JP2018094325A - Suture apparatus - Google Patents

Abstract

PROBLEM TO BE SOLVED: To provide a suture apparatus capable of suturing body tissue in a short time.SOLUTION: A suture apparatus 1 is inserted into a body, with it mounted on an endoscope 2 and used. The suture apparatus includes: a front arm 51 to which a suture thread 6 is fitted; a rear arm 52 having a needle-like member 52a to which a ligator 7 is fitted; arm moving means (a wire 31 and a tube 32) for making the front arm and the rear arm approach to/separate from each other; rear arm coupling means (a tube tip end 32a, a guide tube 52c, a connecting tube 52d, a pin member 52e, a through groove 52f, a guide shaft 53a, a shaft pin 53b and the like) removably coupling the rear arm to the arm moving means.SELECTED DRAWING: Figure 3C

Description

  The present invention relates to a suturing device for suturing an incision formed in a lumen wall of a digestive tract or the like in transluminal endoscopic surgery.

  Transluminal endoscopic surgery (NOTES) has recently attracted attention as a minimally invasive surgery that does not create wounds on the body surface. Unlike conventional surgery, which cuts through the body surface and reaches the affected area in the body cavity, it passes through the gastrointestinal tract, urethra, birth canal, etc. through natural holes such as the mouth, anus, urethral opening, and vaginal opening using an endoscope. And let the treatment tool reach the affected area. Such transluminal endoscopic surgery is applied to various procedures such as appendectomy, cholecystectomy, fallopian tube ligation, ovariectomy, and gastrointestinal anastomosis from diagnostic procedures such as intraperitoneal observation and liver biopsy. The possibility has been reported.

  In a transluminal endoscopic operation, as a suturing device for suturing an incision portion (including a perforated portion or a defect portion) formed in a lumen wall of a digestive tract or the like, the one described in Patent Document 1 below is disclosed. Proposed. This suturing apparatus generally includes a front arm having a bifurcated distal end portion to which a suture thread is passed, a rear arm having a puncture needle, and a mechanism for relatively moving them.

  In order to sew the incised portion with this suturing device, first, the suturing device is attached to the outer peripheral side of the distal end portion of the endoscope to reach the incised portion. Then, the bifurcated tip of the front arm is placed outside the lumen (on the body cavity side) through the incision, and one end of the suture thread spanned between the tips is inserted into the incision. After engaging the tip of the needle punctured from the inside of the lumen with the lumen wall on one side of the part, the needle is pulled back, and one end of the suture is passed through the lumen wall to Lead inside. Next, the other end of the suture is similarly engaged with the tip of the needle punctured from the inside of the lumen to the other lumen wall of the incision, and then the needle is pulled back to The other end of the tube is guided through the lumen wall to the inside of the lumen. Finally, a ligation tool (which is composed of “tubular member 51” and “linear member 52” in Patent Document 1) previously fitted to the outside of the endoscope or the like is placed from the outside of the body. By operating with an instrument for operation (referred to as “moving portion 53” in Patent Document 1), both ends of the suture thread are squeezed and ligated with a ligature tool.

  When a plurality of sutures are required by this suturing device, it is necessary to pull out the suturing device together with the endoscope to the outside of the body after the stitching of one needle, and newly attach a suture thread and a ligature tool outside the body. is there. The attaching work of the suture thread and the ligature tool inevitably needs to be performed at a medical site, but such an operation is very fine and delicate, and is not always easy and requires accuracy. Some time may be required. Such a procedure (suture) is preferably performed as quickly as possible in order to reduce the burden on the patient's body, and improvement thereof is demanded.

International Publication No. 2012/101999

  The present invention has been made in view of such a situation, and an object thereof is to provide a suturing device capable of suturing a body tissue in a short time.

In order to achieve the above object, a suturing device according to the present invention comprises:
A suturing device that is inserted into the body and used.
A front arm to which a suture is attached;
A rear arm having a needle-like member;
Arm moving means for approaching and separating the front arm and the rear arm;
Rear arm connecting means for detachably connecting the rear arm to the arm moving means;
It is characterized by having.

  In the present invention, since the rear arm is detachably connected to the arm moving means by the rear arm connecting means, after the stitching of one needle is completed, the rear arm is removed, and a ligation tool is attached in advance. A separate rear arm can be attached. Accordingly, the work requiring fine accuracy for mounting the ligature tool can be performed in advance at the manufacturing site of the suturing apparatus, and it is not necessary to perform the work of mounting the ligature tool at the medical site. It becomes possible to quickly sew the part.

  In the present invention, the rear arm connecting means is provided on the projecting member provided on the rear arm and on the front arm, and when the rear arm is moved away from the front arm. A projecting member that abuts and holds the connection of the rear arm to the arm moving means, and the abutting member is provided only when the projecting member is in a predetermined positional relationship. It can comprise so that a protrusion member may have a notch part which can pass.

  With this configuration, when the protruding member and the cutout portion of the abutting member are not in a predetermined positional relationship, the protruding arm cannot pass through the cutout portion, so that the rear arm is disconnected from the arm moving means. It is possible to prevent the rear arm from being moved to a possible position, and to allow the rear arm to be attached and detached.

  More specifically, the arm moving means includes a long body having a distal end and a proximal end, respectively, and a tubular cylindrical body through which the long body is slidably inserted. The distal end of the elongated body can be connected to the abutting member, and the distal end of the tubular body can be detachably connected to the rear arm. In this case, the rear arm has a rear guide portion including a substantially cylindrical member through which the elongated body is inserted, and the rear guide portion has a width larger than the diameter of the elongated body. And a through groove that penetrates inward and outward from the proximal end to the distal end of the rear guide portion. By comprising in this way, the attachment or detachment operation | work with respect to the arm moving means of a rear side arm can be performed easily.

  In the present invention, a ligature used for ligating the suture thread obtained by suturing the body tissue can be attached to the rear arm.

FIG. 1A is a front view illustrating the configuration of the operation unit of the suturing device according to the embodiment of the present invention, in which the slider unit is moved to the proximal end side with respect to the base unit, and is positioned at the other end of the normal movement range. It is a figure which shows the case where it was made to do. FIG. 1B is a front view showing the configuration of the suturing unit of the suturing device according to the embodiment of the present invention, and is a diagram showing a case where the operation unit is operated as shown in FIG. 1A. FIG. 2A is a diagram illustrating a case where, in the operation unit illustrated in FIG. 1A, the slider unit is moved to the distal end side with respect to the base unit and is positioned at one end of the normal movement range. 2B is a diagram illustrating a case where the operation unit is operated as illustrated in FIG. 2A in the stitching unit illustrated in FIG. 1B. FIG. 2C is a side view of the stitched portion shown in FIG. 2B. FIG. 3A is a diagram illustrating a case where, in the operation unit illustrated in FIG. 2A, the replacement button is pressed and the slider unit is positioned at the replacement position beyond one end of the normal movement range. FIG. 3B is a diagram illustrating a case where the operation unit is operated as illustrated in FIG. 3A in the stitching unit illustrated in FIG. 2A. FIG. 3C is a side view of the suture portion shown in FIG. 3B. FIG. 4A is a plan view of a rear arm constituting the stitching portion shown in FIG. 1B. 4B is a side view of the rear arm shown in FIG. 4A. 4C is a cross-sectional view taken along line IVc-IVc in FIG. 4A. FIG. 5A is a rear view of the front guide portion constituting the stitching portion shown in FIG. 1B. FIG. 5B is a bottom view of the front arm constituting the stitching portion shown in FIG. 1B. FIG. 5C is a perspective view of a guide shaft constituting the front guide portion shown in FIG. 5A. 5D is a cross-sectional view taken along line Vd-Vd in FIG. 5C. FIG. 5E is a plan view of a shaft pin constituting the front guide portion shown in FIG. 5A. FIG. 6A is a partial cross-sectional view of the operation unit illustrated in FIG. 1A, and illustrates a case where movement beyond one end of a normal movement range of the slider unit with respect to the base unit is limited. FIG. 6B is a diagram illustrating a case where the restriction on movement beyond the one end of the normal movement range of the slider portion with respect to the base portion is released by pressing the replacement button in FIG. 6A. FIG. 7A is a diagram illustrating a procedure of a procedure (suture) performed using the suturing device according to the embodiment of the present invention, and is a diagram illustrating a first step. FIG. 7B is a diagram showing a second step subsequent to FIG. 7A. FIG. 7C is a diagram showing a third step subsequent to FIG. 7B. FIG. 7D is a diagram showing a fourth step that follows FIG. 7C. FIG. 7E is a diagram showing a fifth step subsequent to FIG. 7D. FIG. 7F is a diagram showing a sixth step that follows FIG. 7E. FIG. 7G is a diagram showing a seventh step that follows FIG. 7F. FIG. 7H is a diagram showing an eighth step that follows FIG. 7G. FIG. 7I is a diagram showing a ninth step that follows FIG. 7H. FIG. 7J is a diagram showing a tenth process continued from FIG. 7I. FIG. 7K is a diagram showing a final step subsequent to FIG. 7J.

  Hereinafter, embodiments of the present invention will be described in detail with reference to the drawings.

(Overall configuration of suturing device)
As shown in FIGS. 1A and 1B, a suturing device 1 according to this embodiment is a device that is inserted into a body while being attached to an endoscope (soft endoscope or the like) 2. This is a device for suturing an incision or the like formed in an organ in the abdominal cavity or the digestive tract by an operation outside the body while being visually recognized by a camera (not shown).

  The suturing device 1 is provided at a sheath portion 3 disposed along the shaft of the endoscope 2, an operation portion (handle) 4 provided at the proximal end of the sheath portion 3, and a distal end of the sheath portion 3. The sewing part 5 is generally provided.

(Sheath part)
The sheath part 3 is a long member extending along the axial direction, and has two tubes and one wire (or one having flexibility enough to follow the bending of the shaft of the endoscope 2). 3 tubes). That is, the sheath portion 3 is configured to include a front arm moving wire (long body) 31, a rear arm moving tube (tubular body) 32, and a case tube 33. The front arm moving wire 31 and the rear arm moving tube 32 of the sheath part 3 are arm moving means for approaching and separating a front arm 51 and a rear arm 52, which will be described later.

  The front arm moving wire 31 is made of a flexible wire, is slidably inserted into the rear arm moving tube 32, and can move along the axial direction in the rear arm moving tube 32. It is provided so that it can rotate around. As the front arm moving Y 31, a wire rope is used in this embodiment. The wire rope is a rope made of a stranded wire formed by twisting a plurality of wires (cables) made of, for example, metal (stainless steel) or the like. However, the wire 31 may be a single wire. Further, a hollow tube may be used instead of the wire 31.

  The rear arm moving tube 32 is a hollow tube that is slidably inserted into the case tube 33, and is provided in the case tube 33 so as to be movable along its axial direction and rotatable about the axis. The rear arm moving tube 32 has flexibility and may be a tube made of resin or the like. However, in this embodiment, a coil tube that can be used repeatedly by washing and has excellent durability is used. Yes. As the coil tube, a flat wire coil tube formed by spirally winding a long flat plate made of metal (stainless steel) or the like can be used. However, a round wire coil tube or an inner flat coil tube may be used.

  As the rear arm moving tube 32, a wire tube may be used. The wire tube is a tube formed by spirally twisting a plurality of wires (cables) made of, for example, metal (stainless steel) or the like so as to be hollow.

  The rear arm moving tube 32 may be a uniform member (coil tube in this embodiment) from the proximal end to the distal end, but in this embodiment, a rigid metal is attached to the distal end of the coil tube. A substantially cylindrical member made of is welded and fixed to form a distal end portion (tube distal end portion) 32a of the rear arm moving tube 32.

  The case tube 33 is a flexible hollow tube made of resin or the like. The proximal ends of the front arm moving wire 31 and the rear arm moving tube 32 are connected to the operation unit 4, and the distal ends of the front arm moving wire 31 and the rear arm moving tube 32 are connected to the suture unit 5. Yes. The proximal end of the case tube 33 reaches the vicinity of the operation unit 4, but is not connected to the operation unit 4, and the distal end of the case tube 33 reaches the vicinity of the suture unit 5, It is not connected to the stitched portion 5. The case tube 33 can be formed of a material such as polyethylene or vinyl chloride, for example.

  A substantially cylindrical fixing member 33a is integrally attached to the distal end of the case tube 33. The distal end portion of the shaft of the endoscope 2 is press-fitted into the fixing member 33a, whereby the suturing device 1 is fixed. It can be detachably fixed to the endoscope 2. By moving (sliding) the entire operation unit 4 to the distal end side or the proximal end side with respect to the case tube 33, the entire suture unit 5 is moved with respect to the endoscope 2, and the operation unit 4 is moved. Is rotated about its axis with respect to the case tube 33, so that the entire suture portion 5 can be rotated.

(Suture)
The suturing portion 5 of the suturing device 1 is configured as shown in FIGS. 1B, 2B, 2C, 3B, and 3C. That is, the suturing portion 5 includes a front arm 51 to which the suture thread 6 is attached, a rear arm 52 having a needle-like member 52a to which the ligature tool 7 is attached, and the rear arm 52 to arm moving means (front arm movement). A rear arm connecting means that is detachably connected to the wire 31 and the rear arm moving tube 32) is provided. The rear arm connecting means includes a tube tip portion 32a, a rear guide portion (guide tube 52c, connection tube 52d, pin member 52e, through groove 52f), front guide portion 53 (guide shaft 53a, shaft pin 53b), and the like. included.

  As shown in FIGS. 4A, 4B, and 4C, the rear arm 52 includes a needle-like member 52a and a needle support portion 52b. The rear arm 52 includes a guide tube 52c, a connection tube 52d, and a pin member 52e that constitute a rear guide portion. The guide tube 52c is made of a substantially cylindrical member, and a connecting tube 52d made of a substantially cylindrical member having a slightly larger diameter than the guide tube 52c is integrally fixed to the upper end of the guide tube 52c. A proximal end portion of a substantially strip-shaped needle support portion 52b is integrally fixed to the upper portion of the guide tube 52c, and is directed to the front end (distal end side) of the needle support portion 52b. The base end portion of the member 52a is fixed.

  The guide pipe 52c and the connection pipe 52d are formed with through grooves 52f extending in both axial ends and inside and outside. The width of the through-groove 52f is set to such a level that the front arm moving wire 31 can pass through the through-groove 52f from the side and inserted inward or can pass from this state to the outside. That is, the width of the through groove 52 f is set to a value slightly larger than the diameter of the front arm moving wire 31.

  A through hole extending inward and outward is formed in the lower portion (distal end side) of the guide tube 52c on the side facing the through groove 52f (on the side of the needle-like member 52a) at approximately 180 °. A pin member (projection member) 52e is fixed so as to protrude inside. Each of these members 52a, 52b, 52c, 52d, and 52e is made of a metal member such as stainless steel and is integrally fixed to each other by laser welding or the like. The tip of the pin member 52e existing in the guide tube 52c is processed into a substantially spherical shape.

  A distal end portion (tube distal end portion) 32a of the rear arm moving tube 32 is inserted (fitted) into the connecting tube 52d so as to be insertable / removable, and the tube distal end portion 32a is inserted. The connection tube 52d can be detachably coupled to the tube tip portion 32a by fitting a substantially cylindrical cap 55 into which the tube tip portion 32a is inserted into the connection tube 52d from the outside. Yes.

  Inside the guide tube 52c, a guide shaft 53a of a front guide portion 53 (to be described later) is slidably inserted along the axial direction from the end opposite to the connecting tube 52d (free fitting). It has come to be.

  A needle-like member 52 a is provided at the tip of the needle support portion 52 b of the rear arm 52. The needle-like member 52a has a medium diameter part 52a1, a large diameter part 52a2, a taper part 52a3, a small diameter part 52a4, and a twisting part 52a5 from the proximal end side toward the distal end side. The edge portion 52a5 is formed so that the outer diameter of the base end thereof is larger than the outer diameter of the distal end of the small diameter portion 52a4, and a step is slightly formed at the connecting portion with the small diameter portion 52a4. The needle-like member 52a is fixed to the needle support portion 52b so that the tip thereof faces the front arm 51 and the center axis thereof is substantially parallel to the center axis of the guide tube 52c.

  If the rear arm moving tube 32 is rotated around its central axis, the needle-like member 52a is kept in the state where the central axis of the needle-like member 52a is substantially parallel to the central axis of the tube front-end portion 32a. It can be swung around the central axis of 32a.

  The needle-like member 52a can be inserted into the object to be sutured (lumen wall) to penetrate the object, and can be pulled out of the object by moving the object in the reverse direction from the state of penetration. What is necessary is just to have length and intensity | strength, The raw material, length, and shaft diameter are not specifically limited. For example, when the stomach wall is sutured by the suturing device 1, the length may be a length that can penetrate the stomach wall, and the material is preferably made of metal in terms of strength. For example, the length of the needle-like member 52a is preferably about 7 to 20 mm, and more preferably about 7 to 10 mm. Further, the shaft diameter of the large diameter portion 52a2 of the needle-like member 52a is about 1.5 to 3.0 mm, the shaft diameter of the medium diameter portion 52a1 is about 1.0 to 2.0 mm, and the shaft diameter of the small diameter portion 52a4 is 0. About 5 to 1 mm, and the shaft diameter of the twisted portion 52a5 is preferably about 0.6 to 1.5 mm at the maximum.

  As shown in FIG. 1B and the like, a ligation tool 7 for ligating the suture thread 6 is attached to the proximal end portion (medium diameter portion 52a1) of the needle-like member 52a. The ligature tool 7 combines both ends of a flexible wire and forms it into a substantially loop shape (endless shape) to form a loop member, with the middle part of the loop member being close to each other so as to be substantially parallel, A substantially cylindrical tube (clamping tube) 7a made of an elastic material is slidably fitted to the intermediate portion. For example, polyamide resin is used as the material of the loop member, and silicone elastomer is used as the material of the fastening tube 7a.

  As shown in FIG. 5B, the front arm 51 is formed in a substantially arc shape (may be V-shaped, U-shaped, U-shaped, etc.), and a pair of thread support portions (bifurcated portions) 51a. , 51a, and the suture thread 6 is attached so as to cross over the thread support portions 51a, 51a. Engagement members 6a and 6b formed in an annular shape are attached to both ends of the suture thread 6, respectively.

  Through holes 51b and 51b penetrating over the front surface (lower surface in FIG. 1B) and the rear surface (upper surface in FIG. 1B) are formed at the respective tip portions of the yarn support portions 51a and 51a of the front arm 51, A receiving space (not shown) in which the engaging members 6a and 6b can be engaged is formed on the rear surface side of the through holes 51b and 51b. A through groove is formed in part of the side portions of the through holes 51b and 51b so as to allow the suture thread 6 to pass therethrough. The accommodation space has a slightly larger diameter than the through holes 51b and 51b, and the through holes through which the engaging members 6a and 6b penetrate the front and back surfaces of the accommodation spaces with respect to the through holes 51b and 51b of the yarn support portions 51a and 51a. It is set to a diameter that can be engaged and disengaged by the inner wall in a state of being arranged so as to be substantially concentric.

  The through-holes of the engaging members 6a and 6b can be inserted through the thread-like portion 52a5 of the needle-like member 52a. However, when the screw-like portion 52a5 is completely inserted through the through-hole, the engagement member starts from the needle-like member 52a. 6a, 6b has a structure that does not fall out. Specifically, the inner diameters of the engaging members 6a and 6b are smaller than the outer diameter of the handle portion 52a5 of the needle-like member 52a, but the tip of the small-diameter portion 52a4 of the needle-like member 52a (that is, the handle-like portion 52a5). It is formed so as to be larger than the shaft diameter of the connecting portion. A suture accommodating portion 51d is provided at the center of the thread supporting portions 51a and 51a, and an intermediate portion of the suture 6 arranged over the thread supporting portions 51a and 51a is the suture accommodating portion 51d. Is to be housed.

  Further, the front arm 51 is formed with a needle accommodation hole 51c for protecting the needle-like member 52a (the binding portion 52a5) when the suturing device 1 is inserted into the body. Further, the front arm 51 is provided with a pair of protruding portions 51g and 51g on the rear surface. The protrusions 51g and 51g are provided so that the inner surfaces thereof are in contact with the outer side of the outer guide 53d of the front guide part 53 when the front arm 51 is connected to the front guide part 53.

  A through hole 51e penetrating vertically is formed in the joint portion of each of the yarn support portions 51a and 51a of the front arm 51, and a front guide portion 53 shown in FIG. 5A is formed in the through hole 51e. Is detachably fitted and fixed. The front guide portion 53 includes a guide shaft 53a, a shaft pin 53b, a connection pin 53c, an outer guide 53d, and a leaf spring 53e.

  As shown in FIGS. 5C and 5D, the guide shaft 53a is formed of a substantially cylindrical member, and three guide grooves 53a1, 53a2, and 53a3 are formed along the axial direction thereof. These guide grooves 53a1, 53a2 and 53a3 have tip portions protruding into the pin member 52e along any one of them in a state where the guide shaft 53a is inserted into the guide tube 52c of the rear arm 52. By moving, the rotation of the guide tube 52c (rear arm 52) around its axis is restricted.

  The guide grooves 53a1 and 53a2 reach both ends of the guide shaft 53a in the axial direction (from the upper end to the lower end in FIG. 5A), and the guide groove 53a3 reaches the front end (the lower end in FIG. 5A). It does not reach the end (upper end in FIG. 5A), but is halfway. The vicinity of the rear end 53a5 of the guide groove 53a3 is connected to the guide groove 53a1 via the connection groove 53a4. At this connection groove 53a4, the pin member 52e passes through the connection groove 53a4 and passes through the guide groove 53a1 or The guide tube 52c (rear arm 52) is allowed to turn (rotate) in this portion.

  Returning to FIG. 5A, a shaft pin (contact member) 53b is fixed to the rear end of the guide shaft 53a via a substantially cylindrical connection pin 53c. As shown in FIG. 5E, the shaft pin 53b is formed of a substantially cylindrical member having substantially the same diameter as the guide shaft 53a, and a connection pin 53c is inserted and fixed in the inner cavity thereof. The distal end of the front arm moving wire 31 is inserted into the lumen of the shaft pin 53b from the rear end side, and is integrally fixed to each other by welding. The shaft pin 53b is formed with a notch 53f extending on both side surfaces on the side surface. The notch 53f is formed on a side substantially 180 ° opposite to the guide groove 53a1 in a state where the shaft pin 53b is fixed to the guide shaft 53a.

  The shaft pin 53 b is a member for defining one end of the normal movement range of the front arm 51. When the front arm 51 is moved away from the rear arm 52, the shaft pin 53b abuts (interferes) with the pin member 52e to define one end of the normal movement range of the front arm 51. This is a member for holding the connection of the rear arm 52 to the tube distal end portion 32a.

  That is, when the front arm 51 is moved away from the rear arm 52 while the pin member 52e is along the guide groove 53a1 or 53a2, it passes through the rear end of the guide groove 53a1 or 53a2. The pin member 52e comes into contact with the front end surface of the shaft pin 53b almost simultaneously with the completion of the operation, thereby restricting the movement of the front arm 51 beyond one end of the normal movement range.

  When the pin member 52e is in the portion of the connection pin 53c (connection groove 53h) between the rear end of the guide shaft 53a and the front end of the shaft pin 53b, the rotation of the rear arm 52 around its axis with respect to the front arm 51 Is acceptable. For this reason, the rear arm moving tube 32 is rotated with respect to the front arm moving wire 31 so that the pin member 52e can be inserted into the desired guide groove 53a1 or 53a2. Then, by sliding the front arm moving wire 31 to the proximal end side, the movement along the corresponding guide groove 53a1 or 53a2 becomes possible.

  The notch 53f of the shaft pin 53b allows the passage of the pin member 52e only when the pin member 52e and the pin member 52e are in a predetermined positional relationship around the shaft pin 53b. This is to allow movement beyond one end of the normal movement range. Therefore, in the case of other positional relationships, the passage of the pin member 52e is restricted, and therefore the movement of the front arm 51 beyond one end of the normal movement range is not allowed.

  Referring back to FIG. 5A, the front end side of the guide shaft 53a of the front side guide portion 53 (the side opposite to the shaft pin 53b) is a substantially cylindrical shape whose front end side is closed and has an open portion communicating with the inside and outside of the side portion. It is fixed to the inner surface (rear end surface) of the closed surface of 53d. A protrusion 53g is integrally fixed to the outer surface (front end surface) of the closed surface of the outer guide 53d, and a leaf spring 53e is fixed to the protrusion 53g.

  When the protruding portion 53g is inserted into the through hole 51e of the front arm 51, the leaf springs 53e, 53e are pressed against the inner surface of the through hole 51e in accordance with the insertion, and deformed inward, and the leaf springs 53e, 53e, 53e is opened by its own elasticity, and the front arms 51 are connected to the front guide portion 53 by engaging the tip portions of the leaf springs 53e and 53e with the step surfaces 51f and 51f formed in the through hole 51e, respectively. Can be fixed. From this state, the leaf springs 53e, 53e are elastically deformed so as to be closed using a dedicated jig or the like, and the engagement of the tip portions of the leaf springs 53e, 53e with the step portions 51f, 51f is released, The front arm 51 can be separated from the front guide portion 53.

  Thus, in this embodiment, since the front arm 51 is configured to be detachably connected to the front guide portion 53, after the stitching of one needle is completed, the front arm 51 is attached to a dedicated jig. The front arm 51 with the new suture thread 6 attached thereto can be attached to the front guide portion 53. Therefore, a fine and delicate work for attaching the suture thread 6 to the front arm 51 can be performed in advance at the manufacturing site of the suturing device 1 in advance, and it is not necessary to perform this work at the medical site. Can be performed in a short time.

(Operation section)
The operation unit (handle) 4 of the suturing device 1 is configured as shown in FIGS. 1A, 2A, 3A, 6A, and 6B. In other words, the operation unit 4 includes a slider unit 41, a base unit 42, and a pair of exchange buttons 43 and 43.

  Schematically, the slider portion 41 is slidably provided on the base portion 42, and the slider portion 41 moves to the tip (distal end) side and the base end (proximal) with respect to the base portion 42. The slider unit 41 can move within the normal movement range defined by the two positions moved to the (end) side. By operating (pressing) the exchange buttons 43 and 43, the slider portion 41 can move within the normal movement range. It can move to a predetermined position (an exchange position where the rear arm 52 can be exchanged) beyond one end.

  Specifically, as best shown in FIG. 6A, the slider portion 41 is a columnar portion 41a whose distal end side is formed in a substantially columnar shape, and the proximal end side includes the columnar portion 41a. The cylindrical part 41a has a grip member 41b whose distal end is fixed. The cylindrical portion 41a of the slider portion 41 is formed with a substantially cylindrical wire insertion hole 41c that opens at the distal end thereof and extends along the axial center.

  The diameter of the wire insertion hole 41c is set to a value substantially equal to the outer diameter of the front arm movement wire 31, and the proximal end side of the front arm movement wire 31 is inserted into the wire insertion hole 41c. The proximal end side portion of the slider portion 41 is connected and fixed to the cylindrical portion 41 a of the slider portion 41.

  The base portion 42 is formed of a substantially cylindrical member formed by joining a pair of substantially symmetric half members by a plurality of screws or the like (not shown), and opens at a proximal end thereof. It has a substantially cylindrical slider portion insertion hole 42a extending along. The diameter of the slider portion insertion hole 42a is set to a value slightly larger than the outer diameter of the cylindrical portion 41a of the slider portion 41, and the cylindrical portion 41a of the slider portion 41 is inserted into the slider portion insertion hole 42a. The slider portion 41 is slidably attached to the base portion 42 along the axis. The dimension (depth) in the longitudinal direction (direction along the axial center) of the slider part insertion hole 42 a is set to a value larger than the dimension in the longitudinal direction of the columnar part 41 a of the slider part 41.

  Further, the base portion 42 has a substantially cylindrical tube insertion hole 42b that opens at the distal end thereof and extends along the axis. The tube insertion hole 42b is provided substantially coaxially with the slider portion insertion hole 42a. The diameter of the tube insertion hole 42b is set to a value substantially equal to the outer diameter of the rear arm movement tube 32, and the proximal end side of the rear arm movement tube 32 is inserted into the tube insertion hole 42b, so that the rear arm A portion on the proximal end side of the moving tube 32 is connected and fixed to the base portion 42.

  Furthermore, the base part 42 has a substantially cylindrical wire insertion hole 42c provided substantially coaxially with the slider part insertion hole 42a and the tube insertion hole 42b so as to communicate with each other. The diameter of the wire insertion hole 42c is set to a value slightly larger than the outer diameter of the front arm moving wire 31, and the front arm pulled out from the proximal end of the rear arm moving tube 32 to the wire insertion hole 42c. With the proximal end side of the moving wire 31 slidably inserted, the proximal end side portion of the front arm moving wire 31 is connected and fixed to the cylindrical portion 41a.

  A substantially ring-shaped engagement portion 42e protruding in a hook shape is provided at a slightly inner portion of the proximal end surface 42d of the base portion 42.

  A pair of exchange buttons 43 and 43 are provided in a vicinity of a portion of the grip member 41b connected to the cylindrical portion 41a so as to be substantially symmetrical with respect to the cylindrical portion 41a (so as to face each other via the cylindrical portion 41a). ) Is arranged. The exchange buttons 43 and 43 rotate with respect to a pair of rotating shafts 44 and 44 provided in the slider portion 41 so as to be substantially orthogonal to the axial center direction of the slider portion 41 (slidable direction of the slider portion 41). Supported as possible. The exchange buttons 43 and 43 are used when the rear arm 52 is removed from or attached to the arm moving means (the front arm moving wire 31 and the rear arm moving tube 32) in order to replace the rear arm 52 of the stitching portion 5. Button used.

  A single compression coil spring 44 is interposed in the proximal end portion of the pair of exchange buttons 43, 43 so as to bias the proximal end portion of the exchange buttons 43, 43 outward. In a state where no external force is applied to the pair of exchange buttons 43, 43 (a state where the force is not pressed), as shown in FIG. 6A, a state in which the inner portion on the distal end side of the exchange buttons 43, 43 sandwiches the cylindrical portion 41a. It has become. In this state, when the slider portion 41 is moved to the distal end side with respect to the base portion 42, the proximal end face 42 d of the base portion 42 abuts against the tip portions 43 a and 43 a of the exchange buttons 43 and 43. Further movement is restricted.

  In this state, the proximal end surface 42d of the base portion 42 abuts against the tip portions 43a and 43a of the exchange buttons 43 and 43, whereby the front arm moving wire 31 is moved to the distal end side with respect to the rear arm moving tube 32. Because the sliding in the direction of pushing in is restricted, one end of the normal movement range with respect to the rear arm 52 of the front arm 51 is defined.

  When both of the pair of exchange buttons 43 and 43 are pressed against the urging force of the coil spring 44 by, for example, being held between fingers, the exchange buttons 43 and 43 are rotated around the rotation shafts 44 and 44 as shown in FIG. 6B. Respectively, and the tip portions 43a, 43a are opened in a direction away from the cylindrical portion 41a. In this state, the movement restriction on the proximal end surface 42d of the base portion 42 by the distal end portions 43a and 43a of the exchange buttons 43 and 43 is released, and the slider portion 41 and the proximal end surface 42d of the base portion 42 are moved with respect to the base portion 42. Until it comes into contact with the distal end surface of the grip member 41b of the slider portion 41, it can be moved further to the distal end side.

  Thereby, the movement beyond the end of the normal movement range with respect to the rear arm 52 with respect to the front arm 51 becomes possible. In addition, when the replacement buttons 43 and 43 are pressed and the proximal end surface 42d of the base portion 42 is in contact with the distal end surface of the grip member 41b of the slider portion 41, the replacement button 43 is provided near the proximal end of the base portion 42. The engaged portions 42e are engaged with the inner portions of the tip portions of the exchange buttons 43, 43, and the exchange buttons 43, 43 are maintained open. From this state, when the slider part 41 is moved to the proximal end side with respect to the base part 42, these engagements are released, and the exchange buttons 43, 43 released from pressing are caused by the biasing force of the coil spring 45, The original state (the state of FIG. 6A) is restored.

(Suture process)
Hereinafter, an incision stitching process (sewing operation) using the suturing device 1 described above will be described with reference to FIGS. 7A to 7K. Hereinafter, a case where an incision formed in the stomach wall is sutured will be described as an example.

  First, prior to the first step shown in FIG. 7A, as shown in FIG. 1A, in the operation part 4, the slider part 41 is slid toward the proximal end side with respect to the base part 42, and as shown in FIG. In the stitched portion 5, the rear arm 52 is brought close to the front arm 51, and the tip of the needle-like member 52 a of the rear arm 52 (the edge portion 52 a 5) is housed in the needle housing hole 51 c of the front arm 51. To do. In this state, the shaft of the endoscope 2 to which the suturing device 1 is attached is inserted into the stomach, and the suturing device 1 is disposed in the vicinity of the incision to be sutured.

  Next, in the operation part 4, the slider part 41 is slid to the distal end side with respect to the base part 42, and the front arm 51 is separated from the rear arm 52 in the stitching part 5. At this time, the pin member 52e of the rear arm 52 is disposed in the guide groove 53a3 of the guide shaft 53a of the front guide portion 53, and the pin member 52e comes into contact with the end surface 53a5 of the guide groove 53a3 to thereby form the base portion. Therefore, the slider portion 41 is rotated in a predetermined direction with respect to the base portion 42 to pass the pin member 52e through the connection groove 53a4. The guide groove 53a1 is disposed.

  In the state where the pin member 52e is arranged along the guide groove 53a1, as shown in FIG. 2A, the slider portion 41 is further slid to the distal end side with respect to the base portion 42 in the operation portion 4, and FIG. As shown in FIG. 7, in the stitching portion 5, the front arm 51 is separated from the rear arm 52, and the first step shown in FIG. 7A is performed.

  In the first step shown in FIG. 7A, first, the operating unit 4 is pushed into the distal end side as a whole with respect to the case tube 33 and rotated as necessary, as shown in FIG. Only the front arm 51 that protrudes with respect to the rear arm 52 is inserted into the incision SH, and one of the thread support portions 51a of the front arm 51 and the needle-like member 52a (the edge portion 52a5) of the incision SH. The front arm 51 and the rear arm 52 are arranged so that one mouth edge portion Sa is sandwiched.

  Next, as shown in FIG. 1A, in the operation unit 4, the slider unit 41 is slid toward the proximal end side with respect to the base unit 42, and the front arm is compared with the rear arm 52 in the stitching unit 5. When 51 is brought close, as shown in FIG. 7B, the needle-like member 52a pierces one of the mouth edge portions Sa, penetrates through the mouth edge portion Sa, and the needle-like portion 52a5 of the needle-like member 52a It passes through the through hole of the engaging member 6a accommodated (supported) in the accommodation space of the one yarn support portion 51a. Thereby, the through hole of the engagement member 6a reaches the small diameter portion 52a4 of the needle-like member 52a, and the engagement member 6a is engaged with the needle-like member 52a.

  Next, as shown in FIG. 2A, in the operation portion 4, the slider portion 41 is located on the distal end side with respect to the base portion 42, and the proximal end surface 42 d of the base portion 42 is the tip portions 43 a and 43 a of the exchange buttons 43 and 43. When the front arm 51 is separated from the rear arm 52 in the stitching portion 5 as shown in FIG. 7C, the engagement member 6a is engaged. The needle-like member 52a goes back through the hole (hereinafter referred to as the first perforation) formed when the needle-like member 52a is inserted into one of the mouth edge portions Sa. As a result, a part of the suture thread 6 (a part on the engagement member 6a side) is in a state of penetrating the one edge portion Sa.

  At this time, the pin member 52e of the rear arm 52 passes through the guide groove 53a1 of the guide shaft 53a of the front guide portion 53, and a portion of the connection pin 53c (connection groove 53h) between the guide shaft 53a and the shaft pin 53b. ), The slider portion 41 is slightly rotated in a predetermined direction with respect to the base portion 42, and the pin member 52e is disposed at a position where it can be inserted into the guide groove 53a2.

  Thereafter, as shown in FIG. 7D, the front arm 51a is so held that the other mouth edge Sb of the incision SH is sandwiched between the other thread support 51a of the front arm 51 and the needle-like member 52a. 51 and the rear arm 52 are arranged.

  From this state, as shown in FIG. 1A, in the operation portion 4, the slider portion 41 is slid toward the proximal end side with respect to the base portion 42, and in the stitching portion 5, the front arm 51 with respect to the rear arm 52. 7E, as shown in FIG. 7E, the needle-like member 52a pierces the other mouth edge Sb, penetrates the mouth edge Sb, and the needle-like part 52a5 of the needle-like member 52a Passes through the through hole of the engagement member 6b accommodated (supported) in the accommodation space of the yarn support portion 51a. Thereby, the through hole of the engagement member 6b reaches the small diameter portion 52a4 of the needle-like member 52a, and the engagement member 6b is engaged with the needle-like member 52a.

  Next, in the operation unit 4, the slider unit 41 is slid to the distal end side with respect to the base unit 42, and the front arm 51 is separated from the rear arm 52 in the stitching unit 5. As shown in FIG. 7F, a hole formed when the needle-like member 52a engaged with the engaging member 6b is inserted into the other mouth edge Sb (hereinafter referred to as a second perforation) is reversed. Return to stomach. As a result, a part of the suture thread 6 (a part on the engagement member 6b side) enters the other mouth edge Sb.

  As a result, the pair of engaging members 6a and 6b, to which both ends of the suture thread 6 are fixed, are both engaged with the single needle-like member 52a, and the needle-like member 52a (that is, the stomach) is engaged by the suture thread 6. A ring is formed that penetrates the first perforation from the inner side to the outside of the stomach and returns from the outer surface of the stomach to the needle-like member 52a (that is, the stomach) through the second perforation.

  Next, in the operation portion 4, the slider portion 41 and the base portion 42 are entirely slid toward the proximal end side with respect to the case tube 33, and as shown in FIG. The part 51a) is moved into the stomach through the incision SH. When the front arm 51 (thread support part 51a) enters the stomach, the needle-like member 52a moves away from the incision part SH, and both ends of the suture thread 6 move away from the incision part SH. The portion that penetrates the first perforation and the portion that penetrates the second perforation are drawn, and the end surfaces of the pair of mouth edge portions Sa and Sb of the incision SH are brought into contact with each other and joined.

  When the operation of suturing the incision SH with the suturing apparatus 1 is completed, the operation of ligating the suture thread 6 is performed. A ligation device (not shown) is used for this work. The ligation apparatus includes, for example, a ligation tube that is introduced into a lumen via a treatment instrument guide tube of an endoscope, and a ligation wire that is slidably inserted into the ligation tube. At the upper end, there is provided a connection hook that protrudes from the distal end of the tube to open in a substantially V shape by its own elasticity and closes by being pulled into the distal end of the tube. The configured one can be used.

  As shown in FIG. 7G, the ligature tool 7 includes two loops formed by one end of the loop member (externally fitted fastening tube 7a) on the proximal end (medium diameter portion 52a1) of the needle-like member 52a. Since one of them is held in the inserted state, the distal end of the ligation tube 8 (see FIG. 7H) of the ligation apparatus is used as the other end of the loop member of the ligation tool 7 (externally fitted fastening tube). The other end of the loop member is disposed in the vicinity of the other of the two loops formed by 7a, and the other end of the loop member is gripped by a connecting hook protruding from the ligation tube 8 and opened. Is pulled into the distal end of the ligation tube 8 to connect the ligation tool 7 to the distal end of the ligation tube 8.

  Next, as shown in FIG. 7H, the distal end portion of the ligation tube 8 to which the ligature tool 7 is connected is moved to the incision portion SH side (downward in FIG. 7H), and one end of the loop member of the ligature tool 7 is obtained. The both ends of the suture thread 6 are inserted into the inside of the section. As a result, the suture thread 6 is squeezed and both ends of the suture thread 6 are bundled.

  When the ligature wire is slid so that the connecting hook is further pulled into the ligation tube 8 from the state where both ends of the suture thread 6 are bundled, as shown in FIG. 7I, a loop is formed in the tightening tube 7a. One end portion of the member is drawn together with the suture thread 6, and the one end portion of the loop member and the suture thread 6 are accommodated in the tightening tube 7a in a closely contacted and compressed state. That is, since one end portion of the loop member and the suture thread 6 are accommodated in a state of being tightly fitted in the tube 7a, the suture thread 6 and one end portion of the loop member are fixed so as not to fall out of the tube 7a. Is done. Thereby, the ligation of the suture thread 6 is completed.

  When the ligation of the suture thread 6 is completed, when the ligation tube 8 is slid toward the proximal end side so as to draw the ligation tube 8 while keeping the position of the ligation wire unchanged, the distal end of the ligation tube 8 is removed. The other end of the connecting hook and the loop member protrudes (exposes), the connecting hook is opened by its own elasticity, the grip is released, and the ligating tool is in a ligated state as shown in FIG. 7J. Separate the ligation device from 7.

  Finally, as shown in FIG. 7K, the suture thread 6 between the ligature tool 7 and the suture part 5 (needle member 52a) is cut with an endoscopic scissors forceps called a loop cutter. Then, the ligation tool 7 and the suture part 5 are separated, and if necessary, the other end of the loop member of the ligation tool 7 in a ligated state is cut and collected by a loop cutter or the like, so that one stitch is sewn. A series of procedures related to is completed.

(Replacing the rear arm)
When one or more stitches are sutured after the above-described procedure is performed, one suture thread 6 and a ligature 7 need to be attached to the suture part 5. In the present embodiment, a structure is employed in which the front arm 51 and the rear arm 52 to which the ligature tool 7 is attached can be attached and detached as necessary, and the front arm 51 and the rear arm 52 are exchanged (ligation is completed). The front arm 51 and the rear arm 52 are removed, and the front arm 5 to which the suture thread 6 is attached and the rear arm 52 to which the ligature 7 is attached are attached).

  In other words, when the stitching of one needle is completed, the suturing device 1 is pulled out of the body together with the endoscope 2, and the front arm 51 and the rear arm 52 are exchanged. Regarding the replacement of the front arm 51, as described above, the front arm 51 may be removed using a dedicated jig or the like, and the front arm 51 to which a new suture 6 is attached may be attached to the front guide portion 53. The rear arm 52 can be replaced as follows. That is, as shown in FIG. 2A, first, as shown in FIG. 2B, the operating portion 4 is sewn as shown in FIG. In the part 5, the front arm 51 is separated from the rear arm 52, and the front arm 51 is positioned at one end of the normal movement range.

  In this state, the pin member 52e of the rear arm 52 is located in the portion of the connection pin 53c (connection groove 53h) (see FIG. 5A) between the guide shaft 53a and the shaft pin 53b. By rotating the slider portion 41 by a predetermined angle (approximately 180 °) with respect to the portion 42, the pin member 52e passes through the cutout portion 53f (see FIG. 5E) of the shaft pin 53b as shown in FIG. 2C. Place in the position to get. Here, the cap 55 is moved to the proximal end side to release the fitting of the cap 55 to the connecting pipe 52d.

  In this state, as shown in FIG. 3A or 6B, in the operation unit 4, the pair of replacement buttons 43, 43 are pressed against the urging force of the coil spring 45, and the tip portions 43a, 43a are pushed. Open state. As a result, it is possible to move beyond one end of the normal movement range, so that the slider portion 41 is further slid to the distal end side with respect to the base portion 42, and the proximal end 42 d of the base portion 42 is moved to the slider portion 41. This is brought into contact with the distal end of the grip member 41b.

  By this operation, as shown in FIG. 3B, in the stitched portion 5, the pin member 52e passes through the notch 53f of the shaft pin 53b, and the guide shaft 53a and the shaft pin 53b of the front guide portion 53 are on the rear side. The arm 52 comes out of the rear guide portion (guide tube 52c), and the connection of the rear arm 52 to the front guide portion 53 is released.

  Next, as shown in FIG. 3C, the rear arm 52 is moved to the distal end side (downward in FIG. 3C) so that the distal end portion 32 a of the rear arm moving tube 32 comes out from the connection pipe 52 d of the rear arm 52. ), The rear arm 52 is moved away from the front arm moving wire 31 so that the front arm moving wire 31 passes through the through groove 52f of the rear arm 52. Thereby, the rear arm 52 can be separated (removed) from the arm moving means (the front arm moving wire 31 and the rear arm moving tube 32).

  When the separation of the used rear arm 52 is completed, the arm moving means ( It can be attached (attached) to the front arm moving wire 31 and the rear arm moving tube 32).

  According to the embodiment described above, the front guide portion 53 is moved by the rear arm connecting means (tube tip portion 32a, guide tube 52c, connection tube 52d, pin member 52e, through groove 52f, shaft pin 53b, notch portion 53f, etc.). Since the arm moving means (the front arm moving wire 31 and the rear arm moving tube 32) is detachably connected, after the stitching of one needle is completed, the used rear arm 52 is removed and a new ligation is performed. The rear arm 52 to which the tool 7 is attached can be attached. Therefore, a very fine and delicate work of attaching the ligature tool 7 to the rear arm 52 can be performed separately in advance at the manufacturing site of the suturing apparatus, and it is not necessary to perform this work at the medical site. The body tissue can be sutured in a short time. Therefore, the burden on the patient's body can be reduced.

  Further, according to the above-described embodiment, when the rear arm 52 is moved away from the front arm 51 by sliding the slider portion 41 toward the distal end side with respect to the base portion 42. In the operation unit 4, the proximal end surface 42 d of the base portion 42 abuts on the tip portions 43 a and 43 a of the replacement buttons 43 and 43, and the pin member protrudes into the guide tube 52 c of the rear arm 52 at the stitching portion 5. 52e contacts the distal end surface (front end surface) of the shaft pin 53b of the front guide portion 53 in the guide tube 52c.

  Accordingly, the replacement buttons 43 and 43 of the operation unit 4 are pressed due to an erroneous operation or the like, and the slider unit 41 can be moved beyond one end of the normal movement range with respect to the base unit 42. However, since the pin member 52e contacts the shaft pin 53b, the shaft pin 53b does not come out of the guide tube 52c of the rear arm 52.

  On the other hand, when the slider portion 41 is rotated with respect to the base portion 42 due to an erroneous operation or the like, and the pin member 52e and the notch portion 53f of the shaft pin 53b have a predetermined relationship (when they are arranged at positions corresponding to each other). ), The pin member 52e cannot pass through the cutout portion 53f unless both the pair of exchange buttons 43 and 43 are intentionally pressed. Therefore, the shaft pin 53b is removed from the guide tube 52c of the rear arm 52. Never get out.

  In this way, with the clear intention to remove the rear arm 52, the relative position of the slider portion 41 around the axis with respect to the base portion 42 is adjusted so that the pin member 52e can pass through the notch 53f. The rear side only when the operation of pressing both of the exchange buttons 43 and 43 by holding both the pair of exchange buttons 43 and 43 with a finger and moving the slider portion 41 to the exchange position is performed. The arm 52 can be detached from the arm moving means (the front arm moving wire 31 and the rear arm moving tube 32). Therefore, it is possible to effectively prevent the rear arm 52 from being unexpectedly dropped from the arm moving means (the front arm moving wire 31 and the rear arm moving tube 32).

  In the above-described embodiment, the exchange buttons 43 and 43 are provided with a pair arranged substantially symmetrically, but only one of them may be provided. The replacement button may be any button that can selectively allow or restrict movement of the slider portion 41 beyond one end of the normal movement range with respect to the base portion 42. Not limited to. Furthermore, in the above-described embodiment, the ligature tool 7 is attached to the proximal end portion (medium diameter portion 52a1) of the needle-like member 52a of the rear arm 52. What is necessary is just to select suitably according to the shape of the back side arm 52, etc., so long as it does not interfere with the suturing operation and the ligation tool 7 can be removed after the suturing operation is completed and the suture thread 6 is to be ligated.

  The embodiment described above is described for facilitating understanding of the present invention, and is not described for limiting the present invention. Therefore, each element disclosed in the above-described embodiment is intended to include all design changes and equivalents belonging to the technical scope of the present invention.

DESCRIPTION OF SYMBOLS 1 ... Suture apparatus 2 ... Endoscope 3 ... Sheath part 31 ... Front arm moving wire (long body, arm moving means)
32. Rear arm moving tube (tubular body, arm moving means)
33 ... Case sheath 4 ... Operation part 41 ... Slider part 42 ... Base part 43 ... Exchange button 44 ... Rotating shaft 45 ... Coil spring 5 ... Suture part 51 ... Front arm 51a ... Thread support part 52 ... Rear arm 52a ... Needle shape Member 52c ... Guide tube 52d ... Connection tube 52e ... Pin member (projection member)
52f ... Through groove 53 ... Front side guide part 53a ... Guide shaft 53b ... Shaft pin (contact member)
53c ... Connection pin 53f ... Notch 53h ... Connection groove 6 ... Suture 6a, 6b ... Engagement member 7 ... Ligature 7a ... Tightening tube SH ... Incision part Sa, Sb ... Mouth edge

Claims (5)

A suturing device that is inserted into the body and used.
A front arm to which a suture is attached;
A rear arm having a needle-like member;
Arm moving means for approaching and separating the front arm and the rear arm;
Rear arm connecting means for detachably connecting the rear arm to the arm moving means;
A suturing device. The rear arm connecting means is
A projecting member provided on the rear arm;
A contact member that is provided on the front arm and holds the connection of the rear arm to the arm moving means when the rear arm is moved away from the front arm. And
The suturing device according to claim 1, wherein the abutting member has a cutout portion through which the protruding member can pass only when the protruding member is in a predetermined positional relationship. The arm moving means has a long body having a distal end and a proximal end, respectively, and a tubular tubular body through which the long body is slidably inserted.
Connecting the distal end of the elongate body to the abutment member;
The suturing device according to claim 1 or 2, wherein a distal end of the cylindrical body is detachably connected to the rear arm. The rear arm has a rear guide portion including a substantially cylindrical member through which the elongated body is inserted,
The said rear side guide part has a width | variety larger than the diameter of the said elongate body, and has a penetration groove which penetrates inward and outward from the proximal end of this rear side guide part to a distal end. The suturing device according to any one of the above.   The suturing device according to any one of claims 1 to 4, wherein a ligature used for ligating the suture thread obtained by suturing a body tissue is attached to the rear arm.

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