JP2010136733A - Suture device for endoscope, and stomach wall incision suturing method performed by using suture device for endoscope - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To solve the problem that, while the one of a patent document 1 is proposed as a technology (NOTES) for suturing the incision of a stomach wall, various kinds of adverse effects occur since the side faces of an incision edge part are sutured in the state of being bonded with each other and it is not in a usable stage yet. <P>SOLUTION: A front side arm 3, an intermediate arm 4 and a rear side arm 5 are disposed at a position near the front of the distal end part of an endoscope 1, a connector housing part 31 is provided on the rear surface of the front side arm, a penetration needle 41 is provided on the front surface of the intermediate arm, and a push rod 51 is provided on the front surface of the rear side arm. In the state of housing a first connector in the connector housing part of the front side arm and housing a second connector in the penetration needle of the intermediate arm, the front side arm is positioned outside the stomach wall from the inside of the stomach wall through the incision 82, the penetration needle of the intermediate arm is penetrated through the stomach wall from the inside of a stomach, and the push rod of the rear side arm is moved forward. Thus, the second connector housed inside the penetration needle can be connected to the first connector housed in the connector housing part. <P>COPYRIGHT: (C)2010,JPO&amp;INPIT

Description

  The present invention relates to an endoscopic suturing device for suturing an incision portion of a stomach wall from the inside of a stomach using an endoscope together, and a gastric wall incision portion suturing method performed using the endoscopic suturing device. It is.

  In recent years, the stomach wall is incised from the stomach using an endoscope together, and the distal end of the endoscope is inserted through the gastric wall incision to diagnose and treat various abdominal organs (eg, liver, pancreas, spleen, gallbladder, etc.) The development of such technology is underway. In addition, such a technique is abbreviated as NOTES (transluminal endoscopic surgery or abdominal endoscopic surgery), and has recently attracted much attention as a treatment means for abdominal organs.

  By the way, when performing the above NOTES, an incision for insertion of an endoscope is formed in the stomach wall through the endoscope from the oral cavity, and the stomach wall incision needs to be sutured later. In order to suture this stomach wall incision, at present, a small hole is made in the body surface, and an endoscope (with a suturing device) is inserted through the hole from the outside of the body and is surgically performed. The hole formed in the body surface is also closed by means such as suturing after the gastric wall incision is sutured.

  However, when a hole is made in the body surface for suturing the gastric wall incision in this way, there is a problem that pain is felt, healing of the hole takes time, and a wound remains on the body surface.

  On the other hand, in recent years, a technique has been proposed in which the gastric wall incision is sutured from the stomach. As this known technique, for example, there is a “treatment apparatus for living tissue” disclosed in Japanese Patent Application Laid-Open No. 2004-601 (Patent Document 1).

  21 (A) to (D) and FIGS. 22 (A) to (D) show a suture device portion in the “treatment device for living tissue” of the above Japanese Patent Application Laid-Open No. 2004-601. This corresponds to FIGS. 21 (A) to (D) and FIGS. 22 (A) to (D) show the respective steps for suturing the incision 147 of the living tissue (hereinafter described with respect to the stomach wall) from the inside of the stomach. ing. In this example, as shown below, following the steps (A) → (B) → (C) → (D) in FIG. 21, (A) → (B) → (C) in FIG. Through each step, as shown in FIG. 22 (D), the mouth edges (biological tissues) 147a and 147b of the gastric wall incision 147 are stitched together.

  In the known suturing apparatus shown in FIGS. 21 (A) to 21 (D) and FIGS. 22 (A) to 22 (C), reference numeral 102 denotes an overtube into which an endoscope (not shown) is inserted, A side opening 108 is opened on the side surface near the tip of the overtube 102. In the overtube 102, hollow needles 128 (two in parallel) for puncturing a living tissue are installed so as to freely advance and retract. Inside the needle 128, a T bar 136 with a thread 121 serving as a stopper is accommodated, and the T bar 136 can be pushed forward from the tip of the needle by the pushing member 134. Further, in the overtube 102, as shown in FIG. 21D and FIGS. 22A to 22C, a pusher tube 119 for ligating the yarn 121 and a thread 121 on the outer periphery of the pusher tube 119 are provided. A cutter 127 for cutting is installed so as to freely advance and retract. The needle 128, the pushing member 134, the pusher tube 119, and the cutter 127 can be individually advanced and retracted from the proximal side of the endoscope. The tip of the ligating thread 121 is a knot 121 a that can be squeezed (slidable) with respect to the original thread 121 after being inserted into the hole of the T-bar 136. Further, the proximal end side of the thread 121 extends through the pusher tube 119 to the proximal side of the endoscope. In FIGS. 21 and 22, (A) to (D), reference numeral 146 denotes a stomach wall, and the upper surface side of the stomach wall 146 is the stomach inner surface (the lower surface side is the stomach outer surface).

  And this well-known suturing apparatus can sew each mouth edge part (living tissue) 147a, 147b which the gastric wall incision part 147 opposes in the following procedures.

  First, as shown in FIG. 21 (A), the overtube 102 is inserted into the stomach together with an endoscope (not shown), and the side opening 108 of the overtube 102 faces the incision 147 of the stomach wall 146. By sucking the inside of the overtube 102 from the proximal side, the mouth edge portions (biological tissues) 147 a and 147 b facing the incision portion 147 are caused to enter the side mouth 108. At this time, each of the mouth edge portions 147a and 147b of the incision part comes to face the outer surface side of the stomach wall 146 in the side mouth 108.

  Next, as shown in FIG. 21 (B), the needle 128 is advanced with respect to the overtube 102, and the needle 128 is penetrated through the mouth edge portions 147a and 147b of the incision portion.

  Next, as shown in FIG. 21C, the push-out member 134 is advanced while the needle 128 is pierced through each mouth edge, and the T bar 136 with the thread in the needle 128 is pushed out from the tip of the needle.

  Subsequently, when the needle 128 and the pushing member 134 inside thereof are retracted, as shown in FIG. 21 (D), the T-bar 136 remains as a stopper on the front surface of the front side edge portion 147b, and each of the edge portions 147a. , 147b, the thread 121 is inserted. At this time, a knot 121a that can be squeezed (slidable) is located in the thread 121 portion on the rear side (hand side) from the rear edge portion 147a.

  Next, by pushing forward the pusher tube 119 while pulling the thread 121 on the hand side, the knot 121a of the thread 121 is pushed forward, and both the mouth edges 147a and 147b of the incision portion are moved as shown in FIG. The ligation is made at the front part from the knot 121a (the ligation part P is formed). Thereafter, when the pusher tube 119 is retracted, the state shown in FIG.

  Next, as shown in FIG. 22C, after the ligation portion P of the incised portion edge portions 147a and 147b is discharged from the side port 108 of the overtube 102, the cutter 127 is advanced to thread the thread 121 into the knot 121a. Cut in the vicinity of

  As a result, as shown in FIG. 22D, both mouth edge portions 147a and 147b of the stomach wall incision portion can be sewn in a state where the outer surfaces of the stomach wall are joined to each other. In addition, when the incision part of a stomach wall is large, the said suturing process is performed several times, shifting a suturing position.

JP 2004-601 A (particularly FIGS. 6 to 9)

  By the way, in the suturing method using the suturing device of the above-described known example (FIGS. 21 to 22), the stomach wall incision portion 147 (both mouth edge portions 147a and 147b) can be sutured from the inside of the stomach. Although it can be performed without making a hole in the body surface as compared with a simple suturing treatment, the following various problems are conceivable.

  (1) As shown in FIG. 22 (D), the mouth edge portions 147a and 147b of the ligated stomach wall incision portion are sutured with the outer surfaces of the stomach wall 147 joined to each other. In a state where the outer surfaces are joined together, it is considered that adhesion between living tissues does not proceed easily, and the wound is not completely closed.

  (2) It is conceivable that the living tissue ahead of the sutured portion in each of the mouth edge portions 147a and 147b may be necrotized, and a serious adverse effect is expected later.

  (3) When the side surfaces (outer surfaces) of the lip portions 147a and 147b of the incision portion are joined and stitched together, the front side of the stitched portion protrudes in a heaped manner inside the stomach, and various kinds of foods put in the stomach It becomes an obstacle.

  (4) The T-bar (stopper) 136 that becomes a foreign substance remains in the stomach.

  As described above, the suturing method using the suturing device of the above known example (FIGS. 21 to 22) has an advantage that treatment can be performed from the inside of the stomach without making a hole in the body surface. It is thought that it cannot be said.

  Therefore, the present invention enables a suture treatment from the inside of the stomach to the incision portion of the stomach wall, and can be sutured in a state where the end surfaces of the lip portion of the stomach wall incision portion are joined together (adhesion between the joining end surfaces). It is an object of the present invention to provide an endoscopic suturing device and a gastric wall incision suturing method performed using the endoscopic suturing device.

  The present invention has the following configuration as means for solving the above problems.

[Invention of Claim 1 of the Present Application]
The invention of claim 1 of the present application is directed to an endoscopic suturing device for suturing an incision in the stomach wall from the inside of the stomach using an endoscope in combination. The endoscope suturing device according to claim 1 of the present application includes the following components.

  First, the front arm, the intermediate arm, and the rear arm are arranged in the front and rear positions in a position near the front of the distal end portion of the endoscope in a posture that is parallel to the distal end surface of the endoscope. Since the imaging device (CCD camera) and the illumination lamp are installed on the front surface of the distal end of the endoscope, the front arm, the intermediate arm, and the rear arm are substantially omitted so as not to obstruct their field of view or illumination. It is preferable to use a shape that is curved into a C shape (an arc shape having a length of about a half circumference).

  The front arm, the intermediate arm, and the rear arm can be moved forward and backward by the forward / backward operation means from the proximal side of the endoscope. As each advance / retreat operation means, a thin rod (one innermost) or a thin tube (two outside) installed coaxially along the outer tube of the endoscope and movable back and forth can be used. The front arm, the intermediate arm, and the rear arm are individually fixed to the distal ends of the thin rod and the thin tube, and the thin rod and the thin tube can be individually advanced and retracted from the proximal side of the endoscope. You can adopt what you do. In addition, you may employ | adopt a thin tube also for the said thin rod used for innermost side.

  Further, the front arm, the intermediate arm, and the rear arm can be rotated in a plane parallel to the distal end surface of the endoscope from the proximal side of the endoscope by the rotation operation means. This rotation operation means adopts one that can rotate each arm (front arm, middle arm, rear arm) by rotating the above-mentioned thin rod and each thin tube from the hand side of the endoscope. it can. The rotation operation means is preferably one in which each arm (front arm, intermediate arm, rear arm) is integrally rotated at equal angles.

  On the rear surface (surface on the hand side) of the front arm, there is provided a connector storage portion that can store the first connector of the pair of connectors connected to each other. In addition, a pair of connector is a thing of a small diameter of the grade which can penetrate the biological tissue of a stomach wall, respectively.

  On the front surface of the intermediate arm, a hollow penetrating needle that can penetrate the stomach wall and can accommodate the second connector connected to the first connector is protruded toward the connector storage portion of the front arm.

  The pair of connectors (the first connector and the second connector) have a small diameter that can penetrate the living tissue of the stomach wall. Moreover, this pair of couplers (the first coupler and the second coupler) are used in such a manner that when one of them is pressed against the other, the concave and convex fittings are connected to each other.

  A push bar is provided on the front surface of the rear arm to push forward the second connector inserted into the penetrating needle and housed in the penetrating needle.

  In the endoscope suturing device according to claim 1, the front arm is accommodated in a state where the first connector is accommodated in the connector accommodating portion of the front arm and the second connector is accommodated in the penetration needle of the intermediate arm. Is positioned outside the stomach wall through the incision from inside the stomach wall, and the second arm accommodated in the penetration needle is advanced by advancing the push rod of the rear arm after the penetration needle of the intermediate arm is penetrated from the inside of the stomach to the stomach wall. It is comprised so that a connection tool can be connected with the 1st connection tool accommodated in the connection tool accommodating part.

  The endoscopic suturing device according to claim 1 is capable of suturing the incision portion of the stomach wall as described in the next item (claim 2).

[Invention of claim 2 of the present application]
The invention of claim 2 of the present application is directed to a gastric wall incision suture method performed using the endoscope suturing device of claim 1 described above. The gastric wall incision suture method according to the second aspect of the invention is characterized in that the following first to twelfth steps are sequentially performed.

  In the first step, the two first connectors connected by the first suture are accommodated in the connector accommodating portion of the front arm, while the two second connectors connected by the second suture are inserted into the penetrating needle of the intermediate arm. In the state accommodated in the endoscope, the distal end side of the endoscope is inserted into the stomach.

  In the second step, the front arm is advanced from the stomach through the stomach wall incision to the outside of the stomach wall, and the connector housing portion is brought close to or in contact with the position to be sutured from the stomach wall outside. In this case, the intermediate arm and the rear arm remain in the stomach wall, and the incision edge is located between the front arm and the intermediate arm (penetrating needle). Further, in this state, the connector accommodating portion of the front arm is located at a position corresponding to the front of the penetrating needle of the intermediate arm with the mouth portion of the incised portion being separated.

  In the third step, the penetration needle of the intermediate arm is penetrated from the stomach to the stomach wall. At this time, the tip of the penetrating needle penetrates through the incision mouth edge and enters the connector housing portion of the front arm.

  In the fourth step, the push rod of the rear arm is advanced to connect the first second connector in the penetrating needle to the first first connector accommodated in the connector accommodating portion. At this time, the first second connector and the first first connector are connected outside the stomach wall. In the following description, the connection between the first second connector and the first first connector is referred to as a first coupling connector.

  In the fifth step, the second arm is retracted by moving the rear arm and the intermediate arm until the push rod and the penetrating needle are completely located in the stomach while the second second connector is housed in the penetrating needle. The second suture thread on the connector side is passed through the stomach wall, and the front arm is advanced until the connected first coupling connector comes out of the connector housing part outside the stomach wall. In this state, the first first connector of the first connector and the second first connector remaining in the connector housing are connected by the first suture outside the stomach wall, The first second coupling tool of the first coupling coupling tool and the second second coupling tool remaining in the penetrating needle are connected by the second suture in a state of penetrating the incision mouth edge. .

  In the sixth step, the front arm, the intermediate arm, and the rear arm are moved in a state where the second first connector is housed in the connector housing portion and the second second connector is housed in the penetrating needle. By rotating the angle 180 °, the connector accommodation portion, the penetrating needle, and the push rod are faced to the incision mouth edge portion at a position opposite to the position where the suture thread is first inserted. At this time, the first and second sutures are positioned so as to straddle the incision portion inside and outside the stomach wall.

  In the seventh step, the front arm is retracted until it approaches or comes into contact with the outer surface of the stomach wall, while the penetrating needle of the intermediate arm is penetrated from the stomach into the stomach wall (the same contents as the second step and the third step).

  In the eighth step, the push rod of the rear arm is advanced to connect the second second connector in the penetrating needle to the second first connector stored in the connector storage section (the first step). Same contents as 4 steps). At this time, the second second connector and the second first connector are connected outside the stomach wall. In the following description, the connection between the second second connector and the second first connector is referred to as a second coupling connector.

  In the ninth step, the second arm on the second second connector side is passed through the stomach wall by retracting the rear arm and the intermediate arm until the push rod and the penetrating needle are completely located in the stomach. Then, the front arm is moved forward until the connected second coupling connector comes out of the connector housing portion outside the stomach wall (the same content as the fifth step). At this time, in a state where the second suture thread penetrates through each mouth edge portion at the position opposite to the incision portion, both suture threads are continuous in a closed ring shape inside and outside the stomach wall via two coupling connectors.

  In the tenth step, the front arm is retracted from the incision into the stomach. When the length of the incision portion is long, the above-described first to tenth steps are repeated as many times as necessary while shifting the position, and sutures are sewn in an annular manner at a plurality of locations on the incision portion.

  In the eleventh step, the stomach wall incision is opposed to the incision by pulling the inner side of the stomach wall of the suture thread, which is continuous in a closed ring shape, to the proximal side by the pulling means provided in the endoscope. The mouth edges are drawn together until the end faces of the mouth edges are joined together. At this time, the two coupling couplers located outside the stomach wall are pulled out into the stomach through the living tissue at the incision lip, respectively, when the suture is pulled into the stomach. In addition, when the several location of an incision part is sewn, the suture thread of each location is squeezed sequentially. In this state, the end faces of the mouth edges facing each other of the incision part are joined to each other.

  In the twelfth step, each coupling tool (first coupling coupling tool and second coupling coupling tool) is excised from the first suture with a cutting means provided in the endoscope.

  In the gastric wall incision part suturing method according to the second aspect, the gastric wall incision part can be sutured from the stomach interior by performing the first step to the twelfth step using the endoscope suturing apparatus according to the first aspect. It is possible to perform suturing in a state where the end surfaces of the mouth edge of the gastric wall incision are joined. In addition, when the end surfaces of the mouth edges of the gastric wall incision are joined together in this manner, the mouth edges (living tissue) of the incision are well adhered to each other.

  The endoscopic suturing device according to claim 1 and the gastric wall incision suturing method according to claim 2 have the following effects.

  First, since the incision in the stomach wall can be sutured from the stomach as described above, there is no need to make a hole in the body surface in order to suture the stomach wall incision. That is, as in the case of making a hole in the body surface, it is possible to solve various problems such as feeling pain, taking time to heal the hole, and leaving a wound on the body surface.

  In addition, since the incision can be sutured with the end faces of the mouth edges of the gastric wall incision part joined together (the cuts of the living tissue), the living tissues of the incision part of the incision can be satisfactorily (Not)) and the above NOTES (transluminal endoscopic surgery or abdominal endoscopic surgery) can be practically enabled.

  In addition, this gastric wall incision suture method can eliminate the connection tool for continuation of the suture, so that there is also an effect that no foreign matter remains in the stomach.

  In addition, when the end surfaces of the incised portion rim portions (the cut ends of the living tissue) are joined together in this manner, the adhesion between the end surfaces of the rim portions is fast, and the rim portions are connected to each other. It can be cleanly joined in a flat state without unevenness, and the living tissues at the cut end are well adhered to each other, so that there is no risk of necrosis of the living tissues at the sutured portion.

  Hereinafter, an endoscopic suturing apparatus according to an embodiment of the present invention and a gastric wall incision suturing method performed using the endoscopic suturing apparatus will be described with reference to FIGS.

  First, the configuration of the endoscopic suturing device shown in FIGS. 1 to 3 will be described. The endoscopic suturing device of this embodiment includes a suturing device 2 on a normal endoscope 1 called a stomach camera. They are arranged side by side.

  The endoscope 1 is provided with an imaging device (CCD camera) 12 and an illumination lamp 13 as shown in FIG. 2 at the tip of a flexible outer tube 11 having a predetermined length. The distal end portion of the outer tube 11 of the endoscope 1 can change the directing direction by the hand controller 10. The outer tube 11 of the endoscope 1 is often about 10 to 15 mm in thickness.

  A forceps insertion port 14 is provided on the proximal side of the outer tube 11 of the endoscope 1. An insertion hole 14 a is provided from the forceps insertion opening 14 to the distal end surface of the endoscope 1, and forceps and other instruments are inserted from the forceps insertion opening 14 to perform various operations from the distal end surface of the endoscope 1. Can be done.

  The suturing device 2 includes three arms, a front arm 3, an intermediate arm 4, and a rear arm 5, which are arranged in the vicinity of the front of the distal end of the outer tube 11 of the endoscope 1, and the arms 3, 4, and the like. The three systems of advancing / retracting operation means 23, 24, 25 that can move the arm 5 back and forth from the proximal side of the endoscope 1 and the arms 3, 4, 5 are rotated in a plane parallel to the distal end surface of the endoscope. Rotational operation means 22 to obtain.

  The front arm 3, the intermediate arm 4, and the rear arm 5 of the suturing device 2 are each of a shape that is curved into a substantially C shape (an arc shape of about a half circumference) as shown in FIG. The maximum outer diameters of the arms 3, 4, 5 are designed to be approximately the same as or slightly larger than the outer diameter of the outer tube 11 of the endoscope 1. The reason why each of the arms 3, 4, 5 is formed in a substantially C shape (an arc shape having a half circumference) is that the CCD camera 12 and the illumination lamp 13 are installed on the front surface of the distal end portion of the endoscope 1. In order not to obstruct the field of view or illumination.

  The front arm 3, the intermediate arm 4 and the rear arm 5 can be moved forward and backward by the forward / backward operation means 23, 24, 25 from the proximal side of the endoscope 1, respectively. 23, 24, and 25 are a thin rod 23A connected to one end of each of the arms 3, 4, and 5 or inner and outer thin tubes 24A and 25A, respectively, by operating levers 23B, 34B, and 35B provided on the hand operating device 20, respectively. It can be moved forward and backward.

  That is, the thin rod 23A and the inner and outer thin tubes 24A and 25A, which are part of the respective advancing / retreating operation means 23, 24 and 25, are inserted coaxially with each other as shown in FIGS. With the outer side of 25A covered with the outer tube 21, it is installed along the outer surface of the outer tube 11 of the endoscope 1 as shown in FIG. The quadruple portion composed of the thin rod 23A, the inner and outer thin tubes 24A and 25A, and the outer tube 21 on the outer side has moderate flexibility so that it can be bent together with the outer tube 11 of the endoscope 1. It has become. In another embodiment, the thin rod 23A may be a thin tube.

  The central thin rod 23A, the intermediate thin tube 24A, and the outer thin tube 25A can be moved forward and backward individually. The thin rod 23A has an outer diameter of 2 to 3 mm, the intermediate thin tube 24A has an outer diameter of 3 to 4 mm, and the outer thin tube 25A has an outer diameter of about 4 to 5 mm. , 25A have portions that are not easily bent.

  One end 3a of the front arm 3 is fixed to the tip of the thin rod 23A, one end 4a of the intermediate arm 4 is fixed to the tip of the intermediate thin tube 24A, and the rear arm is attached to the tip of the outer thin tube 25A. 5 is fixed, while the thin rod 23A, the intermediate thin tube 24A, and the outer thin tube 25A are individually provided by three operation levers 23B, 24B, and 25B provided on the hand controller 20 (see FIG. 1). Can be moved forward and backward. In the following description, in each arm (front arm 3, intermediate arm 4, rear arm 5), one end (3a, 4a, 5a) to which the thin rod 23A or the thin tubes 24A, 25A are fixed. ) Is referred to as a base end portion, and the other end portions (3b, 4b, 5b) of the arms 3, 4, 5 may be referred to as distal end portions.

  As the rotation operation means 22 for rotating each arm 3, 4, 5, a single rotation operation knob provided in the hand controller 20 is adopted, and by rotating the rotation operation knob 22, the rotation operation knob 22 is finely adjusted. The rod 23A, the intermediate thin tube 24A, and the outer thin tube 25A can be integrally rotated at equal angles.

  By the way, FIG. 4 shows a connector (6A, 6B, 7A, 7B) for connecting the ends of the two sutures 60, 70 as will be described later. Each of the couplers shown in FIG. 4 is such that the couplers located on the left and right (6A and 7A, 6B and 7B) are coupled to each other, and two first couplers (male couplers) 6A, 6B is continued with one suture (first suture) 60, while the two second connectors (female connectors) 7A and 7B are continued with the other suture (second suture) 70. Used in the state. The two first connectors 6A and 6B have the same shape and size, and the two second connectors 7A and 7B have the same shape and size.

  Each of the first couplers 6A and 6B (FIG. 4) has a small-height column 63 standing on the upper surface of the central portion of a substantially disc-shaped substrate 61 provided with a notch 62 in a part, and the upper portion of the column 63. The latching claw 64 is provided in the structure. The locking claw 64 has elasticity (spring property). And these two 1st connection tools 6A and 6B are connected with the 1st suture 60 of predetermined length.

  Each of the second connectors 7A and 7B (FIG. 4) has a cutout portion 72 in a part thereof and a central portion of a substantially circular base 71 having a thin rising wall 73 in an outer peripheral portion thereof. A hole 74 for engaging the locking claw 64 is provided. And these two 2nd connection tools 7A and 7B are connected with the 2nd suture 70 of predetermined length.

  In the first connector (6A, 6B) and the second connector (7A, 7B), the locking claw 64 on the first connector side is engaged with the hole 74 on the second connector side from the lower surface side. Thus, the locking claws 64 are connected to each other by being locked to the upper edge of the hole 74.

  The maximum outer diameter of the base material 61 of the first connector and the base material 71 of the second connector is, for example, a small diameter of about 1.8 mm, and the second suture 70 is strengthened as described later (explanation of FIG. 17). When pulled up, the first and second coupling couplers A ′ and B ′ coupled with both couplers can penetrate the living tissue of the stomach wall 81 while expanding.

  In addition, the notches 62 and 72 of the first connecting tools 6A and 6B and the second connecting tools 7A and 7B are spaces for inserting the sutures 60 and 70, respectively. Further, the inside of the rising wall 73 of the second connector 7A, 7B is in a state where the locking claw 64 of the first connector 6A, 6B is locked to the upper edge of the hole 74 of the second connector. This is a storage space for the locking claw 64.

  On the rear surface (surface on the hand side) of the front end portion 3b of the front arm 3, a connector housing portion 31 capable of housing the first connectors 6A and 6B is provided. The size of the connector housing portion 31 is slightly larger than the outer diameter of the first couplers 6A and 6B (slightly larger than the outer diameter of a penetrating needle 41 described later) and the two first couplers 6A and 6B. It has a depth that can be accommodated in a stacked state.

  On the front surface of the distal end portion 4 b of the intermediate arm 4, a hollow penetrating needle 41 that can accommodate the second coupling tools 7 </ b> A and 7 </ b> B is projected toward the coupling tool accommodation section 31 of the front arm 3. The inner diameter of the penetrating needle 41 is about slightly larger (for example, 1.9 to 2.0 mm) than the outer diameter (1.8 mm) of the second couplers 7A and 7B. In the state in which the second couplers 7A and 7B are housed inside the penetrating needle 41, the second couplers 7A and 7B are held by the friction force in the penetrating needle 41 and pressed by a push bar 51 described later. By doing so, the second connector 7A, 7B can be extracted from the tip of the penetrating needle 41.

  A push bar 51 is provided on the front surface of the distal end portion 5b of the rear arm 5 to push forward the second couplers 7A and 7B inserted into the penetrating needle 41 and housed in the penetrating needle 41. Yes. The outer diameter of the push bar 51 is slightly smaller than the inner diameter of the penetrating needle 41 (for example, 1.8 mm). The push bar 51 is a pipe-shaped member in the illustrated example, but may be a solid rod.

  Next, a gastric wall incision suture method performed using the above-described endoscopic suturing device will be described with reference to FIGS. 5 to 20. The gastric wall incision suture method of this embodiment is as shown in FIG. This is for suturing the incision 82 formed in the stomach wall 81 in advance.

  And the gastric wall incision part suturing method of this embodiment sequentially performs the following first to twelfth steps.

  First, in the first step, as shown in FIG. 3, the two first connectors 6 </ b> A and 6 </ b> B (see FIG. 4) connected by the first suture 60 are accommodated in the connector accommodating portion 31 of the front arm 3. On the other hand, in a state where the two second couplers 7A and 7B (see FIG. 4) coupled by the second suture thread 70 are accommodated in the penetrating needle 41 of the intermediate arm 4, the endoscope 1 as shown in FIG. The distal end side is inserted into the stomach 8. Then, while observing with the endoscope 1, the distal end portion (front arm 3) of the suturing device 2 faces the incised portion 82 of the stomach wall 81.

  In the second step, the front arm operating lever 23B of the hand controller 20 (FIG. 1) is advanced to advance the front arm 3 from the stomach through the gastric wall incision 82 to the outside of the gastric wall 81 as shown in FIG. Then, the connector accommodating portion 31 of the front arm 3 is brought close to or in contact with the position where the incised portion lip 83 should be stitched from the outside of the stomach wall 81 (the lower surface side of the stomach wall 81 in FIG. 6). In this case, the intermediate arm 4 and the rear arm 5 remain in the stomach wall 81 (on the upper surface side of the stomach wall 81 in FIG. 6), and the incised portion of the incised portion is located between the front arm 3 and the intermediate arm 4 (penetrating needle 41). 83 is located. Further, in this state, the connector accommodating portion 31 of the front arm 3 is located at the front corresponding position of the penetrating needle 41 of the intermediate arm 4 with the incised portion mouth edge portion 83 interposed therebetween.

  In the third step, the intermediate arm operation lever 24B of the hand operating device 20 is advanced, and the penetration needle 41 of the intermediate arm 4 is pierced from the stomach into the incision lip 83 as shown in FIG. At this time, the rear arm operating lever 25B may be moved forward by the same length together with the intermediate arm operating lever 24B. In this state, the tip of the penetrating needle 41 penetrates through the incised portion lip 83 and enters the connector housing portion 31 of the front arm 3.

  In the fourth step, the rear arm operating lever 25B of the hand operating device 20 is advanced to advance the push bar 51 of the rear arm 5 as shown in FIG. The second connector 7A is pressed against the first first connector 6A housed in the connector housing 31. Then, the locking claw 64 (FIG. 4) of the first first connecting tool 6A automatically passes through the hole 74 (FIG. 4) of the first second connecting tool 7A, and the rising wall 73 (FIG. 4). When the locking claw 64 is engaged with the upper edge of the hole 74, the two coupling tools 6A and 7A are connected so as not to be detached. At this time, the first second connector 7 </ b> A and the first first connector 6 </ b> A are connected outside the stomach wall 81. In the following description, the connection between the first second connection tool 7A and the first first connection tool 6A is referred to as a first connection connector A (see FIG. 9).

  In the fifth step, as shown in FIG. 9, the rear arm 5 and the intermediate arm 4 are retracted until the push bar 51 and the penetrating needle 41 are completely located in the stomach (the rear arm operation lever 25B and the intermediate arm). The first connecting connector A (the first first connecting device 6A and the second connecting device 7A) each connected to the front arm 3 is connected to the connecting device accommodating portion outside the stomach wall 81. The vehicle is moved forward until it comes out of 31 (the front arm operating lever 23B is moved forward). At this time, the second second connector 7B remains housed in the penetrating needle 41, and the second first connector 6B remains housed in the connector housing portion 31. In this state, the first first coupling tool 6A of the first coupling coupling tool A and the second first coupling tool 6B remaining in the coupling tool container 31 are first sutured outside the stomach wall. While being connected by the thread 60, the first second connecting member 7A of the first connecting connector A and the second second connecting member 7B remaining in the penetrating needle 41 are the incision edge 83. Are connected by the second suture 70 in a state of penetrating through the.

  In the sixth step, the rotary operation knob 22 of the hand controller 20 (FIG. 1) is rotated to rotate the front arm 3, the intermediate arm 4 and the rear arm 5 by an angle of 180 ° as shown in FIG. The connector housing part 31, the penetrating needle 41, and the push bar 51 are made to face the incised part edge 83 at a position opposite to the position where the suture thread 70 is first inserted. At this time, since the second first connector 6B is housed in the connector housing 31 and the second second connector 7B remains housed in the penetration needle 41, the stomach wall 81 Each of the suture threads 60 and 70 is positioned so as to straddle the incision 82.

  In the seventh step, as shown in FIG. 11, the front arm 3 is retracted until it approaches or comes in contact with the outer surface of the stomach wall, while the piercing needle 41 of the intermediate arm 4 is pierced from the stomach into the incision lip 83 (see above). The same content as the second step and the third step).

  In the eighth step, as shown in FIG. 12, the second second connector 7 </ b> B in the penetrating needle 41 is accommodated in the connector accommodating portion 31 by advancing the push bar 51 of the rear arm 5. To the first connector 6B (the same content as the fourth step). At this time, the second second connector 7B and the second first connector 6B are connected outside the stomach wall 81. In the following description, the connection between the second second connector 7B and the second first connector 6B is referred to as a second connecting connector B (see FIG. 13).

  In the ninth step, as shown in FIG. 13, the rear arm 5 and the intermediate arm 4 are retracted until the push rod 51 and the penetrating needle 41 are completely located inside the stomach, whereby the second second connector 7B side. The suture thread 70 is penetrated through the stomach wall, and the front arm 3 is advanced until the second coupling coupler B to which the front arm 3 has been coupled comes out of the coupling instrument accommodating portion 31 outside the stomach wall 81 (the same content as the fifth step). At this time, in a state where the second suture thread 70 has penetrated the respective mouth edge portions 83 and 83 at positions opposite to the incision portion 82, both the suture threads 60 and 70 are attached to the stomach wall 81 via the two coupling connectors A and B. It is continuous in a closed loop inside and outside.

  In the tenth step, the front arm 3 is retracted from the incision 82 into the stomach as shown in FIG. If the length of the incision portion 82 is long, the first to tenth steps are repeated as many times as necessary while shifting the position, and the suture thread 60, 70 is sewn in an annular shape.

  In the eleventh step, as shown in FIG. 16, the pulling means is inserted from the forceps insertion opening 14 of the endoscope 1 through the insertion hole 14a. As this pulling means, the thing provided with the hook 15 at the front-end | tip of the wire 15a is used. At this time, a tube-like pusher 17 (with a wire 15a inserted therein) is inserted into the insertion hole 14a, and a cylindrical throttle with the wire 15a inserted in front of the tip of the pusher 17 is inserted. The tool 16 is positioned. The inner diameters of the pusher 17 and the restrictor 16 have a size that allows the coupling connectors A and B to pass therethrough. The squeezing tool 16 is preferably of a nature that dissolves naturally over time in the body. In the eleventh step, another endoscope that does not have a suturing device is used as the endoscope 1, but the endoscope 1 with the suturing device 2 described above may be used.

  In the eleventh step (FIG. 16), the hook 15 at the distal end of the wire 15a is operated from the hand side while observing with the CCD camera 12 of the endoscope 1, and the opposite rim 83, As shown in FIG. 17, an incision portion 82 is obtained by hooking the gastric wall inner portion (second suture thread 70) of the suture continuous with the hook 83 with the hook 15 and pulling the wire 15a toward the proximal side. The opposite edge portions 83 and 83 of each other are pulled toward each other to join the end faces 83a and 83a of the respective edge portions. At this time, the two coupling connectors A and B (FIG. 16) located outside the stomach wall 81 are incised as shown by reference numerals A ′ and B ′ in FIG. 17 when the suture thread 70 is pulled. It passes through the living tissue of the mouth edge portions 83 and 83 and is extracted into the stomach. Next, as shown in FIG. 18, the pusher 17 is advanced from the state of FIG. 17 to push down the squeezing tool 16, and the opposing edge portions 83 and 83 of the incision portion 82 are squeezed only by the lower first suture thread 60. Make me jealous. In addition, when a plurality of locations of the incision portion 82 are sewn as shown in FIG. 15, the opposing mouth edge portions 83, 83 at each location are sequentially squeezed with the first suture thread 60 in the same manner. In this state (FIG. 18), the end faces 83a and 83a of the mouth edges facing each other of the incision 82 are joined to each other. Then, the pusher 17 is pulled out from the state of FIG. 18 and the hook 15 is removed from the second suture thread 70, and the hook 15 is also pulled out toward the hand side.

  In the twelfth step, as shown in FIG. 19, a cutting means (cutter) 18 is inserted into the insertion hole 14 a of the endoscope 1, and each coupling connector A, B is excised from the first suture 60 by the cutter 18. To do. When a plurality of locations of the incision portion 82 are sewn, the joint couplers A and B at the respective locations are cut out from the first suture 60 in the same manner. Then, by replacing the forceps into the insertion hole 14a, pinching the joint couplers A and B that have been excised with the forceps (or hooking the second suture thread 70) and pulling it out to the hand side, a series of suturing treatments are completed, It will be in the state of FIG. In addition, if the squeezing tool 16 has a property that does not dissolve in the body, the squeezing tool 16 can also be removed by picking it with forceps at the time of extracting each of the coupling connectors A and B.

  In the gastric wall incision portion suturing method of this embodiment, the gastric wall incision portion 82 can be sutured from inside the stomach by performing the first step to the twelfth step using the endoscopic suturing apparatus, and the gastric wall It can sew in the state which joined the end surfaces 83a and 83a of the edge parts 83 and 83 of an incision part. As described above, when the end surfaces 83a and 83a of the lip portions 83 and 83 of the stomach wall incision portion are joined together, the living tissues of the lip portion of the incision portion adhere well (without any problem). To come.

  Therefore, according to the present application, an epoch-making device and technique capable of realistically enabling the above-mentioned NOTES (transluminal endoscopic surgery or abdominal endoscopic surgery), which has been developed recently. Can provide.

It is a front view of the suturing device for endoscopes of an example of the present application. FIG. 2 is an enlarged perspective view of the vicinity of the distal end of the endoscope suturing device in FIG. 1. FIG. 3 is an enlarged cross-sectional view (corresponding to a cross-section taken along the line III-III in FIG. 2) near the distal end of the endoscope suturing apparatus in FIG. It is a perspective view of the connection tool used for the suturing device for endoscopes of FIG. It is 1st process explanatory drawing of the gastric wall incision part suture method of this-application Example. It is 2nd process explanatory drawing of the stomach wall incision part suture method. It is 3rd process explanatory drawing of the stomach wall incision part suture method. It is 4th process explanatory drawing of the stomach wall incision part suture method. It is 5th process explanatory drawing of the stomach wall incision part suture method. It is 6th process explanatory drawing of the stomach wall incision part suture method. It is 7th process explanatory drawing of the gastric wall incision part suture method. It is 8th process explanatory drawing of the gastric wall incision part suture method. It is 9th process explanatory drawing of the stomach wall incision part suture method. It is 10th process explanatory drawing of the stomach wall incision part suture method. It is explanatory drawing at the time of sewing a gastric wall incision part in multiple places. It is 11th process explanatory drawing of the said gastric wall incision part suture method. It is a state change figure from FIG. It is a state change figure from FIG. It is 12th process explanatory drawing of the said gastric wall incision part suture method. It is explanatory drawing of the state which the suturing treatment was completed. It is an operation | work process figure of the well-known (patent document 1) gastric wall incision part suturing method. FIG. 22 is a work process diagram performed subsequent to the process in FIG.

Explanation of symbols

  1 is an endoscope, 2 is a suturing device, 3 is a front arm, 4 is an intermediate arm, 5 is a rear arm, 6A and 6B are first connectors, 7A and 7B are second connectors, and 10 is an endoscope. 20 is a hand operating device of a suturing device, 22 is a rotation operating means, 23 to 25 are advance / retreat operating means, 23A is a thin rod, 24A is an intermediate thin tube, 25A is an outer thin tube, and 31 is a connector. , 41 is a penetrating needle, 51 is a push rod, 60 and 70 are sutures, 81 is a stomach wall, 82 is an incision, 83 is a lip, 83a is an edge of the lip, A is a first coupling connector, B is A second coupling connector.

Claims (2)

An endoscopic suturing device for suturing an incision in the stomach wall from the inside of the stomach using an endoscope,
The front arm, the intermediate arm, and the rear arm are arranged at the front and rear positions in the vicinity of the front end of the endoscope in a posture that is oriented parallel to the endoscope front end surface,
Each advancing / retracting operation means capable of moving the front arm, the intermediate arm, and the rear arm forward and backward from the hand side of the endoscope, and the front arm, the intermediate arm, and the rear arm from the hand side of the endoscope. Rotation operation means capable of rotating in a plane parallel to the endoscope front end surface,
Provided on the rear surface of the front arm is a connector storage portion that can store the first connector of the pair of connectors connected to each other;
A hollow penetrating needle capable of penetrating the stomach wall and capable of accommodating a second connector connected to the first connector is projected toward the connector storage part of the front arm on the front surface of the intermediate arm;
On the front surface of the rear arm, a push rod is provided for pushing forward the second connector inserted into the penetrating needle and housed in the penetrating needle,
In a state where the first connector is accommodated in the connector accommodating portion and the second connector is accommodated in the penetrating needle, the front arm is positioned outside the stomach wall from the stomach wall through the incision portion, and the intermediate arm After penetrating the penetration needle from the stomach into the stomach wall, the push rod of the rear arm is advanced, whereby the second connector accommodated in the penetration needle is accommodated in the connector accommodation portion. It is configured so that it can be connected to a connector,
An endoscopic suturing device. A gastric wall incision suture method performed using the endoscope suturing device according to claim 1,
The two first connectors connected by the suture are accommodated in the connector accommodating portion of the front arm, while the two second connectors connected by the suture are accommodated in the penetrating needle of the intermediate arm. Inserting the tip of the mirror into the stomach;
Advancing the front arm from the stomach through the gastric wall incision and out of the gastric wall to bring the connector housing from the gastric wall close to or in contact with the position to be sutured on the incision lip;
Penetrating the penetrating needle of the intermediate arm from the inside of the stomach toward the connector housing part of the front arm located outside the stomach wall;
A step of advancing the push rod of the rear arm to connect the first second connector in the penetrating needle to the first first connector stored in the connector storage portion;
By retracting the rear arm and the intermediate arm while the second second connector is housed in the penetrating needle until the penetrating needle and the push rod are completely located inside the stomach, Passing the suture through the stomach wall and advancing the front arm until the connected first coupling coupler is pulled out of the coupling receptacle outside the stomach wall;
The front arm, the intermediate arm, and the rear arm are rotated by 180 ° while the second first connector is housed in the connector housing portion and the second second connector is housed in the penetrating needle. A step of facing the incision mouth edge portion at a position opposite to the position where the suture thread is first inserted through the connector housing portion, the penetrating needle, and the push rod;
Retreating the front arm until it approaches or contacts the outer surface of the stomach wall, while penetrating the penetration needle of the intermediate arm from the inside of the stomach toward the connector housing portion of the front arm located outside the stomach wall;
A step of advancing the push rod of the rear arm to connect the second second connector in the penetrating needle to the second first connector housed in the connector housing portion;
By retracting the rear arm and the intermediate arm until the penetrating needle and push bar are completely located inside the stomach, the suture on the second connector side penetrates the stomach wall and the second arm is connected to the front arm. Advancing until the device comes out of the connector housing outside the stomach wall;
Retracting the front arm from the incision into the stomach;
By pulling the gastric wall inner part of the suture thread that is continuous in a closed loop to the opposite lip of the gastric wall incision with the pulling means provided in the endoscope, the opposing lip of the incision is mutually connected. Drawing and drawing until the end faces of each mouth edge are joined together,
Cutting each connector from the suture with a cutting means provided in the endoscope;
And a gastric wall incision part suturing method using an endoscopic suturing device.

Images