <NUM>. The pusher toggle gear can simultaneously proximally translate the upper pusher button gear <NUM>. For example, when the lower pusher <NUM> is distally translated, the upper pusher <NUM> can be simultaneously proximally translated at the same speed.

The pusher toggle knob <NUM> can be rotated to translate the upper pusher <NUM> and the lower pusher <NUM> by transmitting the torque applied to pusher toggle knob <NUM> through the pusher toggle knob gear <NUM> and to the upper pusher button gear <NUM> and/or lower pusher button gear <NUM> with or without pressing on the proximal terminal ends of the pusher buttons.

<FIG> and <FIG> illustrates that the the pusher toggle knob <NUM> can be rotated to translate the upper pusher <NUM> and the lower pusher <NUM> by transmitting the torque applied to pusher toggle knob <NUM> through the pusher toggle knob gear <NUM> and to the upper pusher button gear <NUM> and/or lower pusher button gear <NUM> with or without pressing on the proximal terminal ends of the pusher buttons.

The diameter of the pusher toggle knob <NUM> can be smaller than the width of the base <NUM>, as shown in <FIG> and <FIG>, or larger than the width and height of the base <NUM>, and the same size or larger than the handle <NUM>, and the compression cover <NUM>, as shown in <FIG> and <FIG>.

In a variation of a method of use, the distal end <NUM> of the device <NUM> including the jaws can be inserted through a percutaneous cannula <NUM> when the jaws are in a closed configuration. When the distal end <NUM> of the device <NUM> exits the distal end <NUM> of the cannula <NUM> at the target site, the handle <NUM> can be released to rotate away from the base <NUM>. The handle rotation away from the base <NUM> can move the jaws to an open configuration. The distal end <NUM> of the device <NUM> can then be further positioned so the target site is between the upper jaw distal tip <NUM> and the lower jaw distal tip <NUM>. The handle <NUM> can then be squeezed to rotate the handle <NUM> toward the base <NUM>. The handle rotation toward the base <NUM> can move the jaws into a closed configuration, pinching together tissue <NUM> at the target site. The shuttle <NUM> can be completely recessed in the jaw into which the shuttle <NUM> is loaded, or the shuttle tip <NUM> can extend out of whichever jaw the shuttle is currently loaded into. The shuttle tip <NUM> can pierce the tissue <NUM> as the jaws are closed or after the jaws are closed when the shuttle <NUM> is translated.

After the jaws are closed, the upper 210a or lower pusher button 210b (e.g., respective to whichever track the shuttle <NUM> is currently in) can be pressed, distally advancing the respective pusher. The respective pusher can press the shuttle <NUM> distally, through the gap between the upper <NUM> and lower jaws <NUM>, if such a gap exists, or directly from one jaw to the other jaw. The shuttle <NUM> can pull the suture <NUM> to follow the path of the shuttle <NUM> or follow a path adjacent to the shuttle <NUM>. When the respective pusher button is fully depressed, the device <NUM> can emit a sound and/or tactile response (e.g., from a snap or detent in the button or pusher and track) and the pusher toggle knob <NUM> can have an indicator (e.g., a line or arrow) indicating that the shuttle <NUM> has been fully translated across the jaws.

The handle <NUM> can then be rotated away from the base <NUM>. For example, the handle <NUM> can be released and spring loaded to return to a position rotated away from the base <NUM>. The rotating handle can proximally translate the transmission loop <NUM>. The transmission loop <NUM> can proximally pull and translate the compression cover <NUM> and jaw control extension <NUM>, opening the jaws.

The device <NUM> can then be repositioned so the jaw tips are removed entirely, for example if stitching is complete, or moved adjacent to their previous position in order to place a new stitch. The handle <NUM><NUM> can then be squeezed, closing the jaws. The pusher button of the track, in which the shuttle <NUM> is positioned can then be pressed. The shuttle <NUM> can then move to the opposite jaw, as described above, pulling the suture <NUM> through the tissue <NUM> and forming a stitch.

The above method can be repeated as needed to create a length and position of desired stitches.

Any or all elements of the device <NUM> and/or other devices <NUM> or apparatuses described herein can be made from, for example, a single or multiple stainless steel alloys, nickel titanium alloys (e.g., Nitinol), cobalt-chrome alloys (e.g., ELGILOY® from Elgin Specialty Metals, Elgin, IL; CONICHROME® from Carpenter Metals Corp. , Wyomissing, PA), nickel-cobalt alloys (e.g., MP35N® from Magellan Industrial Trading Company, Inc. , Westport, CT), molybdenum alloys (e.g., molybdenum TZM alloy, for example), tungstenrhenium alloys, polymers such as polyethylene teraphathalate (PET)/polyester (e.g., DACRON® from E. Du Pont de Nemours and Company, Wilmington, DE), polypropylene, (PET), polytetrafluoroethylene (PTFE), expanded PTFE (ePTFE), polyether ketone (PEK), polyether ether ketone (PEEK), poly ether ketone ketone (PEKK) (also poly aryl ether ketone ketone), nylon, polyether-block co-polyamide polymers (e.g., PEBAX® from ATOFINA, Paris, France), aliphatic polyether polyurethanes (e.g., TECOFLEX® from Thermedics Polymer Products, Wilmington, MA), polyvinyl chloride (PVC), polyurethane, thermoplastic, fluorinated ethylene propylene (FEP), absorbable or resorbable polymers such as polyglycolic acid (PGA), polylactic acid (PLA), polycaprolactone (PCL), polyethyl acrylate (PEA), polydioxanone (PDS), and pseudo-polyamino tyrosine-based acids, extruded collagen, silicone, zinc, echogenic, radioactive, radiopaque materials, a biomaterial (e.g., cadaver tissue <NUM>, collagen, allograft, autograft, xenograft, bone cement, morselized bone, osteogenic powder, beads of bone) any of the other materials listed herein or combinations thereof. Examples of radiopaque materials are barium sulfate, zinc oxide, titanium, stainless steel, nickel-titanium alloys, tantalum and gold.

The shuttle <NUM> throughout the disclosure herein can be attached to a suture <NUM>, Accordingly, the suture <NUM> can be attached to the shuttle <NUM> and can follow the movement of the shuttle <NUM>. Similarly, the suture <NUM> can be attached to and detached from the shuttle <NUM>, for example, attached before and detached after the desired stitching or suturing is complete.

Claim 1:
A suture manipulating device comprising:
a jaw structure (<NUM>) having a longitudinal axis, wherein the jaw structure comprises a first jaw (<NUM>) having a first jaw track (<NUM>, <NUM>) and a second jaw (<NUM>) having a second jaw track (<NUM>, <NUM>);
a shuttle (<NUM>) for holding and moving a suture (<NUM>), said shuttle being movable in said first and second tracks (<NUM>, <NUM>; <NUM>, <NUM>);
wherein said first jaw track (<NUM>, <NUM>) distally terminates at a first track port (<NUM>) and said second jaw track (<NUM>, <NUM>) distally terminates at a second track port (<NUM>), said first and second track ports (<NUM>, <NUM>) aligning with each other and being adjacent to or in contact with each other when the jaw structure (<NUM>) is in its closed configuration;
a first pusher (<NUM>) configured for sliding in said first jaw track and for pushing the shuttle from the first jaw track out the first track port and into the second track port;
a second pusher (<NUM>) configured for sliding in said second jaw track and for pushing the shuttle from the second jaw track out the second track port and into the first track port;
characterised by
an opening element between the first jaw and the second jaw, wherein the opening element is configured to produce an outward force against the first jaw to bring the jaw structure into an open configuration when the opening element is translated proximally along the longitudinal axis of the jaw structure; and
a closing element configured to compress the first jaw toward the second jaw to bring the jaw structure into a closed configuration when the closing element is translated distally with respect to the jaw structure.