US20100155453A1 - Surgical Staples Frangibly Connected to Staple Holding Strip - Google Patents

Abstract

A surgical tool may include a staple holding strip, and surgical staples frangibly connected to an edge of that staple holding strip.

Description

• This application is a continuation of U.S. patent application Ser. No. 11/756,260, filed on May 31, 2007, which in turn is a divisional of U.S. patent application Ser. No. 10/151,441, filed on May 20, 2002, now U.S. Pat. No. 7,285,131, which in turn is a continuation-in-part of U.S. patent application Ser. No. 09/363,255, filed on Jul. 28, 1999, now U.S. Pat. No. 6,391,038, each of which is herein incorporated by reference in its entirety.
FIELD OF THE INVENTION
• The invention relates to an apparatus and method for performing anastomosis.
BACKGROUND
• Anastomosis is a procedure by which two hollow tissue structures are joined together. More particularly, vascular anastomosis is a procedure by which two blood vessels within a patient are surgically joined together. Vascular anastomosis is performed during treatment of a variety of conditions including coronary artery disease, diseases of the great and peripheral vessels, organ transplantation, and trauma. In coronary artery disease (CAD) an occlusion or stenosis in a coronary artery interferes with blood flow to the heart muscle. Treatment of CAD involves the grafting of a vessel in the form of a prosthesis or harvested artery or vein to reroute blood flow around the occlusion and restore adequate blood flow to the heart muscle. This treatment is known as coronary artery bypass grafting (CABG).
• In the conventional CABG, a large incision is made in the chest and the sternum is sawed in half to allow access to the heart. In addition, a heart-lung machine is used to circulate the patient's blood so that the heart can be stopped and the anastomosis can be performed. In order to minimize the trauma to the patient induced by conventional CABG, less invasive techniques have been developed in which the surgery is performed through small incisions in the patient's chest with the aid of visualizing scopes. In both conventional and less invasive CABG procedures, the surgeon has to suture one end of the graft vessel to the coronary artery and the other end of the graft vessel to a blood-supplying artery, such as the aorta. The suturing process is a time consuming and difficult procedure requiring a high level of surgical skill. In order to perform the suturing of the graft to a target vessel such as the coronary artery or the blood supplying artery, a surgeon holds the edges of the incision in the target vessel with one handle and holds a needle in the other hand for suturing, or an assistant may hold the edges of the incision in the target vessel while a surgeon makes small stitches as close as possible to the edges of the incision. This suturing requires a high degree of precision and is quite time consuming. In addition, during conventional CABG procedures blood flow at the anastomosis site is stopped during suturing. This prevents bleeding from the incision site but also prevents blood from reaching a portion of the heart muscle served by the vessel. Further, during off-pump CABG procedures a side clamp or other device may be used to isolate a portion of the wall of the aorta to which a graft vessel is sutured. The use of a side clamp or similar device can cause emboli to detach from the wall of the aorta and enter the bloodstream, which is undesirable.
• Accordingly, it would be desirable to provide a vascular anastomosis system that allows the tissue at the anastomosis site to be controlled during suturing or other connection of the graft and target vessels. It would also be desirable to provide a vascular anastomosis system that allows the connection of a graft vessel to a target vessel prior to making an incision in the target vessel which allows blood flow between the target vessel and the graft vessel.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a perspective view of an anvil and a plurality of staples according to a first aspect of the present invention.
• FIG. 2 is a perspective view of the anvil ofFIG. 1 being inserted into a target vessel.
• FIG. 3 is a perspective view of the anvil tenting a wall of a target vessel for an anastomosis procedure.
• FIG. 4 is a perspective view of a graft vessel placed adjacent an exterior of the tented target vessel for the anastomosis procedure.
• FIG. 5 is a perspective view of the staples being applied to the graft vessel and the target vessel during an anastomosis procedure.
• FIG. 6 is a perspective view of the completed anastomosis according to the first aspect of the present invention.
• FIG. 7 is a perspective view of a staple supported on a staple holding strip.
• FIG. 8 is a side view of the staple and staple holding strip ofFIG. 7 when the ends of the staple have been bent by contact with an anvil.
• FIG. 9 is a perspective view of an anvil and staple according to another aspect of the present invention.
• FIGS. 10A and 10B are is a side views of a plurality of staples supported on two examples of expandable staple holding strips.
• FIG. 11 is a perspective view of a portion of an anvil having a movable cutting device.
• FIG. 12 is a side view of an anvil having an external cutting device.
• FIGS. 12A and 12B are side views of a portion of an anvil and two cutting devices that snap onto the anvil.
• FIG. 13 is a side view of a portion of an anvil with an extendable cutting device.
• FIG. 14 is a side view of the anvil ofFIG. 13 with the cutting device extended.
• FIG. 15 is a side view of a portion of an anvil with an alternate extendable cutting device.
• FIG. 16 is a side view of the anvil ofFIG. 15 with the cutting device extended.
• FIG. 17 is a perspective view of an anvil according to a second aspect of the invention being inserted into a target vessel.
• FIG. 18 is a perspective view of the anvil ofFIG. 17 positioning inside a target vessel and a clamp being advanced to clamp the wall of the target vessel between the anvil and the clamp.
• FIG. 19 is a perspective view of a graft vessel being advanced to the target vessel with a continuous anastomosis staple while the anastomosis site on the target vessel is controlled by the anvil and clamp.
• FIGS. 20-22 are side cross sectional views of the steps of performing the anastomosis with the continuous anastomosis staple shown inFIG. 19.
• FIG. 23 is a perspective view of the completed anastomosis performed as shown inFIGS. 19-22.
• FIGS. 24-27 are perspective views of the steps of an alternative anvil and clamp system for controlling an anastomosis site and forming an incision through the clamped tissue of the target vessel.
• FIG. 28 is a perspective view of a system for controlling a tissue site and performing anastomosis according to the present invention.
• FIG. 29 is a cross sectional view taken along line C-C ofFIG. 28, showing a first step of the anastomosis procedure.
• FIG. 30 is a cross sectional view taken along line C-C ofFIG. 28, showing a second step of the anastomosis procedure.
• FIG. 31 is a cross sectional view taken along line C-C ofFIG. 28, showing a third step of the anastomosis procedure.
• FIG. 32 is a perspective view of an anvil according to another aspect of the present invention for use with sutures.
• FIG. 33 is a perspective view of the anvil ofFIG. 32 positioned within a target vessel and used to locate a plurality of suture at an anastomosis site.
• FIG. 34 is a side cutaway view of a first embodiment of an anvil, a cutter and a staple holder, where the anvil and staple holder are spaced apart from each other.
• FIG. 35 is an end cross-section view of the anvil ofFIG. 34.
• FIG. 36 is a side cutaway view of a portion of the anvil inserted into the lumen of a target vessel.
• FIG. 37 is a side view of the cutter.
• FIG. 38 is a perspective view of the cutter ofFIG. 37.
• FIG. 39 is a side view of the distal end of a second embodiment of a cutter.
• FIG. 40 is a side view of the distal end of a third embodiment of a cutter.
• FIG. 41 is a side view of the distal end of a fourth embodiment of a cutter.
• FIG. 42 is a side view of a portion of a fifth embodiment of a cutter.
• FIG. 43 is a side view of the distal end of a sixth embodiment of a cutter.
• FIG. 44 is a side cutaway view of the anvil and staple holder ofFIG. 34, where the cutter is in a first position.
• FIG. 45 is a side cutaway view of the anvil and staple holder ofFIG. 34, where the cutter is in a second position.
• FIG. 46 is a side cutaway view of the anvil and staple holder ofFIG. 34, where the cutter is in a third position.
• FIG. 47 is a side cutaway view of the anvil and staple holder ofFIG. 34, where the cutter is in a fourth position.
• FIG. 48 is a side cutaway view of the anvil and staple holder ofFIG. 34, where the cutter is in a fifth position.
• FIG. 49 is a side cutaway view of a second embodiment of an anvil and a staple holder, where the anvil and staple holder are spaced apart from each other.
• FIG. 50 is a side cutaway view of the anvil and staple holder ofFIG. 40, where the cutter is in a first position.
• FIG. 51 is a side cutaway view of the anvil and staple holder ofFIG. 40, where the cutter is in a second position.
• FIG. 52 is a side cutaway view of the anvil and staple holder ofFIG. 40, where the cutter is in a third position.
• FIG. 53 is a side cutaway view of the anvil and staple holder ofFIG. 40, where the cutter is in a fourth position.
• FIG. 54 is a side cutaway view of the anvil and staple holder ofFIG. 40, where the cutter is in a fifth position.
• The use of the same reference symbols in different figures indicates similar or identical items.
DETAILED DESCRIPTION
• As shown inFIG. 1, one embodiment of ananvil10 includes ahandle12 and ananvil arm14 extending from thehandle12. Theanvil arm14 may be oriented substantially perpendicular to thehandle12, or oriented at a different angle. Theanvil arm14 may be provided with one or more staple bending features16 on opposite sides of theanvil arm14. In theanvil10 shown inFIG. 1, the staple bending features16 each include a plurality ofrecesses20 which receive the ends ofstaples22 and cause the staple ends to bend over. At least one of the staple bending features16 may be configured differently or omitted, if desired. Thestaples22 may be connected to astaple holding strip24. Thestaples22 are U-shaped and are arranged in a spaced apart parallel configuration such that thestaples22 all lie in a single plane. Alternately, thestaples22 may be shaped differently, and/or lie in one or more different planes. Anexemplary anvil arm14 has a height and a width of about 2 mm or less, advantageously about 1 mm or less, and a length of about 2 to 15 mm, advantageously 5 to 12 mm. The length of the anvil will vary depending on the diameter of the graft vessel selected. The length to width ratio of theanvil arm14 is substantially between 2:1 and 15:1. A different length to width ratio may be used, if desired. As one example, thestaples22 have widths of about 0.2-3 mm. Advantageously, thestaples22 have widths of substantially 2 mm or less. The leg lengths of thestaples22 are substantially 0.2-3 mm. Alternately, other leg lengths may be used.
• Theanvil arm14 has a sharpdistal end28 for puncturing the tissue of a target vessel to insert theanvil arm14 into the target vessel. As illustrated inFIG. 2, theanvil arm14 is inserted into a pressurized orunpressurized target vessel30 by puncturing the target vessel with thedistal end28 of theanvil arm14. The hole that is formed in the wall of thetarget vessel30 by theanvil arm14 is small enough to prevent significant bleeding through the puncture site. Alternately, the hole is closed by hand suturing. Alternately, the hole is closed with a biocompatible glue, adhesive or the like. Alternately, the hole is closed with a clip, clamp, or other implantable device that remains on the target vessel. Such a device may be positioned on the outer surface and/or inner surface of the target vessel, and may extend into the hole. A device for closing the hole may be constructed from nitinol or other superelastic or pseudoelastic material, or from stainless steel or other material, where that device moves between a first configuration and a second configuration during deployment, and where the second configuration holds the hole closed. The hole is less than substantially 2 mm wide, and advantageously less than 1 mm wide. Alternately, theanvil arm14 has a bluntdistal end28 that is inserted through a hole created with a separate instrument, by a different instrument connected to theanvil arm14, or by a sharp member connected to theanvil arm14 that can be refracted into theanvil arm14 or otherwise blunted or concealed after puncturing or creating an incision in the wall of the target vessel.
• Once theanvil arm14 has been inserted into thetarget vessel30, theanvil arm14 may be pulled against an inner wall of thetarget vessel30, causing tenting of the thin tissue of the vessel wall as illustrated inFIG. 3. This tenting of the vessel wall provides control over the anastomosis site during an anastomosis procedure that is described with respect toFIGS. 4-6. However, tenting of the target vessel wall need not be tented in order to control the anastomosis site during the anastomosis procedure.
• As shown inFIG. 4, agraft vessel32 is advanced to the anastomosis site and anend34 of thegraft vessel32 is positioned adjacent an exterior surface of thetarget vessel30 at the anastomosis site. The tented portion of thetarget vessel30 is positioned within the perimeter of theend34 of thegraft vessel32. As shown inFIG. 5, astaple holder38 is provided having twoarms40 which are pivotally connected to thehandle12 of theanvil10. Alternatively, the pivotingarms40 of thestaple holder38 may be connected to thehandle12 in a different way, or may be connected to a separate or additional device. Thearms40 are spaced apart from one another across at least a part of their length. Thus, the graft vessel can be positioned between thearms40. That is, thearms40 are positioned on substantially opposite sides of the graft vessel. In this way, eacharm40 may be positioned against a flap at an end of the graft vessel, as illustrated inFIGS. 29-31. Thearms40 may be configured differently, if desired.
• Referring also toFIG. 1, thestaple holder38 may be used to holdindividual staples22 and/or staple holding strips24. In one embodiment, eacharm40 of thestaple holder38 carries one row ofstaples22 or onestaple holding strip24, where thestaples22 are arranged in a substantially linear row. Alternately,staples22 or staple strips24 may be arranged in two or more rows, parallel or otherwise, on one ormore arms40. Alternately, thestaples22 may be staggered on one or more arms, such that at least one row ofstaples22 does not fall along a straight line. Thestaples22 or staple strips24 may be arranged or aligned in any manner on eacharm40 that results in a secure anastomosis between the graft vessel and the target vessel. Thestaples22 are inserted through the flaps at the end of thegraft vessel32, or another portion of the target vessel, and into thetarget vessel30 by pivoting thearms40 of thestaple holder38 towards theanvil arm14. The staple bending features16 are positioned in a configuration corresponding to the configuration of thestaples22, such that each staple22 engages a correspondingstaple bending feature16 during deployment. When the ends of thestaples22 engage the staple bending features16 on theanvil arm14, the ends of thestaples22 are bent over, securing thegraft vessel32 andtarget vessel30 together. Once the staple ends are bent over, thestaples22 are released from thestaple holding strip24 or thestaple holder38, resulting in spaced apartstaples22 securing thegraft vessel32 and thetarget vessel30 together as shown inFIG. 6. Alternately, thestaple holder38 is a connector deployer that deploys connectors other than or in addition tostaples22.
• After stapling is complete, an incision is formed in the wall of thetarget vessel30 to allow blood flow between the target vessel and thegraft vessel32. Some examples of methods and devices for forming the incision will be described in further detail below.FIG. 6 illustrates a completed anastomosis between atarget vessel30 and agraft vessel32 with a plurality ofstaples22. The spacing between thestaples22 is approximately 1 to 4 mm. This spacing is similar to the spacing between sutures in a conventional sutured anastomosis. A different spacing between thestaples22 may be used if desired. After completion of the anastomosis, theanvil arm14 is withdrawn from thetarget vessel30 betweenadjacent staples22. The withdrawal of theanvil arm14 leaves a gap that is approximately the same as the spacing between adjacent staples. Accordingly, substantially no blood leakage occurs at the location where the anvil arm has been withdrawn.
• FIGS. 7 and 8 illustrate one example of a staple22 connected to astaple holding strip24. Thisstaple22 includes barbed staple ends52 extending from the front portion of the staple22 and a C-shapedportion54 extending from a rear of the staple22 for connecting the staple22 to thestaple holding strip24. Thestaple holding strip24 includes a plurality ofprotrusions56 for receiving thestaples22. The C-shapedportion54 of each staple22 is received around one of theprotrusions56 and is secured in place at one or more locations, such as bywelds58 or by a frangible linkage or connection. Alternately, the C-shapedportion54 of each staple22 may be secured to the staple-holdingstrip24 in a different way. As shown inFIG. 8, when thestaple holding strip24 is advanced toward theanvil arm14, the barbed staple ends52 are received in therecesses20 in theanvil arm14. Contact between eachstaple end52 and thecorresponding recess20 generates a moment that causes the barbed staple ends52 to bend towards one another. At the same time that the barbed staple ends52 bend over, or after the bending of the staple ends52, thestaple22 is detached from thestaple holding strip24. The staple22 may be detached from thestaple holding strip24 by the action of bending the barbed staple ends52 such that the C-shapedportion54 of the staple22 splays outward and breaks apart from the correspondingprotrusion56 on thestaple holding strip24, by bending a frangible connection between the staple holding strip and the staples to separate the staples, or any other known separation methods, such as melting of a connection between the staple and the staple holding strip.
• FIG. 9 illustrates an alternate staple22ahaving inwardly curved barbed staple ends52a.Because the staple ends52aare themselves curved, the corresponding staple bending feature or features16aneed not be curved to bend the ends52aof the staples22a.As shown inFIG. 9, the staple bending features16aon each side of the anvil arm14amay be formed as a single longitudinal groove along the anvil arm14a,where the staple bending feature16ahas a substantially flat surface. When the curved ends52aof the staple22aare received in the groove16aof the anvil arm14a,the ends bend inward to secure the tissue with the staple. Alternately, the staple may be configured differently. Alternately, two or more different kinds of staples are deployed by thestaple holder38 in order to form a single anastomosis.
• Referring also toFIG. 10A, a plurality of staples22aare positioned on an expandable staple holding strip called anexpandable backbone66. Theexpandable backbone66 includes a plurality ofelements68 which are interconnected by one or more expandingmembers70. Each of thebackbone elements68 is provided with a connectingdiamond member72 that is connected to one of the staples22a.As shown inFIG. 10A, each staple22ais connected to thecorresponding diamond member72 by a thin connectingsection74. Theexpandable backbone66 allows the spacing between the staples22ato be adjusted for the particular anastomosis to be performed. Thebackbone66 allows expansion of the distance between staples from a distance of approximately 0.1 mm to a distance of approximately 1 to 4 mm, i.e., expansion of up to 40 times the original spacing. Alternately, thebackbone66 allows a different amount of expansion. The expandingbackbone66 also includes twoopenings76 at opposite ends which may be engaged by holding pins (not shown) on an anastomosis system or staple holder. Theopening76 allow thebackbone66 to be easily expanded by relative motion of the holding pins. The connectingdiamond members72 are configured to collapse inwardly toward the backbone when the staples22aengage the staple bending surface or surfaces16aof the anvil. The collapsing of eachdiamond member72 forces the corresponding staple22ato separate from thediamond member72 at a connectingsection74. The connectingsection74 is a frangible linkage connecting a staple22ato acorresponding diamond member72.
• FIG. 10B illustrates another example of staples22adetachably connected to abackbone66. The staples22aare each connected to the associatedbackbone elements68 at two connectingsections74. The staples22a,backbone66, and associated components are substantially as described above with regard toFIG. 10A.
• FIG. 11 shows a portion of ananvil arm14 with amovable cutting device44. The cuttingdevice44 includes abase46 and ablade48. Thebase46 of the cuttingdevice44 is positioned in alongitudinal groove50 in theanvil arm14. After theanvil arm14 has been inserted into the target vessel, the cuttingdevice44 may be moved longitudinally along theanvil arm14 to form an incision in the target vessel.
• FIGS. 12,12A, and12B illustrate external cutting devices that are advanced down onto theanvil arm14 after the anastomosis procedure and cut an incision in the target vessel from an exterior of the target vessel as theanvil arm14 is withdrawn. As shown inFIG. 12, aknife62 is positioned on aknife arm64 that is movable along thehandle12 of the anvil. Theknife62 is moved downward in a direction substantially parallel to the longitudinal axis of thehandle12 until theknife62 engages arecess65 in theanvil arm14. Theknife62 is thereby positioned substantially at the anastomosis site. The end of the graft vessel is then placed substantially against the wall of the target vessel at the anastomosis site, over theknife62 andknife arm64. As theanvil arm14 is withdrawn from the anastomosis site, theknife62 forms an incision in the target vessel. Theknife62 andknife arm64 exit the anastomosis site via the joint between the graft vessel and the target vessel. The withdrawal of theanvil arm14,knife62 andknife arm64 leaves a gap in the wall of the target vessel that is approximately the same as the spacing between adjacent staples to minimize or eliminate leakage through that gap. Alternately, theknife62 may be moveable relative to thehandle12 in at least one direction in addition to a direction substantially parallel to the longitudinal axis of thehandle12. For example, theknife62 may be moveable in a direction substantially parallel to the wall of the target vessel to create an arteriotomy in the target vessel at the junction between the graft vessel and the target vessel.
• FIGS. 12A and 12B illustrate two alternate examples of theknife62 which snap onto acorresponding engagement surface65 of theanvil arm14 so that the knife and anvil are secured together for formation of the incision during removal of theanvil arm14 from the anastomosis site.
• FIGS. 13-16 illustrate two variations of extendable cutting devices for making an incision in the target vessel while withdrawing theanvil arm14 from the target vessel.FIG. 13 illustrates ananvil arm14bhaving ablade78 connected to aflexible blade support80. When theblade support80 is pulled in the direction of the arrow A with respect to theanvil arm14b,theblade78 moves from a forwardly extending position shown inFIG. 13 to an upwardly extending position shown inFIG. 14 as a result of flexure of theblade support80. Theblade78 in the forwardly extending position may be used to form a small opening in the wall of the target vessel through which theanvil arm14 is inserted into the target vessel. After an anastomosis has been performed, or while an anastomosis is performed, theblade78 is moved to an upwardly angled or a vertical position in which theblade78 is used to form an incision in the target vessel as theanvil arm14bis removed from the target vessel.
• FIGS. 15-16 illustrate an alternate example of ananvil arm14chaving ablade84 and ablade support86. While theanvil arm14cis inserted into the target vessel and during the anastomosis procedure, theblade84 is positioned in arecess88 in the anvil arm. Theblade84 may be moved from the position ofFIG. 15 to the extended position ofFIG. 16 by moving theblade support86 in the direction of the arrow B with respect to the anvil arm. Theblade84 is flexible and stressed, such that freeing theblade84 from therecess88 causes theblade84 to move to the extended position. Alternatively, theblade84 may be extended automatically upon withdrawal of theanvil arm14 when ablade tip90 catches on an interior surface of the target vessel wall during withdrawal of the anvil arm.
• The extendable cutting devices shown inFIGS. 13-16 are merely shown as examples of the type of cutting devices which may be used for making the incision. Once these cutting devices or blades have been extended from the anvil arm, they may be fixed to perform cutting as the anvil arm is removed from the target vessel or the blades may be movable along the anvil arm to make an incision prior to removal of the anvil arm from the target vessel.
• Another embodiment of theanvil10 also includes acutter200 that is moveable relative to theanvil10 for making an incision in the wall of a target vessel. Referring toFIGS. 34 and 35, atissue stop220 is formed into or connected to theanvil10. The portion of theanvil10 distal to thetissue stop220 is configured to penetrate into the wall of a target vessel, and may be referred to as theanvil arm14. Achannel246 is defined within theanvil arm14, through which acutter200 is configured to move. Thecutter200 is narrower than thechannel246, such thatinterior surfaces202 on either side of thechannel246 may guide the translation of thecutter200 relative to theanvil arm14. As used in this document, the term “translation” as used in regard to thecutter200 refers to motion of thecutter200 in the distal or proximal direction, whether or not thecutter200 or a portion thereof moves upward or downward during that motion. For convenience, the direction substantially perpendicular to the longitudinal centerline of theanvil arm14 toward the wall of the target vessel may be referred to as “upward”, and the direction substantially perpendicular to the longitudinal centerline of theanvil arm14 away from the wall of the target vessel may be referred to as “downward”. However, the positioning of theanvil arm14 in use is not limited to an orientation in which these directions correspond to absolute directions measured relative to the ground. Similarly, for convenience, motion upward or downward may be referred to as “vertical” motion, and motion substantially parallel to the longitudinal centerline of theanvil arm14 may be referred to as “horizontal” motion.
• Theanvil arm14 includes acontact surface206. Referring also toFIG. 36, in use, thecontact surface206 of theanvil arm14 is placed substantially against theinner surface203 of atarget vessel201. Thecontact surface206 substantially defines a place that is substantially parallel to the longitudinal centerline of theanvil arm14. Alternately, thecontact surface206 is contoured and/or oriented differently. Anupper opening248 extends along at least a portion of thecontact surface206 in a direction substantially parallel to the longitudinal centerline of theanvil arm14, and opens into thechannel246. Theupper opening248 may divide thecontact surface206 into symmetrical or asymmetrical sections. Further, thecontact surface206 may be formed by two substantially planar surfaces, by one substantially planar surface and a differently-shaped surface, or by another set of surfaces. Additionally, thecontact surface206 may be formed by two thin edges, each edge occurring at the intersection of a wall of theupper opening248 and an outer surface of theanvil arm14. Theupper opening248 need not extend proximally any further than thetissue stop220. However, theupper opening248 may extend proximal to thetissue stop220, if desired. A firstlower opening254 and a secondlower opening268 are defined through alower surface256 of theanvil arm14. Thelower surface256 of theanvil arm14 may be substantially parallel to thecontact surface206 or may be oriented differently relative to thecontact surface206. Alternately, the firstlower opening254 and/or the secondlower opening268 do not extend completely through theanvil arm14, and instead are depressions extending along at least part of abottom surface266 of thechannel246
• Referring also toFIGS. 37-38, thecutter200 is a thin, rigid member, shaped such that it can be held within thechannel246 in theanvil arm14. Thecutter200 has a substantially constant width along its entire length. Alternately, the width of thecutter20 may vary along its length. Thecutter200 may be made of metal, ceramic, plastic, or other material, or from a combination of different materials. Asharp projection208 extends upward from thecutter200 at or near its distal end. Theprojection208 is substantially triangular, but may be shaped differently. Theprojection208 may be smooth or serrated, or otherwise shaped or formed. A portion of theprojection208 may be ground or otherwise honed to a sharp edge to facilitate the motion of theprojection208 through the tissue of the wall of a target vessel, as described in greater detail below. If so, thecutter200 is composed of a material that can be sharpened adequately to cut tissue. Alternately, thecutter200 may be flexible, at least in part. Further, theprojection208 may be located at a different position on thecutter200 than at or near its distal end. An additional sharp point (not shown) may be provided at the distal end of thecutter200, extending in a distal direction, in order to create an initial puncture or incision in the wall of the target vessel. Such a point may be as described in U.S. patent application Ser. No. 10/134,081, which is herein incorporated by reference in its entirety.
• One or moreadditional projections208 may be provided, if desired. For example, two ormore projections208 may extend upward from thecutter200. Wheremultiple projections208 are used, they may cooperate with one another to create an incision in the wall of the target vessel. Referring also toFIG. 39, asecond projection208 extends upward from thecutter200 proximal to afirst projection208. Theprojections208 are both substantially the same triangular shape and the same size. However, theprojections208 may be shaped and sized differently. Theprojections208 are both substantially planar, and are aligned such that bothprojections208 lie in substantially the same plane. Eachprojection208 may include at least one sharpened orbeveled edge209 oriented to engage and incise the wall of the target vessel when thecutter200 is translated, as described below. Referring toFIG. 40, at least twoprojections208 extend upward from thecutter200. Theprojections208 each have abarb211 at the tip. However, thebarb211 may be omitted from some or all of theprojections208. Under thebarb211, a sharpened orbeveled edge209 extends downward and proximally. Theedge209 may be straight or curved. The upper end of theedge209 is distal to the lower, proximal end of the corresponding barb. Theedge209 of eachprojection208 is oriented to engage and incise the wall of the target vessel when thecutter200 is translated. Referring toFIG. 41, at least twoprojections208 extend upward from thecutter200, at least one of which has abarb211 at its tip. Theedge209 associated with eachprojection208 is more curved than theedge209 shown inFIG. 40. Alternately, theedge209 is substantially straight, or gently curved, or positioned on a portion of a largercurved segment213 extending downward from and proximal to thebarb211. Referring toFIG. 42, a number ofprojections208 may be placed along a length of thecutter200. This length may be comparable to the desired length of the incision in the wall of the target vessel. Theseprojections208 may be substantially triangular as shown, or may be shaped differently. Where more than oneprojection208 is used on thecutter200, theprojections208 need not have the same configuration. For example,projections208 such as theexemplary projections208 shown inFIGS. 39-41 may be mixed together on thesame cutter200. Alternately, one or more of theprojections208 are moveable relative to thecutter200, such that one ormore projections208 can be moved upward or downward relative to thecutter200.
• As another example of a configuration of theprojections208, referring toFIG. 43, theprojections208 extending upward from thecutter200 each are substantially planar, and are aligned such that not all of theprojections208 lie in the same plane. In such a configuration, theprojections208 may create a wider incision in the wall of the target vessel than would be created if theprojections208 were substantially aligned. For example, one set ofprojections208 may be aligned substantially in a first plane, and a second set ofprojections208 may be aligned substantially in a second plane substantially parallel to the first plane. The second plane and the first plane may be oriented differently relative to one another, if desired. As another example, none of theprojections208 lie in a common plane with one or moreother projections208. Referring toFIGS. 39-42, by using multiple projections, thecutter200 need not be translated as far to make an incision in the wall of the target vessel as it would if only asingle projection208 were used, as described in greater detail below.
• Referring back toFIGS. 34-35, aninterior surface202 is located on each side of thechannel246. Eachinterior surface202 may be substantially planar, curved, or may be shaped differently. Further, eachinterior surface202 may be oriented at an angle to vertical or substantially vertical. The interior surfaces202 may be formed such that thechannel246 is substantially bilaterally symmetrical, or may be formed to result in achannel246 that is not bilaterally symmetrical. The interior surfaces202 of thechannel246 within theanvil arm14 may include raisedfeatures204 that correspond to depressed staple bending features (not shown) on the outer surface of theanvil arm14. That is, if the staple bending features are stamped into theanvil arm14, or formed in another way that causes deformation of theanvil arm14, the depressed staple bending features result in corresponding raised features204 on theinterior surface202 of thechannel246. The raised features204 do not interfere with the motion of thecutter200 through thechannel246. Alternately, the raised features204 are not present on theinterior surface202 of thechannel246.
• Asafety feature210 is connected to the underside of theanvil10 and is biased toward theanvil10 and thecutter200. Thesafety feature210 may be biased into thechannel246 within theanvil10. Alternately, thesafety feature210 is connected to a different location, such as the underside of theanvil arm14. Thesafety feature210 may be flexible or rigid. Thesafety feature210 includes atip212 that is oriented substantially transverse to the longitudinal centerline of thecutter200. Alternately, thetip212 may be oriented in a different direction. Thecutter200 includes asafety recess214 defined in it, corresponding to thetip212 of thesafety feature210. Thetip212 is shaped and sized such that it can engage thesafety recess214. Thetip212 may be a bar or rod oriented substantially transverse to the direction of translation of thecutter200, or may be shaped or oriented differently. InFIG. 34, thestaple holder38 has not yet been moved into position to perform anastomosis. In this position, thetip212 of thesafety feature210 is biased upward to engage thesafety recess214. The engagement between thesafety recess214 and thetip212 of thesafety feature210 substantially prevents translation of thecutter200 within thechannel246. Thus, thecutter200 and theprojection208 are prevented from deploying until thestaple holder38 has been moved into the appropriate position relative to theanvil arm14, and inadvertent deployment of thecutter200 is prevented.
• Thecutter200 includes anengagement member216 extending upward from a location at or near its proximal end. Theengagement member216 instead may extend downward from thecutter200 or to the side of thecutter200. Further, theengagement member216 may be positioned at a location other than at or near the proximal end of thecutter200. Theengagement member216 is configured to engage at least a portion of acorresponding receiver218 in thestaple holder38. Thus, after engagement between theengagement member216 and thereceiver218, translation of thereceiver218 results in translation of thecutter200. Thereceiver218 is a structure that is at least partially open on its underside and that includes at least onesurface219 configured to engage theengagement member216. As shown inFIG. 34, thesurface219 is a partially-curved surface shaped to receive the curved upper end of theengagement member216. However, thereceiver218 may be a flat vertical surface, a curved surface, a structure such as an inverted cup that is open on its underside and that has a wall or walls encircling theengagement feature216, or any other structure or mechanism capable of engaging theengagement feature216 and urging it distally.
• Ananvil insert222 is fixed to theanvil10. Alternately, theanvil insert222 is connected to and capable of motion relative to theanvil10. Further, theanvil insert222 may be connected to the proximal end of theanvil arm14, or another location on theanvil arm14. Acavity228 is defined within theanvil insert222. Anaperture230 is defined through the distal end of theanvil insert222 into thecavity228, connecting thechannel246 in theanvil arm14 andanvil10 to thecavity228. Thecutter200 extends through theaperture230, such that the distal end of thecutter200 is positioned within thechannel246 and the proximal end of thecutter200 is positioned within thecavity228.
• Acutter stop236 may be formed into or connected to theanvil insert222. Thecutter stop236 may engage the proximal end of thecutter200 if thecutter200 is moved to a defined position within thecavity228, thereby restricting its proximal translation. Acavity262 may be defined within thestaple holder38 or a separate component connected to thestaple holder38. Apost258 is positioned at the upper end of thecavity262, where thepost258 is oriented downward. A biasingelement260 is connected at one end to thepost258. The biasingelement260 may be a coil spring, a leaf spring, a different type of spring, an elastomer, a wire form, or other structure or mechanism capable of exerting a biasing force. The biasingelement260 is positioned within and protected by thecavity262, where thecavity262 is used. Thecavity262 may be a cylindrical opening having a diameter substantially the same as the outer diameter of the biasingelement260, such that thecavity262 restricts the biasingelement260 to motion substantially along the axis of thecavity262 and thus directs the force exerted by the biasingelement260 in a substantially downward direction, preventing bending or other undesirable motion of the biasingelement260. The end of the biasingelement260 that is not connected to thepost258 contacts thecutter200. As an example, the biasingelement260 may be a compression spring that is compressed between thepost258 and thecutter200, resulting in a force on thecutter200 that biases thecutter200 downward. Thecutter200 is slidable relative to the biasingelement260, such that the biasingelement260 exerts a downward force on thecutter200 at different locations along itsupper surface252 as thecutter200 translates. Thus, at least the distal end of thecutter200 is biased downward throughout its translation along theanvil10. Theentire cutter200 may be biased downward, if desired. Alternately, thepost258 is omitted, and the biasingelement260 is fixed to an upper surface of thecavity260. Alternately, the biasingelement260 is omitted, and thecutter200 is biased downward in another way. For example, thecutter200 may be constructed from an elastic or superelastic material that is formed in such a way as to produce a downward bias.
• As shown inFIG. 34, the distal end of theanvil arm14 initially is spaced apart from thestaple holder38. While the distal end of theanvil arm14 is spaced apart from thestaple holder38, theanvil arm14 is inserted through the wall of the target vessel, which is not shown for clarity. Advantageously, theanvil arm14 has a cross-section small enough to allow it to enter the target vessel easily and to result in minimal or no leakage from the target vessel after theanvil arm14 is removed. The distal tip of theanvil arm14 may be sharp such that theanvil arm14 itself penetrates the wall of the target vessel, resulting in an opening in the wall of the target vessel substantially the same size as the cross-section of theanvil arm14. Alternately, a sharp retractable projection (not shown) is provided at the distal end of theanvil arm14. The retractable projection is extended to allow the distal end of theanvil arm14 to penetrate the wall of the target vessel, then retracted into theanvil arm14. The retractable projection may be a wire, a blade, a substantially conical member, a screw or a screw-tipped rod, or any other sharp structure or mechanism capable of penetrating the wall of the target vessel. Such a retractable projection may be as described in U.S. patent application Ser. No. 10/134,081, which is herein incorporated by reference in its entirety. Alternately, thecutter200 includes a blade (not shown) at its distal end, where the blade is configured to swivel. In a first position, the blade is configured to extend substantially distal to the distal end of theanvil arm14, such that the blade can penetrate the wall of the target vessel. Then, the blade is swiveled upward such that it can act as aprotrusion208 such as described inFIGS. 39-42. Alternately, a separate mechanism or structure is used to penetrate the wall of the target vessel, and theanvil arm14 is later inserted through that penetration.
• Referring also toFIG. 36, after insertion, the distal end of theanvil arm14 enters the lumen of the target vessel. Theanvil arm14 is advanced into the target vessel until atissue stop220 on theanvil arm14 encounters the edge of the penetration in the wall of the target vessel. Thetissue stop220 is substantially flat and/or blunt, and extends upward or in another direction relative to theanvil arm14 to increase the height and/or width of theanvil arm14. Thetissue stop220 increases the cross-section of theanvil arm14 such that theanvil arm14 cannot easily move further into the penetration in the wall of the target vessel after the tissue stop220 encounters the outer wall of the target vessel. Because thetissue stop220 is blunt, it does not penetrate the wall of the target vessel or act to expand the size of the existing penetration. Thus, the distance between the distal end of theanvil arm14 and the tissue stop220 substantially determines how much of theanvil arm14 is allowed into the lumen of the target vessel. After theanvil arm14 has been inserted into the lumen of the target vessel, thecontact surface206 of theanvil arm14 is substantially in contact with the inner surface of the wall of the target vessel.
• Next, referring also toFIG. 44, thestaple holder38 and theanvil10 are rotated or otherwise moved closer to one another to a standby position. As thestaple holder38 andanvil10 move closer together, thestaple holder38 holds flaps at the end of the graft vessel, which are configured substantially as shown inFIGS. 29-31, against the surface of the target vessel at the site of the anastomosis. The flaps are substantially fixed relative to the surface of the target vessel, such that the end of the graft vessel is substantially immobile relative to the wall of the target vessel. Thus, the position of the end of the graft vessel relative to the wall of the target vessel remains substantially unchanged throughout the duration of the anastomosis procedure. The perimeter of the end of the graft vessel defines a closed area on the wall of the target vessel. Consequently, the location of a connection made between the end of the graft vessel and the wall of the target vessel is substantially registered with an opening made within the closed area in the wall of the target vessel, regardless of the order in which the connection and the opening are made. Further, the position of the end of the graft vessel relative to the wall of the target vessel substantially maintains position registration throughout the duration of the anastomosis procedure relative to the opening in the wall of the target vessel through which theanvil arm14 is inserted. For clarity, the flaps and graft vessel are not shown inFIG. 44. Thestaple holder38 andanvil10 may be actuated to move between the position shown inFIG. 34 and the position shown inFIG. 44 by any structure, mechanism or method. As one example, a cable (not shown) is connected to theanvil10 at or near ashoulder224 proximal to thetissue stop220. This connection may be made by soldering, welding, winding the cable tightly around theanvil10 at theshoulder224, or in any other way that results in a secure connection between the cable and theanvil10. To move theanvil10 and thestaple holder38 relative to one another, the cable is tensioned, causing theanvil10 and/or the connectedanvil insert222 to rotate around a pivot point such as apin226 that pivotally connects thestaple holder38 to theanvil10. Thepin226 may be formed into or otherwise fixed to thestaple holder38 oranvil arm14, if desired. Thus, theanvil10 and thestaple holder38 rotate relative to one another to the standby position.
• As thestaple holder38 andanvil10 move together, theengagement member216 engages thereceiver218. Further, the relative motion of thestaple holder38 and theanvil10 causes thestaple holder38 to contact thesafety feature210 and urge it downward against its upward bias. Consequently, thetip212 of thesafety feature210 is moved downward out of engagement with thesafety recess214 of thecutter200. Alternately, another structure or mechanism is configured to engage thesafety feature210 when thestaple holder38 andanvil10 are moved together, so as to urge thetip212 out of thesafety recess214. Thus, in the standby position, thecutter200 is freed for translation along thechannel246
• Optionally, aninterface structure238 may be connected to or formed into thestaple holder38. Theinterface structure238 engages theanvil10 or a component associated with theanvil10 as thestaple holder38 and theanvil10 move to the standby position, such as by snapping onto a corresponding feature (not shown) on theanvil10. By doing so, theinterface structure238 holds thestaple holder38 substantially fixed relative to theanvil10, in order to maintain registration between the target vessel, the graft vessel, theanvil10 and thestaple holder38. Theinterface structure238 may be a tab, rail, bump, or any other feature that is capable of engaging a corresponding feature and holding thestaple holder38 substantially fixed relative to theanvil10. Alternately, theinterface structure238 is formed into or connected to theanvil10 and engages a corresponding feature on thestaple holder38.
• Referring also toFIG. 45, after thecutter200 has been freed for translation, thecutter200 is urged distally relative to theanvil arm14. Advantageously, thestaple holder38 has stapled or otherwise connected the graft vessel to the target vessel before thecutter200 is urged forward, such that the two vessels are connected before thecutter200 makes an incision between them. Alternately, thecutter200 may be urged forward while thestaple holder38 is stapling or otherwise connecting the graft vessel to the target vessel, or before thestaple holder38 has stapled or otherwise connected the graft vessel to the target vessel.
• Thecutter200 is urged distally by thereceiver218, which engages theengagement feature216 of thecutter200. Thereceiver218 is configured to travel along aguide structure241. Theguide structure241 is a rail or other structure along which thereceiver218 slide, and thereceiver218 interfaces with and translates along the rail. Thus, theguide structure241 guides the translation of thereceiver218. Alternately, theguide structure241 is a hollow channel defined within thestaple holder38, such that the walls of the channel guide the translation of thereceiver218. Alternately, theguide structure241 may be any other structure or mechanism capable of guiding the translation of thereceiver218. Theguide structure241 is substantially aligned with theanvil arm14. That is, the longitudinal centerline of theguide structure241 is substantially parallel to the longitudinal centerline of theanvil arm14. Thus, motion of thereceiver218 along theguide structure241 causes translation of theengagement feature216 and therefore translation of thecutter200 substantially parallel to the centerline of theanvil arm14. Thereceiver218 may be actuated to translate along theguide structure241 by an actuator (not shown). The actuator may directly transmit force from a human hand or the like to the cutter, such as via a cable (not shown). The cable may be the same cable described above that may be utilized to rotate theanvil10 andstaple holder38 relative to one another, or may be a different cable. Alternately, the actuator may convert stored energy to force that is applied to the cutter. Such stored energy may be provided by a spring, battery, source of compressed gas, or other source. Alternately, any mechanism, structure or method, using stored energy or not, may be used to translate thereceiver218 along theguide structure241. The particular mechanism, structure or method used to cause translation of thecutter200 is not critical to the invention. Acavity240 is provided in thestaple holder38 adjacent to theguide structure241 to allow for motion of thereceiver218 along theguide structure241. Thecavity240 is sized to allow thereceiver218 to translate freely.
• Theupper surface252 of thecutter200 is substantially planar proximal to theprojection208. The biasingelement260 contacts theupper surface252 of thecutter200 and biases thecutter200 downward. Thecutter200 includes akeel264 that extends downward. Thekeel264 may be formed into thecutter200, or may be a separate component connected to thecutter200. Thekeel264 is substantially as wide as the adjacent portion of thecutter200. However, thekeel264 may be wider or narrower than the adjacent portion of thecutter200. Thekeel264 is positioned at or near the distal end of thecutter200. Alternately, thekeel264 may be positioned at a different location on thecutter200.
• As shown inFIG. 45, thekeel264 initially extends into the firstlower opening254, which is defined through alower surface256 of theanvil10. Thekeel264 may extend completely through the firstlower opening254, such that its lowest point extends outside theanvil10. Thekeel264 is biased downward into the firstlower opening254 as a result of the downward force exerted on thecutter200 by the biasingelement260. While thekeel264 is biased into the firstlower opening254, theprojection208 remains below thecontact surface206 of theanvil arm14. In this way, theprojection208 does not extend out of theanvil arm14 while theanvil arm14 is inserted into the wall of a target vessel. The firstlower opening254 extends along a fixed length of thelower surface256 of theanvil10. As thecutter200 translates distally, thekeel264 continues to remain at least partially within the firstlower opening254, such that theprojection208 continues to remain below thecontact surface206 of theanvil arm14. Initially, thekeel264 may be positioned proximal to the distal end of the firstlower opening254. The length of the firstlower opening254 is selected to cause theprojection208 to remain below thecontact surface206 of theanvil arm14 across that distance. That is, this distance is selected such that theprojection208 on thecutter200 does not engage the wall of the target vessel until theprojection208 is positioned within the circumference of the graft vessel. That is, the connection between the graft vessel and the target vessel substantially defines a closed area, and theprojection208 is configured to engage the wall of the target vessel within that closed area. In this way, theprojection208 makes an incision completely within the connection between the graft vessel and the target vessel, completing the anastomosis between the two vessels and minimizing or eliminating leakage at the anastomosis site. While theprojection208 on thecutter200 remains below the upper surface of theanvil arm14, it neither engages nor cuts the wall of the target vessel.
• Referring also toFIG. 46, thecutter200 continues to advance distally as thereceiver218 continues to impel theengagement feature216 distally. As described above, at least the distal end of thecutter200 is biased downward. As thecutter200 advances distally, thekeel264 encounters the distal end of the firstlower opening254. This encounter, and the continued proximal translation of thecutter200, causes thekeel264 to move upward relative to theanvil arm14. Thekeel264 and/or the distal end of the firstlower opening254 may be constructed to provide a smooth, gradual upward motion of thekeel264, such as by providing a gradual slope on thekeel264 and/or the distal end of the firstlower opening254. Alternately, thekeel264 and/or the distal end of the firstlower opening254 may be constructed to allow or cause thekeel264 to move upward abruptly upon encountering the distal end of the firstlower opening254. The upward motion of thekeel264 causes the distal end of thecutter200 and theprojection208 to move upward. Thus, the size and position of the firstlower opening254, including the position of the distal end of the firstlower opening254, control the motion of thecutter200 and theprojection208 in the vertical direction.
• As the distal end of thecutter200 moves upward, theprojection208 moves upward through theupper opening248 in theanvil arm14. Thecontact surface206 of theanvil arm14 is substantially adjacent to the inner surface of the wall of the target vessel. Thus, upward motion of theprojection208 through theupper opening248 and above thecontact surface206 of theanvil arm14 causes theprojection208 to enter the wall of the target vessel. Thecutter200 continues to move distally, such that thekeel264 moves out of the firstlower opening254 completely and contacts thebottom surface266 of thechannel246 of theanvil arm14. Theprojection208 is sized such that theprojection208 completely penetrates the wall of the target vessel when thekeel264 has moved proximally to the firstlower opening254 and is in contact with thebottom surface266 of thechannel246. That is, at least a portion of theprojection208 passes through the wall of the target vessel and enters the lumen of the target vessel. This initial penetration of the wall of the target vessel defines the starting point of an arteriotomy performed on the target vessel by theprojection208. The starting point of the arteriotomy is spaced apart from the location on the target vessel at which theanvil arm14 is inserted, because thecutter200 and theprojection208 have moved proximally a selected distance before penetrating or incising the wall of the target vessel. The portion of the wall of the target vessel between the arteriotomy and the insertion point of theanvil arm14 may be referred to as a tissue bridge. The incision is referred to as an arteriotomy for convenience, and this terminology does not limit the type of anastomosis that may be performed. For example, anastomosis may be performed between two tissue structures that are not blood vessels, such as bile ducts.
• Referring also toFIG. 47, thecutter200 continues to advance distally as thereceiver218 continues to impel theengagement feature216 distally. The lower surface of thekeel264 contacts thebottom surface266 of thechannel246 during this translation. The contact between thekeel264 and thebottom surface266 of thechannel246 counteracts the downward bias of the distal end of thecutter200. In this way, theprojection208 is maintained above thecontact surface206 of theanvil arm14. As thecutter200 continues to translate distally, theprojection208 moves through the tissue of the wall of the target vessel in a direction substantially parallel to the longitudinal centerline of theanvil arm14, and incises the tissue of the wall of the target vessel to create an arteriotomy. Because theprojection208 is connected to and translated by thecutter200, which is within the target vessel, the arteriotomy is performed from within the target vessel. The tip of theprojection208 may maintain substantially the same height relative to thecontact surface206 of theanvil arm14 during translation of thecutter200, or may change its height relative to thecontact surface206 of the anvil arm, as long as theprojection208 continues to incise completely through the wall of the target vessel.
• Referring also toFIG. 48, a secondlower opening268 is defined through thelower surface256 of theanvil arm14. The secondlower opening268 is distal to and substantially aligned with the firstlower opening254. Thecutter200 continues to advance distally as thereceiver218 continues to impel theengagement feature216 distally. As a result of this translation, thekeel264 encounters the proximal end of the secondlower opening268. Because the distal end of thecutter200 is biased downward, thekeel264 moves downward at least partially into the secondlower opening268. The downward motion of thekeel264 causes the distal end of thecutter200 and theprojection208 to move downward. Thekeel264 and/or the proximal end of the secondlower opening268 may be constructed to provide a smooth, gradual downward motion of thekeel264, such as by providing a gradual slope on thekeel264 and/or the proximal end of the secondlower opening268. Alternately, thekeel264 and/or the proximal end of the secondlower opening268 may be constructed to allow or cause thekeel264 to move downward abruptly upon encountering the proximal end of the secondlower opening268. The downward motion of the distal end of thecutter200 causes theprojection208 to retract into or completely through theupper opening248, such that theprojection208 no longer encounters the tissue of the wall of the target vessel. Theprojection208 may be urged downward completely into thechannel246, depending on the depth of thechannel246 and the height of theprojection208. Alternately, the upper tip of theprojection208 may remain within theupper opening248. Thecutter200 may stop its distal translation at substantially the same time that theprojection208 retracts completely into theupper opening248, or may continue to translate distally within thechannel246 before coming to a stop. Alternately, the secondlower opening268 is not provided, and only the firstlower opening254 extends through thelower surface156 of theanvil arm14 into thechannel246. In such a configuration, thecutter200 is retracted in the proximal direction after the arteriotomy is formed, until thekeel264 moves downward into the firstlower opening254 and theprojection208 consequently retracts completely into theupper opening248.
• When theprojection208 is retracted out of the tissue of the wall of the target vessel, the distal end of the arteriotomy is defined, and the arteriotomy is complete. The distal end of the firstlower opening254 and the proximal end of the secondlower opening268 control the motion of theprojection208 and thereby control the penetration of the wall of the target vessel. That is, the distance between the distal end of the firstlower opening254 and the proximal end of the secondlower opening268 determines the length of the arteriotomy.
• After performing the arteriotomy, thecutter200 is in a distally-extended position. Thecutter200 remains in that position as theanvil arm14 is removed from the target vessel. Thus, theprojection208 does not extend out of theupper opening248 during removal of theanvil arm14 from the target vessel. Theanvil arm14 is removed from the target vessel after the anastomosis between the graft vessel and the target vessel has been completed. Alternately, after performing the arteriotomy, thecutter200 may be moved proximally within thechannel246 in theanvil arm14 before removing theanvil arm14 from the target vessel. The hole in the wall of thetarget vessel30 through which theanvil arm14 enters the target vessel is small enough to prevent significant bleeding through the puncture site. Alternately, the hole is closed by hand suturing. Alternately, the hole is closed with a biocompatible glue, adhesive or the like. Alternately, the hole is closed with a clip, clamp, or other implantable device that remains on the target vessel. Such a device may be positioned on the outer surface and/or inner surface of the target vessel, and may extend into the hole. A device for closing the hole may be constructed from nitinol or other superelastic or pseudoelastic material, or from stainless steel or other material, where that device moves between a first configuration and a second configuration during deployment, and where the second configuration holds the hole closed. The hole is less than substantially 2 mm wide, and advantageously less than 1 mm wide.
• Referring toFIG. 49, another embodiment of theanvil10 also includes acutter200 moveable relative to theanvil10 for making an incision in the wall of a target vessel. Theanvil10,anvil arm14,staple holder38, and other components are substantially as described above with regard toFIGS. 34-38 and44-49. Referring toFIGS. 35 and 49, theanvil insert222 is connected to theanvil10. Anaperture230 is defined through the distal end of theanvil insert222 into thecavity228 defined within theanvil insert222, connecting thechannel246 to thecavity228. Thecutter200 extends through theaperture230 in theanvil insert222, such that the distal end of thecutter200 is positioned within thechannel246 and the proximal end of thecutter200 is positioned within thecavity228. Acam232 is positioned within thecavity228 above theaperture230. Alternately, thecam232 may be positioned differently relative to theaperture230. Thecam232 is a structure used in controlling the motion of thecutter200, as is described in greater detail below.
• At least the distal end of thecutter200 may be biased upward. This biasing may be performed by any appropriate structure or mechanism, such as by one or more springs (not shown). Such a spring or springs may act in compression to push the distal end of thecutter200 upward, or may act in tension to pull the distal end of the cutter upward. As another example, thecutter200 may be constructed from an elastic or superelastic material that is formed in such a way as to produce an upward bias. Theentire cutter200 may be biased upward, if desired. At least the distal end of thecutter200 is biased upward during the translation of thecutter200 along theanvil arm14. Alternately, thecutter200 is not biased, either upward or downward. Instead, thecutter200 is urged upward and downward at different locations during its translation by the interaction between at least one cam follower on thecutter200 and at least thecam232.
• As shown inFIG. 49, the distal end of theanvil arm14 is spaced apart from thestaple holder38. Theanvil arm14 is inserted through the wall of the target vessel, as described above, such that thecontact surface206 of theanvil arm14 is in substantial contact with the inner wall of the target vessel. Next, referring toFIG. 50, thestaple holder38 andanvil10 are moved relative to one another into the standby position, as described above. In the standby position, thecutter200 is freed for translation along thechannel246, because thetip212 of thesafety feature210 no longer engages thesafety recess214 of thecutter200. At least the distal end of thecutter200 is biased upward, and thecam232 limits the upward motion of thecutter200 by contacting at least a portion of theupper surface252 of thecutter200. Thecam232 controls the motion of the distal end of thecutter200 in the vertical direction as thecutter200 translates within thechannel246. Because theprojection208 is fixed to thecutter200, thecam232 also controls the motion of theprojection208 in the vertical direction, and thus controls the location at which theprojection208 encounters the wall of the target vessel.
• Referring also toFIG. 51, after thecutter200 has been freed for translation, it is urged distally by thereceiver218 as described above. Afirst cam follower242 is defined on theupper surface252 of thecutter200. Thefirst cam follower242 is a raised structure formed into theupper surface252 of thecutter200. Alternately, thefirst cam follower242 is a separate structure or mechanism constructed separately from thecutter200 and later connected to thecutter200. Alternately, thefirst cam follower242 may be located on a surface of thecutter200 in addition to or instead of itsupper surface252, depending on the position and configuration of thecam232. Thefirst cam follower242 may be shaped as a trapezoid or similar shape, or may be shaped differently.
• Thecam232 is fixed, and thefirst cam follower242 is raised relative to theupper surface252 of thecutter200. At least the distal end of thecutter200 is biased upward. Thus, as thecutter200 translates distally, thecam232 engages thefirst cam follower242 and causes thecutter200 to move downward. Thecam232 and thefirst cam follower242 are shaped to smoothly engage each other. Alternately, thefirst cam follower242 is shaped to induce thecutter200 to abruptly move downward when thefirst cam follower242 initially encounters thecam232. The height of thefirst cam follower242 relative to thecontact surface206 of theanvil arm14 determines the distance that the distal end of thecutter200 is moved downward. As described above, thecutter200 may include akeel264 or similar projection extending downward. As the distal end of thecutter200 moves downward, thekeel264 or other projection moves into the firstlower opening254. In this embodiment, the firstlower opening254 does not control the motion of thecutter200; instead, it provides a space for thekeel264 to move downward without interfering with the vertical motion of the distal end of thecutter200. If thekeel264 is omitted, the firstlower opening254 and the secondlower opening268 may be omitted as well.
• The connection between the graft vessel and the target vessel substantially defines a closed area, and theprojection208 is configured to engage the wall of the target vessel within that closed area. That is, the end of the graft vessel has a perimeter that contacts the side of the target vessel, such that the perimeter of the end of the graft vessel defines a closed area on the wall of the target vessel. In this way, theprojection208 makes an incision completely within the connection between the graft vessel and the target vessel, completing the anastomosis between the two vessels and minimizing or eliminating leakage at the anastomosis site. While theprojection208 on thecutter200 remains below thecontact surface206 of theanvil arm14, it neither engages nor cuts the wall of the target vessel. Thus, thefirst cam follower242 is sized to translate the tip of theprojection208 below thecontact surface206 of theanvil arm14 for a selected distance such that theprojection208 does not engage the tissue of the target vessel until theprojection208 is positioned to enter the closed area on the wall of the target vessel defined by the perimeter of the end of the graft vessel.
• Referring also toFIG. 52, thecutter200 continues to advance distally as thereceiver218 continues to impel theengagement feature216 distally. Thus, thefirst cam follower242 of thecutter200 advances distally relative to thecam232. As described above, at least the distal end of thecutter200 is biased upward. Thefirst cam follower242 decreases in height at its proximal end. Thus, as the upwardly-biasedfirst cam follower242 moves distally relative to thecam232, thecam232 and thefirst cam follower242 gradually disengage, causing both the distal end of thecutter200 and theprojection208 to move upward. Thefirst cam follower242 is constructed to provide a smooth, gradual upward motion of the distal end of thecutter200 and theprojection208, such as by providing a gradual slope between anupper surface250 of thefirst cam follower242 and anupper surface252 of thecutter200. Alternately, thefirst cam follower242 may be constructed to allow the distal end of thecutter200 and theprojection208 to abruptly snap upward as thefirst cam follower242 moves distal to thecam232.
• As the distal end of thecutter200 moves upward, theprojection208 moves upward through theupper opening248 in theanvil arm14. Thecontact surface206 of theanvil arm14 is adjacent to the inner surface of the wall of the target vessel. Thus, upward motion of theprojection208 through theupper opening248 causes theprojection208 to enter the wall of the target vessel. Theprojection208 is sized, and thefirst cam follower242 andcam232 are shaped, such that the upward motion of theprojection208 after thefirst cam follower242 has moved distal to thecam232 causes theprojection208 to completely penetrate through the wall of the target vessel. That is, at least a portion of theprojection208 passes through the wall of the target vessel and enters the lumen. This initial penetration of the wall of the target vessel defines the starting point of an arteriotomy performed on the target vessel by theprojection208. The starting point of the arteriotomy is spaced apart from the location on the target vessel at which theanvil arm14 is inserted, resulting in a tissue bridge therebetween.
• Referring also toFIG. 53, thecutter200 continues to advance distally as thereceiver218 continues to impel theengagement feature216 distally. Theupper surface252 of thecutter200 may contact thecam232 during this motion, because the distal end of thecutter200 continues to be biased upward. As thecutter200 translates, theprojection208 moves through the tissue of the wall of the target vessel in a direction substantially parallel to the longitudinal centerline of theanvil arm14. In this way, theprojection208 incises the tissue of the wall of the target vessel to create an arteriotomy. The tip of theprojection208 may maintain substantially the same height relative to thecontact surface206 of theanvil arm14 during its distal translation, or may change its height relative to thecontact surface206 of theanvil arm14, as long as the tip of theprojection208 remains in the lumen of the target vessel during that translation.
• Referring also toFIG. 54, asecond cam follower244 is defined on theupper surface252 of thecutter200, proximal to and spaced apart from thefirst cam follower242. Alternately, a single cam follower is defined on theupper surface252 of thecutter200, where that single cam follower includes a feature corresponding to thefirst cam follower242, a feature corresponding to thesecond cam follower244, and a section of reduced height between them corresponding to theupper surface252 of thecutter200. Thecutter200 continues to advance distally as thereceiver218 continues to impel theengagement feature216 distally. As a result of this motion, thesecond cam follower244 contacts thecam232. Engagement between thesecond cam follower244 and thecam232 pushes the distal end of thecutter200 downward. The shape and size of thesecond cam follower244 andcam232 are selected such that the distal end of thecutter200 is pushed downward far enough to cause theprojection208 to retract into theupper opening248. Theprojection208 may be urged downward completely into thechannel246, depending on the depth of thechannel246 and the height of theprojection208. Alternately, the upper tip of theprojection208 may remain within theupper opening248. Thecutter200 may stop its distal translation at substantially the same time that theprojection208 retracts completely into theupper opening248, or may continue to translate distally within thechannel246 before coming to a stop.
• When theprojection208 is retracted out of the tissue of the wall of the target vessel, the distal end of the arteriotomy is defined, and the arteriotomy is complete. The distance between thefirst cam follower242 and thesecond cam follower244, and the shape of thecam followers242,244, determine the length of the arteriotomy. That is, eachcam follower242,244 includes a location thereon having a height relative to theupper surface252 of thecutter200 sufficient to cause theprojection208 to be pushed out of contact with the wall of the target vessel. The distance between these locations defines the length of the arteriotomy. Thus, thecam followers242,244 control the motion of theprojection208 and control the penetration of the wall of the target vessel.
• After performing the arteriotomy, thecutter200 is in a distally-extended position. Thecutter200 remains in that position as theanvil arm14 is removed from the target vessel. Theanvil arm14 is removed from the target vessel after the anastomosis between the graft vessel and the target vessel has been completed. Alternately, after performing the arteriotomy, thecutter200 may be moved proximally within thechannel246 before removing theanvil arm14 from the target vessel. The hole at the puncture site and its closure are substantially as described above.
• Alternately, in the embodiment ofFIGS. 34-35 and44-49, or the embodiment ofFIGS. 50-54, thecutter200 is initially in a distally-extended position, and retracted proximally in order to make an incision in the wall of the target vessel. The structures and mechanisms are as described above, but operated in substantially the reverse order as described above. Alternately, thecutter200 and theprojection208 may be moved in a different way in order to incise the tissue of the wall of the target vessel.
• Wheremultiple projections208 are provided on thecutter200 as shown inFIGS. 39-43, thecutter200 need not be translated as far to make an incision in the wall of the target vessel as it would if only a single projection were used. Because theprojections208 are spaced apart from each other along the direction of translation of thecutter200, eachprojection208 is able to form a portion of the incision during translation of thecutter200. Thus, by translating eachprojection208 across a distance less then the intended length of the entire incision, the complete incision can be formed. The distance that thecutter200 is translated to form the incision is related to the distance between theprojections208. That is, because eachprojection208 forms a portion of the incision, nosingle projection208 need be translated along the entire length of the incision.
• Alternately, wheremultiple projections208 are utilized, theprojections208 may be inserted into the wall of the target vessel, after which energy is applied to theprojections208 via thecutter200 or directly in order to create an incision in the wall of the target vessel. In such an embodiment, an energy source (not shown) is connected to thecutter200. For example, an ultrasound generator (not shown) may be connected to thecutter200 and to the energy source. The ultrasound generator may be a piezoelectric crystal, as is standard, or a different structure or mechanism. Electrical energy may be applied to the ultrasound generator from the energy source, thereby causing the ultrasound generator to vibrate theprojections208. Thus, energy may be applied from the energy source to the ultrasound generator after theprojections208 have been inserted into the wall of the target vessel, causing theprojections208 to move and thereby create an incision. Advantageously, a plurality ofprojections208 spaced relatively close to one another are utilized. Other methods may be used to vibrate, move or oscillate theprojections208.FIGS. 17-23 illustrate analternate anvil100 that is used with aclamp102 for controlling an incision site during an anastomosis procedure. As shown inFIGS. 17 and 18, theanvil100 includes ananvil arm104 and ahandle106. Theclamp102 is slidable on thehandle106 to clamp the tissue of thetarget vessel30 between theclamp102 and theanvil arm104. As with theanvil arm104 described above, theanvil arm104 includes two rows of staple bending features108 in the form of recesses positioned in two parallel rows along a top surface of theanvil arm104. Theclamp102 has acentral opening110. Once the tissue of the target vessel wall has been trapped between theclamp102 and theanvil arm104, an incision may be made through the target vessel wall and the edges of the incision are controlled by the combination of theanvil arm104 and theclamp102.
• As shown inFIG. 19, a continuous anastomosisstaple device114 may be used to connect thegraft vessel32 to thetarget vessel30 at the anastomosis site. Thestaple device114 as shown inFIG. 19 includes a plurality of linkages forming a tubular configuration and a plurality of staple ends extending from the linkages.FIGS. 20-22 illustrate how the staple ends116 of thestaple device114 are positioned in the end of thegraft vessel32 and are inserted through theincision118 in the target vessel and bent over by contact with the staple bending features108 of the anvil. As shown inFIG. 22, the opposite ends120 of thestaple device114 are folded over to complete the anastomosis.FIG. 23 illustrates a completed anastomosis performed according to the steps illustrated inFIGS. 19-22.
• FIGS. 24-27 illustrate an alternate example of ananvil arm14dhaving acutting wire124 for forming the incision in the wall of thetarget vessel30. Thecutting wire124 may be used to form an incision before, during or after performing an end-to-side anastomosis procedure. Referring particularly toFIGS. 26-27, for forming the incision after the anastomosis procedure, aclamp126 is used to trap the tissue at the anastomosis site between theclamp126 and theanvil arm14dprior to performing the incision. The incision is spaced apart from the entry point of theanvil arm14dinto the target vessel, creating a tissue bridge between the incision made in the wall of the target vessel and the entry point of theanvil arm14dinto the target vessel. A portion of the contact between the anastomosed graft vessel and target vessel extends across the tissue bridge, such that the incision is located within the closed area defined by the contact between the perimeter of the end of the graft vessel and the wall of the target vessel.
• FIG. 28 shows asystem140 for controlling a tissue site and performing anastomosis. For purposes of clarity, the staple holder and staples have been omitted fromFIG. 28. Thesystem140 includes ananvil arm142, acutter144, and agraft vessel holder146 all mounted on ahandle148. Theanvil arm142 is mounted on thehandle148 and connected to afirst actuator150 that allows the anvil to be moved downward against the bias of a spring inside the handle. Thecutter144 may be spring biased or fixed and is positioned on thehandle148 directly above theanvil arm142. Thegraft vessel holder146 includes two fixedarms152 and twomovable arms154. The twomovable arms154 are connected to asecond actuator156 on thehandle148. Depression of thesecond actuator156 against the bias of a spring within the handle causes themovable arms154 to be moved downward away from the fixed arms to receive portions of a graft vessel between the movable and fixed arms.
• The operation of thesystem140 ofFIG. 28 is shown in the cross sectional views ofFIGS. 29-31. As shown inFIG. 29, an end of agraft vessel32 is split so that each half of thegraft vessel32 can be held between afixed arm152 and amovable arm154. In order to load thegraft vessel32 into thesystem140, thefirst actuator150 and thesecond actuator156 are depressed to move theanvil arm142 and themovable arms154 downward. Thesplit graft vessel32 is then inserted between the fixed andmovable arms152,154 and thesecond actuator156 is released to trap the ends of thegraft vessel32, as shown inFIG. 30. Theanvil arm142 is then inserted into thetarget vessel30 in the same or similar manner as described above.
• Once the anvil has been inserted in thetarget vessel30 as shown inFIG. 30, thefirst actuator150 is released to allow the anvil to move upward to tent the wall of the target vessel.FIG. 31 illustrates thetented target vessel30 positioned adjacent the split and trappedgraft vessel32 in a position for performing anastomosis. Thestaple holders38 are then advanced in the direction of the arrows D toward opposite sides of the anvil to staple the graft vessel and target vessel together. Thestaple holders38 may hold a staple strip with an expandable backbone as shown inFIGS. 10A and 10B, or may instead or additionally hold different types of staples not connected to a backbone. Thestaple holders38 may be provided with movable pins which allow the spacing between the staples to be adjusted depending on a size of the graft vessel used. Once the staples have been placed, theanvil arm142 is removed and thecutter144 makes an incision in the target vessel before or during removal of the anvil.
• As described above, staple bending features are provided on the anvil and staples are provided at an exterior of the tissue. Alternately, the staples and/or staple holding strips may be positioned on the anvil and an exterior member with staple bending features may be moved toward the anvil to bend the ends of the staples and secure the graft and target vessels together.
• FIGS. 32-33 illustrate the use of analternate anvil130 for controlling the tissue at an anastomosis site. Theanvil130 includes alongitudinal opening132 extending through theanvil130 for application of a plurality of conventional sutures at the anastomosis site. According to this method, theanvil130 is inserted into thetarget vessel30 and pulled against the interior wall of thetarget vessel30, tenting the target vessel as shown inFIG. 33.Sutures134 are then passed through theopening132 in theanvil130 and through the tissue of the target vessel wall on opposite sides of theanvil130. Once thesutures134 are placed as shown inFIG. 33, an incision is made in the target vessel along a center of theanvil130. A center portion of each of thesutures34 is then pulled out through the incision in the target vessel and cut so that an even row of sutures is provided along each of the sides of the incision. This system eliminates the tedious procedure of placing each individual suture very close to the edge of the incision in the very thin and flexible target vessel wall. Each of thesutures134 is connected to a graft vessel in a conventional manner completing the anastomosis. The anvil as shown inFIGS. 32-33 allows quick and easy placement of a plurality of sutures in a very even manner close to the edge of the incision. For example, the sutures of a conventional anastomosis are generally within about one millimeter of the edge of the incision and are advantageously within 0.5 millimeters of the edge of the incision.
• In an alternate embodiment, thecutter200 does not include one ormore projections208. Instead, thecutter200 includes or is connected directly or indirectly to an energy source (not shown), which is used to create an opening in the wall of the target vessel. For example, an emitter of laser or RF energy, or another type of energy, may be connected to thecutter200 and to the energy source. As thecutter200 translates along theanvil arm14, it translates the emitter of laser or RF energy relative to the wall of the target vessel. The emitter of laser or RF energy is selectively actuated to transmit energy into the wall of the target vessel during translation of thecutter200, thereby creating an opening therein. The energy source may transmit a first type of energy to the emitter or other mechanism, which is converted by the emitter into a second type of energy delivered into the wall of the target vessel. Alternately, thecutter200 may include aprojection208 and additionally be connected to an energy source that is selectively actuated in order to assist in creating an opening in the wall of the target vessel.
• In an alternate embodiment, thecutter200 does not translate through theanvil arm14. Instead, thecutter200 is spatially removed from theanvil arm14, and creates an opening in the wall of the target vessel before or after theanvil arm14 is inserted into the target vessel. In one example of such an embodiment, theanvil arm14 is inserted into a hole in the wall of the target vessel and thestaple holder38 deploys staples or other connectors to connect the graft vessel to the target vessel, as described above. Theanvil arm14 is removed, and anindependent cutter200 is then introduced through the hole in the wall of the target vessel. Thecutter200 may be configured as described above, including aprojection208 extending therefrom, or may be configured differently. Thecutter200 is manipulated relative to the connection between the target vessel and the graft vessel to create an opening at the junction therebetween. That is, registration is maintained between thecutter200 and the junction between the end of the graft vessel and the wall of the target vessel. In order to position and manipulate thecutter200 to create an opening at the location of the junction between the target vessel and the graft vessel, an imaging device (not shown) or other device may be connected to thecutter200 or utilized in conjunction with thecutter200. For example, a standard intravascular ultrasound unit may be connected to or used in conjunction with thecutter200. The intravascular ultrasound unit is connected to a display device (not shown) visible to the operator. The operator controls the intravascular ultrasound unit to visualize the interior of the target vessel and the surrounding area, thereby locating the junction between the target vessel and the graft vessel and allowing thecutter200 to be controlled to incise an opening in the wall of the target vessel within the closed area on the wall of the target vessel defined by the perimeter of the end of the graft vessel, thereby allowing blood to flow through the opening into the target vessel. A different visualization device or devices may be inserted into or positioned outside of the target vessel to locate the junction with the graft vessel. Thecutter200 and any visualization device present in the lumen of the target vessel are then removed from the lumen of the target vessel, and the opening in the wall of the target vessel through which they were removed is sealed.
• In another example of such an embodiment, theanvil arm14 is inserted into a hole in the wall of the target vessel and thestaple holder38 deploys staples or other connectors to connect the graft vessel to the target vessel, as described above. Theanvil arm14 is removed, and the hole in the wall of the target vessel is removed. A cannula (not shown) is inserted into the lumen of the graft vessel through the free end of the graft vessel, and a stylet (not shown) is inserted through the lumen of the cannula. The cannula and the stylet are surgical instruments that are well known in the art. The stylet has a distal end configured to penetrate the wall of the target vessel. Thus, a sharp point, blade, or other penetrating member may be formed into or connected to the distal end of the stylet. The cannula may be inserted into the lumen of the graft vessel such that its distal end contacts the outer wall of the target vessel. After the stylet has been inserted into the cannula, a force is exerted on the stylet to cause its distal end to penetrate the wall of the target vessel. Consequently, an opening is created between the graft vessel and the target vessel within the circumference of the end of the graft vessel. The cannula and stylet are then removed from the lumen of the graft vessel through its free end.
• In another example of such an embodiment, theanvil arm14 is inserted into a hole in the wall of the target vessel and thestaple holder38 deploys staples or other connectors to connect the graft vessel to the target vessel, as described above. Theanvil arm14 is removed, and the hole in the wall of the target vessel is closed. Anindependent cutter200 is then introduced through the wall of the graft vessel. Thecutter200 itself may create an opening in the wall of the graft vessel through which it can enter, or a separate implement may be used to create an opening in the wall of the graft vessel. Thecutter200 may be configured as described above, including aprojection208 extending therefrom, or may be configured differently. For example, thecutter200 may be J-shaped or L-shaped to facilitate creation of the opening between the graft vessel and the target vessel through the wall of the graft vessel. Thecutter200 is manipulated relative to the connection between the target vessel and the graft vessel to create an opening in the wall of the target vessel at the junction therebetween. That is, registration is maintained between thecutter200 and the junction between the end of the graft vessel and the wall of the target vessel. Thecutter200 is then removed through the wall of the graft vessel, and the opening in the wall of the graft vessel is sealed.
• While the invention has been described in detail, it will be apparent to one skilled in the art that various changes and modifications can be made and equivalents employed, without departing from the present invention. It is to be understood that the invention is not limited to the details of construction, the arrangements of components, and/or the steps of performing anastomosis set forth in the above description or illustrated in the drawings. Therefore, the invention is not to be restricted or limited except in accordance with the following claims and their legal equivalents.

Claims (8)

1. A surgical tool, comprising:

a staple holding strip; and

a plurality of surgical staples frangibly connected to an edge of said staple holding strip.

2. The surgical tool ofclaim 1, wherein said staple holding strip is expandable.

3. The surgical tool ofclaim 1, wherein all of said staples are affixed to a single edge of said staple holding strip.

4. The surgical tool ofclaim 1, wherein at least one said staple is connected to said staple holding strip at only a single connection point.

5. The surgical tool ofclaim 4, wherein at least one said staple is frangibly connected to said staple holding strip at said single connection point.

5. The surgical tool ofclaim 1, wherein said staples are substantially coplanar with said staple holding strip.

6. The surgical tool ofclaim 1, wherein at least one staple is at least partially curved.

7. The surgical tool ofclaim 1, further comprising a staple holder that receives at least part of said staple holding strip, wherein at least part of said staple holding strip is movable within said staple holder.

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