US20100305401A1

Movatterモバイル変換

Info

Publication number: US20100305401A1
Application number: US12/850,289
Authority: US
Inventors: Jeffrey C. Leung; Matthew A. Megaro; Gregory Ruff; Andrew Kaplan
Original assignee: Quill Medical Inc
Current assignee: Ethicon Inc; Ethicon LLC
Priority date: 2001-06-29
Filing date: 2010-08-04
Publication date: 2010-12-02
Also published as: US8777988B2; RU2355333C2; US20070208377A1; RU2005113280A; US7056331B2; US7857829B2; US8747437B2; US20060111734A1; US20100298848A1; US20100318123A1; US20100298639A1; US20100318124A1; US20100298880A1; US8764796B2; WO2004030517A3; US8764776B2; US8777989B2; US20060111742A1; US20030074023A1; AU2003278981A1

Abstract

Endoscopic systems utilize self-retaining sutures to approximate tissue in a cavity of a subject. An endoscopic instrument is provided containing the self-retaining suture. The endoscopic instrument may be provided in combination with an endoscope and/or an endoscopic manipulator. The endoscopic instrument is passed through a cavity wall into a cavity of a patient. The self-retaining suture is deployed, using the endoscopic instrument, into a first tissue portion and a second tissue portion within the cavity. The self-retaining suture may be deployed endoscopically in patterns which include, purse string stitch, alpha stitch, linear stitching, curvilinear stitching, continuous helical stitch, and continuous sinusoidal stitch.

Description

CLAIM TO PRIORITY

This application is a continuation of U.S. application Ser. No. 11/307,520, filed Feb. 10, 2006, now pending; which is a divisional of U.S. application Ser. No. 10/065,256, filed Sep. 30, 2002, now U.S. Pat. No. 7,056,331, issued Jun. 6, 2006; which is a continuation-in-part of U.S. application Ser. No. 09/896,455, filed Jun. 29, 2001, now U.S. Pat. No. 6,599,310, issued Jul. 29, 2003. All of the above claimed priority applications are incorporated herein by reference in their entireties.

BACKGROUND OF THE INVENTION

This invention relates generally to a method for joining bodily tissue in surgical applications and wound repair, and more particularly to a surgical suturing method for joining bodily tissue using a suture having a plurality of barbs which permit the suture to be pulled through the tissue in one direction but resisting movement of the suture relative to the tissue in the opposite direction.

Surgical or accidental wounds are typically closed with a length of filament introduced into the tissue by a sharp metal needle attached to one end of the filament. This device is known as a suture. Sutures are used to make stitches to close the wound for holding tissues together for healing and regrowth. Sutures are used in surgical procedures for wound closure, to close the skin in plastic surgery, to secure damaged or severed tendons, muscles or other internal tissues, and in microsurgery on nerves and blood vessels. Generally, the suture needle is caused to penetrate and pass through the tissue pulling the suture through the tissue. The opposing faces of the tissue are then moved together, the needle is removed, and the ends of the suture are tied in a knot. The suture forms a loop as the knot is tied. The knotting procedure allows the tension on the filament to be adjusted to accommodate the particular tissue being sutured and control of approximation, occlusion, attachment or other conditions of the tissue. The ability to control tension is extremely important regardless of the type of surgical procedure being performed.

Suturing is a time-consuming part of most surgical procedures, particularly in microsurgery and endoscopic surgery where there is insufficient space to properly manipulate the suture. Loop sutures can leave scars where they penetrate skin. For adequate closure of some wounds, the suture material must be of a high tensile strength and thus a large diameter thereby increasing scarring. The loop suture also constricts blood flow to the tissue it surrounds, promoting necrosis of the wound margins which compromises healing and increases infection risks. Further, the tissue is distorted as it is secured by the suture loop due to excess tension on the knots. Localized tensions from the knots are the culprit for scar formation. The bulk of the knots are also an impediment to wound healing in internal applications.

Alternatives to conventional sutures for wound closure are known, including fasteners such as staples, clips, tacks, clamps and the like. The fasteners are usually positioned transversely across a wound for joining or approximating each side of adjacent tissue layers laterally. Fasteners have relatively high strength and save time, but are not as accurate as sutures and are bulky and may be painful to remove. Fasteners are also generally unsuitable for deeper layers of tissue. Moreover, fasteners do not provide the advantage of adjustable tension obtained by the knotting of a length of suture material.

Surface adhesive tapes and glues are often used on skin to hold small wounds closed to permit healing. However, these products have relatively low tensile strength and are not useful in many situations.

Other techniques proposed include electrical coagulation and lasers. However, no acceptable alternative has been found which offers the advantages of suturing and tying in most surgical procedures.

One possible alternative is a barbed suture. A barbed suture includes an elongated body having one or more spaced barbs projecting from the surface of the body along the length of the body. The barbs are configured to allow passage of the suture in one direction through tissue but resist movement of the suture relative to the tissue in the opposite direction. In wound closure, a barbed suture is passed through tissue at each of the opposed sides of a wound. The wound is closed by pushing the sides of the wound together with the barbs maintaining the sutures in place and resisting movement of the tissue away from this position. The advantage of using barbed sutures is the ability to put tension in the tissue with less slippage of the suture in the wound. The barbed suture spreads, out the holding forces evenly thereby significantly reducing tissue distortion. Since knots do not have to be tied, there is a time savings and the elimination of suture knots improves cosmetic effects and promotes wound healing. Barbed sutures also allow better apposition of tissue since the incised or insulted tissues are brought together and secured with almost no movement immediately. Unlike the conventional suturing method wherein tension is applied by pulling on the end of the suture after placement, barbed sutures permit tissue to be approximated and held snug during suturing. This is especially advantageous in closing long incisions. The result is better healing when the tissue levels are harmoniously matched as the cosmetic effect is more pronounced at skin level. Moreover, if there is an accidental breakage of the barbed suture, the wound is minimally disturbed. With conventional sutures, dehiscence would occur.

Despite the advantages offered by barbed sutures, the tensile strength of a barbed suture is less than a loop suture of equivalent size. This is due to the reduced tensile strength resulting from imparting the barb structure onto the body of the suture, which reduces its effective diameter. This limitation is not significant since larger barbed sutures with greater tensile strength can be utilized. However, the conventional methods for introducing barbed sutures into tissue still do not exhibit the same biomechanical performance of looped sutures.

For the foregoing reasons there is a need for a suturing method for joining tissue in surgical applications and wound repair which is efficient and expedites the surgical procedure. Ideally, the new method allows a surgeon to suture in an efficient manner to quickly the approximate tissue with appropriate tension. The new method should preserve blood flow, improve wound healing strength, prevent distortion of the tissue and minimize scarring. The method should also incorporate the self-retaining benefits of the barbed suture with the holding power of conventional suturing methods. A particularly useful method would be utilized in surgical applications where space is limited such as microsurgery, endoscopic or arthroscopic surgery.

SUMMARY OF THE INVENTION

The present invention provides a way to close wounds, fasten junctions of tissue, tie off wounds, join a foreign element to tissue, mount a device to tissue, alter the position of tissue where there is only a single portion of tissue without a wound or junction, and perform other procedures. The methods of the present invention are performed with a two-way barbed suture. Specifically, the two-way barbed suture includes an elongated body, first and second sharp pointed distal ends for penetrating the tissue, and a plurality of barbs extending from the periphery of the body. The barbs on a first portion of the body between the first end of the suture and a first axial location on the body permit movement of the suture through the tissue in a direction of movement of the first end, and prevent movement of the suture relative to the tissue in a direction opposite the direction of movement of the first end. The barbs on a second portion of the body between the second end of the suture and a second axial location on the body, which is less than the distance from the second end to the first axial location, permit movement of the suture through the tissue in a direction of movement of the second end, and prevent movement of the suture relative to the tissue in a direction opposite the direction of movement of the second end.

In some embodiments of the present invention an insertion device is used to insert the barbed suture. Such an insertion device is tubular and has leading and trailing ends with openings therein. The suture is initially disposed in the insertion device. The first end of the suture is proximate to the leading end of the insertion device. Where no insertion device is used, the sharp pointed ends of the suture are used to insert the suture in tissue; while these ends may be embodied, or be referred to, as needles herein, it should be understood that the suture may terminate in any type of sharp pointed end.

Some embodiments provide a method for joining and holding portions of a stomach to each other in the performance of a Nissen fundoplication procedure. The Nissen fundoplication procedure requires grasping the fundus of the stomach at a proximal location and pulling the fundus around the esophagus, wrapping the fundus around the esophagus one time and attaching the proximal stomach to an apposing portion of the stomach. One method that uses the sharp pointed ends of the barbed suture to penetrate tissue comprises the steps of inserting the first pointed end of the suture into tissue of the proximal stomach and pushing the first end of the suture through the stomach tissue until the first end of the suture extends out of the tissue at an exit point on the exterior of the stomach. The first end of the suture is pulled to draw the first portion of the suture through the tissue until the second axial location is proximate to the point of insertion of the first end of the suture. A length of the first portion of the suture is left in the tissue between the point of insertion and exit point of the first end. The proximal stomach is gripped and the fundus is wrapped around the esophagus until the proximal stomach contacts an apposing portion of stomach. The second pointed end of the suture is inserted into tissue of the apposing stomach, and the second end of the suture is pushed through the stomach tissue until the second end of the suture extends out of the tissue at an exit point on the exterior of the stomach. The second end of the suture is pulled to draw the second portion through the tissue until the second axial location is proximate to the point of insertion of the second end of the suture and a length of the second portion of the suture is left in the tissue between the point of insertion and exit point of the second end.

In another embodiment of a Nissen fundoplication method, an insertion device is used. Again, the fundus is wrapped around the esophagus to form a junction with the apposing portions of stomach. Then the first pointed end of the suture and leading end of the insertion device are inserted into stomach tissue at a point laterally spaced from the junction and on a first side of the junction. The first end of the suture and leading end of the insertion device are pushed through the first side of stomach tissue and penetrate the stomach tissue on a second side of the junction until the portion of the suture between the first and second axial locations is proximate to the junction. The insertion device is removed by gripping and pulling the trailing end, leaving the suture in place.

Another method for joining and holding portions of a stomach to each other in the performance of a Nissen fundoplication is provided, using the sharp pointed ends of the suture, which may be needles. The method comprises the steps of inserting the first pointed end of the suture into the stomach tissue below the surface of the stomach tissue at a first face of the junction at an initial point. The first end of the suture is pushed through the stomach tissue along a curvilinear path until the first end of the suture extends from the stomach tissue at an exit point in the first face of the junction. This exit point is longitudinally spaced in a first direction from the insertion point in the first face of the junction. The first pointed end of the suture is gripped and pulled until it is out of the stomach tissue, drawing the first portion of the suture through the stomach tissue until the second axial location is at the point of insertion of the first end of the suture in the first face of the junction, leaving a length of the first portion of the suture in the stomach tissue of the junction. The first pointed end is inserted at a point below the surface of the stomach tissue in a second face of the junction, and pushed through the stomach tissue along a curvilinear path until the first end of the suture extends from the stomach tissue at an exit point in the second face of the junction below the surface of the stomach tissue. Again, the exit point is longitudinally spaced in the first direction from the insertion point in the second face of the junction. Then the first end of the suture is inserted at a point in the first face of the junction below the surface of the stomach tissue, and the above steps may be repeated for advancing along the junction in the first direction as necessary to one end of the junction. These steps are similarly repeated for the second end and second portion of the suture in a second direction. The initial point may be longitudinally spaced from the ends of the junction or adjacent to an end, and the first and second directions may be the opposite or same directions.

One embodiment provides a method for laparoscopically inserting a barbed suture with a laparoscopic insertion device, similar to the insertion device described above but included in a laparoscopic tool. The first pointed end of the suture and the leading end of the laparoscopic insertion device are inserted through an entry point in the skin, and then through the fat, fascia, muscle, and peritoneum into the abdominal cavity. The first end of the suture and leading end of the insertion device are pushed into the tissue in the abdominal cavity, and the insertion device is pulled at the trailing end to remove the insertion device. Additional embodiments include stabilizing a bowel structure, where the bowel structure is positioned and then stabilized by leaving the inserted suture in place in the bowel tissue and the abdominal wall, and for a closure for a cytostomy, in which the first and second ends and portions of the suture are inserted in urinary bladder muscularis.

Another embodiment involves a method for performing an anastomosis of the liver bile duct to a bowel structure, the bile duct having one end connected to the liver and a free end after having been severed, and the bowel structure having an opening in its wall made to receive the annular free end of the bile duct. One embodiment is performed with an insertion device as described above, with steps comprising placing the free end of the bile duct in contact with the opening in the bowel structure, and forming a junction at the annular contact area between the bile duct tissue and the bowel structure tissue. The first pointed end of the suture and the leading end of the insertion device are inserted into the tissue on one side of the junction. The first end of the suture and leading end of the insertion device are pushed through the tissue on one side of the junction, through the junction, and penetrate the tissue on the other side of the junction. The insertion device is gripped and pulled at the trailing end to remove the insertion device, leaving the suture in place in both the bile duct tissue and the bowel structure tissue. The previous steps are repeated as necessary to provide an anastomotic seal at the junction.

In another embodiment, a method for tying off an appendiceal stump resulting from the performance of an appendectomy is provided, using needles. The appendix extends from the cecum of the large intestine and has a base with a circumference at the juncture of the appendix and the cecum. The first pointed end of the suture is inserted into tissue of the cecum proximate to the appendix base. The first end of the suture is pushed around the circumference of the base in one direction for at least one half of the circumference of the base until extending through an exit point in the tissue. The second pointed end of the suture is then inserted into tissue of the cecum proximate to the entry point of the first end, and the second end of the suture is pushed along the circumference of the base in the other direction for at least one half of the circumference of the base until extending through an exit point in the tissue. The appendix is excised, leaving the appendiceal stump. Then the ends of the suture are gripped and pulled, causing the suture to tighten around the appendiceal stump, and may invert the stump into the cecum.

Another embodiment provides a method for joining and holding closed the muscle layers that define the orifice of a Zenker's Diverticulum using an endoscopic insertion device, similar to the insertion device described above but included in an endoscopic tool. The Zenker's Diverticulum includes a sac extending from a proximal location of the esophagus near the pharynx, the sac having walls including a muscle layer common to the proximal esophagus. The Zenker's Diverticulum may first be manually inverted into the esophagus, or left outside the esophagus. The first pointed end of the suture and the leading end of the endoscopic insertion device are inserted through an entry point in the esophageal muscle between the pharynx and the orifice, and spaced from the orifice. The first end of the suture and leading end of the insertion device are pushed through the muscle until the first end of the suture and the leading end of the insertion device extend out of the muscle at the orifice of the sac. Then the first pointed end of the suture and the leading end of the endoscopic insertion device are inserted through an opposing side of the orifice, and are pushed through the muscle until the second axial location is proximate to a central to the point of the orifice. The insertion device is gripped and pulled at the trailing end to remove the insertion device, leaving the suture in place. Optionally, the above steps may be repeated with additional sutures. The muscle on the two sides of the orifice is advanced together as necessary to close the orifice.

A method is provided for joining and holding closed ulcerative lesions or post-procedural tissue defects on an interior surface of a viscus, using an endoscopic insertion device as described above. The method comprises the step of inserting the first pointed end of the suture and the leading end of the endoscopic insertion device through an entry point in the tissue spaced from and on one side of the lesion. Then the first end of the suture and leading end of the insertion device are pushed through the tissue until the first end of the suture and the leading end of the insertion device extend out of the tissue at the lesion. The first pointed end of the suture and the leading end of the endoscopic insertion device are then inserted through an opposing side of the lesion, and are pushed until the second axial location is proximate to a central to the point of the lesion. The insertion device is gripped and pulled at the trailing end to remove the insertion device, leaving the suture in place. Again, optionally the above steps may be repeated. The tissue on the two sides of the lesion is advanced together to close the lesion.

In another embodiment, a method is provided for joining and holding closed a wound in urinary bladder muscularis tissue, using needles. The first pointed end of the suture is inserted into the tissue below the surface of the tissue at a first face of the wound at an initial point, which may for example be adjacent to one end or longitudinally spaced from both ends of the wound. The first end of the suture is pushed through the tissue along a curvilinear path until the first end of the suture extends from the tissue at a subcutaneous exit point in the first face of the wound and longitudinally spaced in a first direction from the insertion point in the first face of the wound. The first pointed end of the suture is gripped and pulled out of the tissue, drawing the first portion of the suture through the tissue until the second axial location is at the point of insertion of the first end in the first face of the wound and leaving a length of the first portion of the suture in the tissue of the wound. Then the first pointed end of the suture is inserted at a point below the surface of the tissue in a second face of the wound. The first end is pushed through the tissue along a curvilinear path until the first end extends from the tissue at an exit point in the second face of the wound below the surface of the tissue and longitudinally spaced in the first direction from the insertion point in the second face of the wound. The first end of the suture is inserted at a point in the first face of the wound below the surface of the tissue. The above steps are repeated starting with the insertion of the first end of the suture in the first face of the wound to advance longitudinally along the wound in the first direction until reaching the end of the wound. Further, all of the above steps are repeated for the second end and second portion of the suture, in a second direction, starting with inserting the second end in the second face of the wound below the surface of the tissue and adjacent the initial point of insertion of the first end in the first face of the wound.

Another method is provided for joining and holding closed a wound in urinary bladder muscularis tissue, also using needles. The first pointed end of the suture is inserted into the muscularis tissue below the surface of the tissue of a first face of the wound at an initial point adjacent an end of the wound. The first end of the tissue is pushed through the tissue along a curvilinear path until the first end of the suture extends from the tissue at an exit point in the first face of the wound below the surface of the tissue and longitudinally spaced from the end of the wound in a direction toward the other end of the wound. The first pointed of the suture is gripped and pulled out of the tissue, drawing the first portion of the suture through the tissue until the second axial location is at the point of insertion of the first end in the first face of the wound and leaving a length of the first portion of the suture in the tissue of the wound. The first end of the suture is then inserted into the second face of the wound below the surface of the tissue. The first end of the suture is pushed through the tissue along a curvilinear path until the first end extends from the tissue at an exit point in the second face of the wound below the surface of the tissue and longitudinally spaced from the insertion point in the second face of the wound toward the other end of the wound. The first end of the suture is inserted into the first face of the wound below the surface of the tissue, and the above steps are repeated starting with pushing the first end through the tissue until extending from an exit point in the first face of the wound, advancing longitudinally along the wound until reaching the other end of the wound. The steps are repeated similarly for the second end and second portion of the suture, starting with inserting the second end of the suture into the tissue of the second face of the wound below the surface adjacent the point of insertion of the first end.

Some embodiments include a method of mounting a device to bodily tissue, using needles. The device includes at least one eyelet for securing the device and through which a suture may pass. The method starts with the step of placing the device in a desired position. Then a suture is threaded through the eyelet. The first pointed end of the suture is inserted into tissue and is pushed through the tissue until extending out an exit point. The first end of the suture is gripped and pulled out of the tissue while drawing the first portion of the suture through the tissue, leaving a portion of the suture between the first and second axial locations out of the tissue and leaving a length of the first portion of the suture in the tissue between the point of insertion and exit point of the first end. These steps are repeated for the second end and portion of the suture in a second direction, resulting in the first and second portions of the suture extending in the tissue in generally opposing directions and causing the suture to resist displacement of the device. Examples of devices that may be mounted according to the present invention include catheters, electrodes of cardiac pacemakers, and tumor monitors. The device may be mounted internally, for example, to an organ, or externally to the epidermis.

Further, methods of performing cosmetic surgery are provided. One embodiment of a procedure using needles begins with inserting the first pointed end at an insertion point on the surface of a person's body. The first end of the suture is pushed through soft tissue until the first end extends out of the soft tissue at an exit point. The first end of the suture is gripped and pulled to draw the first portion of the suture through the soft tissue until the second axial location is proximate to the point of insertion of the first end of the suture, leaving a length of the first portion of the suture in the soft tissue between the point of insertion and exit point of the first end. The second pointed end of the suture is put in place by repeating these steps for the second end and second portion. The soft tissue is manually grouped and advanced along at least one portion of the suture to provide the desired amount of lift.

Specific applications of cosmetic surgeries as described above include, for example, facelifts, browlifts, thigh lifts, and breast lifts. In an embodiment of a facelift, the insertion point is approximately at the temporal hairline, and the first end of the suture is pushed through subepidermal tissue to the exit point of on the scalp. The second end of the suture is pushed through subepidermal tissue, the superficial muscular aponeurotic system, or combinations thereof, to the exit point proximate to the nasolabial fold. Tissue is manually grouped and advanced along the second portion of the suture to provide the desired amount of lift.

In an embodiment of a browlift, the insertion point is on a person's face above the brow line. The first end of the suture is pushed through subepidermal tissue underneath the forehead, scalp, or both and the exit point of the first end of the suture is on the scalp. The second end of the suture is pushed through subepidermal tissue and the exit point of the second end of the suture is proximate to the brow. The tissue is manually grouped and advanced along the second portion of the suture to provide the desired amount of lift. The insertion may be approximately at the frontal hairline or the midpoint between the brow and frontal hairline.

Another embodiment of a browlift is provided for use with needles, and again the insertion point is on a person's face above the brow line. Examples of insertion point locations for browlifts include approximately at the frontal hairline or halfway between the brow and the frontal hairline. The first end of the suture is pushed through subepidermal tissue and the exit point of the first end of the suture is proximate to the brow. The second end of the suture is pushed through subepidermal tissue and the exit point of the second end of the suture is proximate to the brow and spaced from the exit point of the first end of the suture. Then the tissue is manually grouped and advanced along the first and second portions of the suture to provide the desired amount of lift.

An embodiment of a thigh lift is also provided. For a thigh lift, the insertion point is generally at the inguinal crease. The first end of the suture is pushed cranially through subepidermal tissue until the first end of the suture extends out of the tissue. The second end of the suture is pushed caudally through subepidermal tissue until the second end of the suture extends out of the tissue on the thigh, and then tissues are manually grouped and lifted as desired.

Further, a method of performing a cosmetic breast lift is provided. The insertion point is at the upper aspect of the breast curvature, and the first end of the suture is pushed through subcutaneous tissue, dermal tissue, and pectoralis muscle until extending out of the tissue at an exit point on the upper portion of the breast. The second end of the suture is pushed caudally through fibrous and fatty tissues until the second end of the suture extends out of the tissue at an exit point along the anterior aspect or the lower curvature of the breast, and the tissue is manually grouped and lifted as desired.

Embodiments of cosmetic surgery using an insertion device are also provided. In these methods, the first pointed end of the suture and the leading end of the insertion device are inserted at an insertion point. The first end of the suture and the leading end of the insertion device are pushed through tissue beneath the epidermis until reaching an endpoint. Then the insertion device is gripped and pulled at the trailing end to remove the insertion device, leaving the suture in place, and the tissue is manually grouped and advanced along the first portion of the suture to provide the desired amount of lift. This method applies, for example, to a facelift, where the insertion point is in the scalp distal from the temporal hairline. The suture is pushed through the reticular dermis underneath the scalp, and the first end of the suture passes through the temporal hairline, penetrates the facial tissue such as the reticular dermis, the superficial muscular aponeurotic system, or a combination thereof, extending to the nasolobial fold. The method also applies to browlifts, where, for example, the insertion point is in the scalp at a point distal from the frontal hairline; and the suture is pushed through the reticular dermis underneath the scalp until the first end of the suture passes through the frontal hairline, extending to be proximate to the browline.

Other embodiments are provided for a method for joining and holding closed an axial wound in a blood vessel such as an artery or vein, using an insertion device. The first pointed end of the suture and the leading end of the insertion device are inserted through an entry point in the tissue spaced from and on one side of the wound. The first end of the suture and leading end of the insertion device are pushed through the tissue until penetrating the blood vessel wall on one side of the wound, continuing until extending into the interior of the blood vessel. The first end of the suture and leading end of the insertion device are then pushed through the interior of the blood vessel until the first end of the suture and the leading end of the insertion device penetrate the blood vessel wall on the other side of the wound, continuing through the blood vessel wall and penetrating the tissue on the other side of the wound. The first end of the suture and leading end of the insertion device are pushed through the tissue. In one embodiment, the second axial location is disposed in the blood vessel wall on one side of the wound and the first axial location is disposed in the blood vessel wall on the other side of the wound, resulting in no barbs being disposed in the interior of the blood vessel. The insertion device is gripped and pulled at the trailing end for removal, leaving the suture in place, and the tissue may be advanced on the two sides of the wound together as necessary to close the wound.

BRIEF DESCRIPTION OF THE DRAWINGS

For a more complete understanding of the present invention, reference should now be had to the embodiments shown in the accompanying drawings and described below. In the drawings:

FIG. 1 is a perspective view of an embodiment of a barbed suture with straight pointed ends for use according to the methods of the present invention;

FIG. 2 is a perspective view of a barbed suture with curved pointed ends for use according to the methods of the present invention;

FIGS. 3-6 are plan views of an embodiment of a method according to the present invention for joining two sides of an open wound in tissue;

FIGS. 7-10 are perspective views of another embodiment of a method according to the present invention for joining two sides of an open wound in tissue;

FIG. 11 is a perspective view of a prior art method for joining two sides of an open wound in tissue using a spiraling suture path;

FIGS. 12-15 are perspective views of an embodiment of a method according to the present invention for joining two sides of an open wound in tissue using a spiraling suture path;

FIGS. 16-18 are perspective views of still another embodiment of a method according to the present invention for joining two sides of an open wound in tissue;

FIGS. 19 and 20 are plan views of a further embodiment of a method according to the present invention for joining two sides of an open wound in tissue;

FIG. 21 is a plan view of the embodiment shown inFIGS. 19 and 20 for use in closing a vascular puncture via cinching of tissues directly above the vessel;

FIG. 22 is a cross-sectional view of the method shown inFIG. 21;

FIG. 23 is a side elevation view of a finger with a portion of the outer layer of tissue cut-away to schematically show a severed tendon;

FIG. 24 is a plan view of the Kessler method for joining two ends of a severed tendon;

FIGS. 25-28 are perspective views of an embodiment of a method according to the present invention for joining two ends of a severed tendon;

FIGS. 29-30 are side elevation views of an embodiment of the method according to the present invention for performing a Nissen fundoplication;

FIG. 31 is another embodiment of a method according to the present invention for performing a Nissen fundoplication;

FIGS. 32-34 are cut-away perspective views of an embodiment of the method according to the present invention for laparoscopic insertion;

FIGS. 35-37 are perspective views of two embodiments according to a method of the present invention for performing an anastomosis of a liver bile duct to a portion of a bowel;

FIGS. 38-39 are perspective views of an embodiment of the method according to the present invention for performing an appendectomy;

FIGS. 40-42 are vertical cross-section views of an embodiment of the method according to the present invention for performing a Zenker's Diverticulectomy;

FIGS. 43-44 are partially sectioned perspective views of an embodiment of the method according to the present invention for closure of ulcerative intestinal lesions or other bowel wall defects;

FIG. 45-46 are front elevation views of two embodiments of the method according to the present invention for closure of a cystostomy incision in the urinary bladder;

FIG. 47 is a front elevation view of an embodiment of the method according to the present invention for securing prosthetic heart valves;

FIG. 48 is a front elevation view of an embodiment of the method according to the present invention for securing a catheter in position;

FIG. 49 is a perspective view of embodiments of the method according to the present invention for performing cosmetic surgery;

FIGS. 50-52 are cross-section views of an axial wound closure in a blood vessel according to two embodiments of the present invention.

DETAILED DESCRIPTION

As used herein, the term wound means a surgical incision, cut, laceration, severed tissue or accidental wound in human skin or other bodily tissue, or other condition where suturing, stapling, or the use of another tissue connecting device might be required.

As used herein, the term tissue includes tissues such as skin, bone, muscle, organs, and other soft tissue such as tendons, ligaments and muscle.

Certain other terminology is used herein for convenience only and is not to be taken as a limitation on the invention. For example, words such as “upper,” “lower,” “left,” “right,” “horizontal,” “vertical,” “upward,” and “downward” merely describe the configuration shown in the figures. It is understood that the components may be oriented in any direction and the terminology, therefore, should be understood as encompassing such variations unless specified otherwise.

Referring now to the drawings, wherein like reference numerals designate corresponding or similar elements throughout the several views, there is shown inFIGS. 1 and 2 a suture for use according to the present invention and generally designated at40. Thesuture40 includes anelongated body42 having a plurality ofbarbs44 disposed along the length of thebody42. First and second ends46,48 of thebody42 terminate in

points

50,52 for penetrating tissue.

Thebody42 of thesuture40 is, in one embodiment, circular in cross section. Suitable diameters for thebody42 of thesuture40 range from about 0.001 mm to about 1.0 mm. Thebody42 of thesuture40 could also have a non-circular cross-sectional shape which would increase the surface area of thebody42 and facilitate the formation ofmultiple barbs44.

The length of thesuture40 can vary depending on several factors such as the extent of the wound to be closed, the type of tissue to be joined, the location of the wound, and the like. Asuture40 of proper length is selected for achieving suitable results in a particular application.

Material for thebody42 of thesuture40 is available in a wide variety of monofilament suture material. The particular suture material chosen depends on the strength and flexibility requirements. In one embodiment, the material for thebody42 is flexible and substantially nonresilient so that the shape of an insertedsuture40 will be determined by the path of insertion and the surrounding tissue. In some applications, however, it may be desirable for at least a portion of thebody42 to have sufficient dimensional stability to assume a substantially rigid configuration during use and sufficient resiliency to return to a predetermined position after deflection therefrom. The portions of the

ends

46,48 of thesuture40 adjacent the

points

50,52 may be formed of a material sufficiently stiff to enable the

points

50,52 to penetrate tissue in which thesuture40 is used when a substantially axial force is applied to thebody42. Variations in surface texture of thebody42 of thesuture40 can impart different interaction characteristics with tissues.

Thebody42 can be formed of a bioabsorbable material which allows thesuture40 to be absorbed over time into the tissue as the wound heals. Bioabsorbable material is particularly useful in arthroscopic surgery and methods of suturing. Many compositions useful as bioabsorbable materials can be used to make thebody42 of thesuture40 for use in the methods of the present invention. Generally, bioabsorbable materials are thermoplastic polymers. Selection of the particular material is determined by the desired absorption or degradation time period which depends upon the anticipated healing time for the subject of the procedure. Biodegradable polymers and co-polymers range in degradation time from about one month to over twenty-four months. They include, but are not limited to, polydioxanone, polylactide, polyglycolide, polycaprolactone, and copolymers thereof. Other copolymers with trimethylene carbonate can also be used. Examples are PDS II (polydioxanone), Maxon (copolymer of 67% glycolide and 33% trimethylene carbonate), and Monocryl (copolymer of 75% glycolide and 25% caprolactone). Germicides can also be incorporated into thebody42 of thesuture40 which are retained by thesuture40 to provide long lasting germicidal properties.

Thebody42 of thesuture40 can also be formed from non-absorbable material such as nylon, polyethylene terephthalate (polyester), polypropylene, and expanded polytetrafluoroethylene (ePTFE). Alternatively, thesuture body42 can also be formed of metal (e.g. steel), metal alloys, plastic, or the like.

The plurality ofbarbs44 is axially-spaced along thebody42 of thesuture40. Thebarbs44 are oriented in one direction facing toward thefirst end46 of thesuture40 for afirst portion54 of the length of the suture and in an opposite direction facing thesecond end48 of thesuture40 for asecond portion56 of the suture. Thebarbs44 are yieldable toward thebody42. Thebarbs44 on each

portion

54,56 of the suture are oriented so as to allow movement of thesuture40 through the tissue in one direction along with the

corresponding end

46,48 of thesuture40. Thebarbs44 are generally rigid in an opposite direction to prevent thesuture40 from moving in the tissue in the opposite direction.

Thebarbs44 can be arranged in any suitable pattern, for example, in a helical pattern as shown inFIGS. 1 and 2. The number, configuration, spacing and surface area of thebarbs44 can vary depending upon the tissue in which thesuture40 is used, and depending on the composition and geometry of the suture body. The proportions of thebarbs44 may remain relatively constant while the overall length of thebarbs44 and the spacing of thebarbs44 are determined by the tissue being connected. For example, if thesuture40 is intended to be used to connect the edges of a wound in skin or tendon, thebarbs44 can be made relatively short and more rigid to facilitate entry into this rather firm tissue. If thesuture40 is intended for use in fatty tissue, which is relatively soft, thebarbs44 can be made longer and spaced farther apart to increase the holding ability in the soft tissue. Moreover, the ratio of the number ofbarbs44 on thefirst portion54 of thesuture40 to the number ofbarbs44 on thesecond portion56, and the lengths of each

portion

54,56, can vary depending on the application and needs.

The surface area of thebarbs44 can also vary. For example, fuller-tippedbarbs44 can be made of varying sizes designed for specific surgical applications. For joining fat and relatively soft tissues,larger barbs44 are desired, whereassmaller barbs44 are more suited for collagen-dense tissues. There are also situations where a combination of large andsmall barbs44 within the same structure will be beneficial such as when asuture40 is used in tissue repair with differing layer structures. Use of the combination of large andsmall barbs44 with thesame suture40 whereinbarb44 sizes are customized for each tissue layer will ensure maximum anchoring properties.

Thebarbs44 may be formed on the surface of thebody42 according to any suitable method, including cutting, molding, and the like. The preferred method is cutting with acute angular cuts directly into thesuture body42 with cut portions pushed outwardly and separated from thebody42 of thesuture40. The depth of thebarbs44 formed in thesuture body42 depends on the diameter of the suture material and the depth of cut. A particularly suitable device for cutting a plurality of axially spacedbarbs44 on the exterior of suture filaments utilizes a cutting bed, a cutting bed vise, a cutting template, and a blade assembly to perform the cutting. When operated, the cutting device has the ability to produce a plurality of axially spacedbarbs44 in the same or random configuration and at different angles in relation to each other. Various other suitable methods of cutting thebarbs44 have been proposed including the use of a laser. Thebarbs44 could also be cut manually. However, manually cutting thebarbs44 is labor intensive, decreases consistency, and is not cost effective. Thesuture40 could also be formed by injection molding, extrusion, stamping and the like. Thesuture40 can be packaged in any number of desired pre-cut lengths and in pre-shaped curves.

The ends46,48 of thesuture40 may be straight (FIG. 1) or curved (FIG. 2). In one embodiment, the ends46,48 of thesuture40 may be surgical needles secured at each end of thebody42 of thesuture40 so that thebody42 extends between the shank ends of the two needles. The needles are preferably constructed of stainless steel or other surgical grade metal alloy. The needles may be secured to thesuture body42 by means of adhesives, crimping, swaging, or the like, or the joint may be formed by heat shrinkable tubing. A detachable connection may also be employed such that the needles may be removed from thebody42 of thesuture40 by a sharp tug or pull or by cutting. The length of the needles is selected to serve the type of tissue being repaired so that the needles can be completely removed leaving thesuture body42 in the desired position within the tissue.

Barbed sutures suitable for use according to the methods of the present invention are described in U.S. Pat. No. 5,342,376, entitled Inserting Device for a Barbed Tissue Connector, U.S. Pat. No. 6,241,747, entitled Barbed Bodily Tissue Connector, and U.S. Pat. No. 5,931,855. The contents of U.S. Pat. Nos. 5,342,376, 6,241,747, and 5,931,855 are hereby incorporated by reference.

According to the present invention, a surgical procedure usingbarbed sutures40 is provided for binding together living tissue for healing and regrowth or reconfiguration in vivo. In general, when thesuture40 is used in tissue to repair a wound, the suture is passed through tissue at each of the sides of the wound. Thepoint50 at oneend46 of thesuture40 is inserted into a first side of a wound such that thepoint50 pierces the tissue and thebarbs44 on theend portion54 of thesuture40 corresponding to the oneend46 yield toward thebody42 to facilitate movement of thesuture40 through the tissue in the direction of insertion. Theother end48 of thesuture40 is also inserted into a side of the wound and advanced through the tissue in like manner. The sides or faces of the wound are then moved together along the

suture portions

54,56 within the tissue to close the wound. Thebarbs44 of thesuture40 grasp the surrounding tissue on each side of the wound and maintains the edges of the wound in position during healing. The leading ends46,48 of thesuture40 protruding from the tissue are then cut and discarded. In one embodiment, ends of thesuture40 in the tissue are made to lie below the surface of the skin by first depressing the skin immediately around the ends and severing thesuture body42 closely against the skin. The skin will rise to cover the ends of thesuture40.

FIGS. 3-6 show a section of tissue including a portion of a patient'sskin58 and subcutaneous tissue defining awound60 from the surface of theskin58 down into the tissue. It is understood that thewound60 in the tissue can be of any configuration and from any anatomical part or organ of the body. Accordingly, depending on the configuration of the wound, the wound may comprise several sides and faces. However, the wounds depicted in the figures are straight incisions in theskin58 to reduce the complexity of the description of the method of the present invention. It is understood that the applicants do not intend to limit the method of the present invention to the closure of only straight incisions.

In this embodiment of the method of the present invention, the user, such as a surgeon, selects asuture40 of sufficient length and having straight ends46,48. As noted above, in one embodiment, the ends46,48 may be surgical needles.

Referring toFIG. 3, the surgeon inserts theneedle46 at the end of thefirst portion54 of thesuture40 into the tissue at apoint62 on afirst side64 of thewound60 and laterally spaced from theface66 of thewound60 at thefirst side64. The surgeon advances theneedle46 along a selected substantially straight path through the tissue to extend out of the tissue at a subcutaneous point (not shown) in thefirst face66 of thewound60 and subcutaneously penetrating a point (not shown) in aface68 of asecond side70 of thewound60. The surgeon continues to advance theneedle46 through the tissue until thepoint50 of the needle emerges from the tissue at a distal end of the selected path at anexit point72 on thesecond side70 of thewound60. The exit point is laterally spaced from theface68 of thesecond side70 of the wound and longitudinally spaced in a first direction from the point ofinsertion62 at thefirst side64 of thewound60. The surgeon grips the exposed portion of theneedle46 and pulls theneedle46 out of the tissue. This action draws thefirst portion54 of thesuture40 havingbarbs44 for resisting movement in the opposite direction through the tissue until thebarbs44 on thesecond portion56 engage the surface of theskin58 at theinsertion point62 preventing further advancement of thesuture40 through the tissue. A length of thefirst portion54 of thesuture body42 is thus positioned in the tissue along the selected path. The faces66,68 of thewound60 are approximated by pushing the

adjacent sides

64,70 of the tissue together along thefirst portion54 of thebody42 of thesuture40 in the tissue.

Theneedle46 is next inserted into the tissue at theexit point72 and advanced along a substantially straight path through the tissue to extend out of the tissue at a subcutaneous point74 in thesecond face68 of thewound60 and subcutaneously penetrating apoint76 in thefirst face66 of thewound60. The surgeon continues to advance theneedle46 through the tissue until thepoint end50 emerges from the tissue at a distal end of the selected path at anexit point78 on thefirst side64 of thewound60 that is laterally spaced from thefirst face66 and longitudinally spaced in the first direction from the point ofinsertion72 at thesecond side70 of thewound60. Again the surgeon grips the exposed portion of theneedle46 and pulls theneedle46 out of the tissue, drawing thefirst portion54 of thesuture40 through the tissue.

The previous steps are repeated with thefirst portion54 of thesuture40 by inserting theneedle46 into theexit point78 on thefirst side64 of thewound60 for advancing longitudinally in the first direction along thewound60 in a zigzag pattern as shown inFIG. 4. The number of passes of theneedle46 is chosen in accordance with the size of thewound60 and the strength required to hold the wound closed. The remaining length of thefirst portion54 of thesuture40 protruding from the tissue at afirst end80 of thewound60 is cut and discarded, leaving the remainingfirst portion54 of thesuture40 in the tissue. The faces66,68 of thewound60 are approximated by pushing the

adjacent sides

64,70 of the tissue together along thebody42 of thesuture40 in the tissue.

It is understood that the step of approximating the

sides

64,70 of thewound60 can be performed as thesuture40 is advanced or after theend80 of thewound60 is reached. Moreover, we do not intend to limit ourselves to the depth of the suture paths shown in the FIGS. as the depth of the suture paths may be determined by the surgeon or the wound to be closed. Further, it is understood that straight ends46,48 of the suture may also produce more curved transitions as determined by the surgeon.

The surgeon repeats the steps of this procedure with thesecond needle48 on thesecond portion56 of the suture (FIG. 5). Theinitial insertion point62 of thesecond needle48 is at the same initial point ofinsertion62 of thefirst needle46 at thefirst side64 of thewound60. The surgeon thus advances thesecond portion56 of thesuture40 into the tissue along thewound60 in a direction toward theother end82 of thewound60 using the same zigzag pattern approximating the

faces

66,68 of thewound60. The remaining length of thesecond portion56 of thesuture40 protruding from theskin58 at theend82 of thewound60 is then cut and discarded (FIG. 6).

An embodiment of the method for joining the sides of an open wound in tissue according to the present invention using a subcuticular stitch is shown inFIGS. 7-10. The tissue shown in the figures includes anepidermis84,dermis86,fat88,fascia90 andmuscle92. By penetrating the subcutaneous layers only and not theouter skin58 layer, awound60 can be closed to facilitate healing while minimizing scar tissue.

Referring toFIG. 7, the subcuticular stitch method of the present invention uses abarbed suture40 including curved ends46,48. The surgeon begins by inserting thefirst needle46 into the tissue below theskin58 surface at aface66 on afirst side64 of thewound60 at aninitial insertion point63 longitudinally spaced from the

ends

80,82 of thewound60. The surgeon advances theneedle46 through the tissue along a curvilinear path until thepoint50 of theneedle46 extends from the tissue at asubcutaneous exit point73 in thefirst face66 of thewound60 longitudinally spaced toward oneend80 of the wound from theentry point63 of theneedle46. The surgeon grips theneedle46 and pulls theneedle46 out of the tissue, drawing thefirst portion54 of thesuture40 through the tissue until thebarbs44 on thesecond portion56 engage the tissue at theinsertion point63 preventing further advancement of thesuture40 through the tissue. A length of thefirst portion54 of thesuture body42 is thus positioned in the tissue along the selected curvilinear path as seen inFIG. 7.

Turning toFIG. 8, the surgeon then inserts theneedle46 into the tissue at a subcutaneous entry point (not shown) in theface68 at thesecond side70 of thewound60. The surgeon repeats the above steps of pushing theneedle46 through the tissue along a selected curvilinear path so that thepoint50 of theneedle46 emerges from a subcutaneous exit point (not shown) in thesecond face68 of thewound60 longitudinally spaced toward theend80 of thewound60 from the entry point. The surgeon grips theneedle46 and draws thefirst portion54 of thesuture40 into the tissue further along thewound60. In this manner, the surgeon advances thefirst portion54 of thesuture40 longitudinally along thewound60 to the oneend80 of the wound in a wave-like or sinusoidal pattern. As noted above, the

faces

66,68 of thewound60 are approximated as the surgeon progresses, or when theend80 of thewound60 is reached, by pushing the

adjacent sides

64,70 of the tissue together along thebody42 of thesuture40. Theneedle46 along with remaining length of thefirst portion54 of thesuture40 is drawn through the surface of theskin58 at the oneend80 of thewound60 is cut and discarded (FIG. 8).

The surgeon repeats the procedure at the other end of the wound (FIG. 9) with thesecond portion56 of thesuture40. The surgeon begins by inserting thesecond needle48 into the tissue at a subcutaneous point (not shown) in thesecond face68 of thewound60. The surgeon advances thesecond needle48 along a curvilinear path from the point of initial insertion toward theother end82 of thewound60 until theneedle48 emerges from a subcutaneous exit point (not shown) thesecond face68 of thewound60 longitudinally spaced from the initial entry point of theneedle48. The surgeon then pulls theneedle48 from the tissue, drawing thesecond portion56 of thesuture40 into the tissue, and inserts theneedle48 into thefirst face66 of thewound60 at a subcutaneous entry point (not shown) at thefirst side64 of thewound60. Again, the surgeon advances theneedle48 along a curvilinear path until theneedle48 emerges from asubcutaneous exit point98 in theface66 further toward theother end82 of the wound and draws theneedle48 andsuture portion56 through the tissue.FIG. 9 shows theneedle48 being drawn a second time from thesecond face68 of thewound60. Thus, the surgeon advances thesecond portion56 of the suture in a sinusoidal pattern to theend82 of the wound60 (FIG. 10) and approximates the

faces

66,68 of thewound60. The length of thesecond portion56 of thesuture body42 protruding from theskin58 at the end of thewound60 is then cut and discarded.

FIG. 11 shows a prior art subcutaneous suturing method for closing awound60 using a spiraling, corkscrew-shaped stitch pattern. The surgeon begins at oneend80 of the wound by tying aknot100 in the first loop and advancing the suture in a corkscrew pattern to the other end of thewound82 where the suture is tied off. Tying the knots at the end and burying them, which is preferred by the surgeon, is technically very challenging, even more so when the incision is almost closed.

FIGS. 12-15 show a similar corkscrew-shaped stitch pattern for closing awound60 according to an embodiment of the method of the present invention. This embodiment is similar to the method described above using a subcutaneous sinusoidal stitch pattern.

Referring toFIG. 12, the surgeon begins by inserting one of theneedles46 into the tissue below theskin58 surface at aface66 on afirst side64 of thewound60 at an initialsubcutaneous insertion point63 longitudinally spaced from the

ends

80,82 of thewound60. The surgeon advances theneedle46 upward through the tissue along a curvilinear path until thepoint50 of theneedle46 extends from the tissue at asubcutaneous exit point73 in thefirst face66 of thewound60 longitudinally spaced toward oneend80 of the wound and above theentry point63 of theneedle46. The surgeon then inserts theneedle46 into the tissue at asubcutaneous entry point102 in theface68 at thesecond side70 of thewound60. The surgeon pushes theneedle46 through the tissue along a selected curvilinear path so that thepoint50 of theneedle46 emerges from asubcutaneous exit point104 in thesecond face68 of thewound60 longitudinally spaced toward theend80 of thewound60 and below theentry point102. The surgeon repeats these steps (FIG. 13) for advancing thefirst portion54 of thesuture40 longitudinally along thewound60 to the oneend80 of the wound in the spiraling, corkscrew stitch pattern. It is understood that the number and diameter of coils can be varied as desired. At any selected convenient point, the surgeon grips theneedle46 for drawing thefirst portion54 of thesuture40 through the tissue until thebarbs44 on thesecond portion56 engage the tissue at theinsertion point63 preventing further advancement of thesuture40 through the tissue. The surgeon approximates the

faces

66,68 of thewound60 as the surgeon progresses or when theend80 of thewound60 is reached as described above. The remaining length of thefirst portion54 of thesuture40 is drawn through the surface of theskin58 at the oneend80 of thewound60 and cut and discarded.

The surgeon repeats the procedure at theother end82 of thewound60 with thesecond portion56 of thesuture40. As seen inFIG. 14, several coils of thesecond portion56 of thesuture40 have been entered into the tissue in a direction toward theother end82 of thewound60. Subcutaneous entry points106 and exit points108 in the

faces

66,68 of thewound60 are visible. The surgeon advances thesecond portion56 of thesuture40 to theend82 of the wound60 (FIG. 15) and approximates the

faces

Another embodiment of a subcutaneous suturing method for joining and holding closed anopen wound60 in tissue according to the present invention is shown inFIGS. 16-18. This method also uses abarbed suture40 having curved pointed ends46,48, such as surgical needles.

Referring toFIG. 16, the surgeon begins by inserting thefirst needle46 subcutaneously into the tissue at aface66 on afirst side64 of thewound60 at aninitial insertion point63 adjacent oneend80 of thewound60 and pushes theneedle46 through the tissue along a selected curvilinear path until theneedle46 extends from the tissue at asubcutaneous exit point73 in thefirst face66 of thewound60 longitudinally spaced from theend80 of thewound60 in a direction toward theother end82 of thewound60. The surgeon grips theneedle46 and pulls theneedle46 out of the tissue for drawing thefirst portion54 of thesuture40 includingbarbs44 for resisting movement in the opposite direction through the tissue until thebarbs44 of thesecond portion56 engage thefirst face66 of thewound60 at theinsertion point63 preventing further advancement of thesuture40 into the tissue. A length of thefirst portion54 of thesuture body42 is thus positioned in the tissue along the selected curvilinear path.

As further seen inFIG. 16, the surgeon next inserts the secondsurgical needle48 into the tissue at a subcutaneous entry point (not shown) in theface68 at thesecond side70 of thewound60 substantially opposite the initial point ofinsertion63 of thefirst needle46 at the oneend80 of the-wound60. The surgeon advances thesecond needle48 through the tissue along a selected curvilinear path until theneedle48 extends from the tissue at a subcutaneous exit point (not shown) in thesecond face68 of thewound60. The surgeon then pulls thesecond needle48 for drawing thesecond portion56 of thesuture40 through the tissue, includingbarbs44 for resisting movement in the opposite direction, leaving a length of thesecond portion56 of thesuture40 in the tissue at theend80 of thewound60.

The surgeon repeats the above steps with thefirst needle46 andsecond needle48 at the second and

first sides

64,70, respectively, of thewound60. In this manner, the surgeon advances thesuture40 longitudinally along thewound60 from the oneend80 of the wound to the other82 in a shoelace pattern. As seen inFIG. 17, several passes of thesuture40 have been entered into the tissue of thewound60. The faces66,68 of thewound60 are approximated as the surgeon progresses, or when theend82 of thewound60 is reached, by pushing the

adjacent sides

64,70 of the tissue together along thebody42 of thesuture40. The lengths of thefirst portion54 andsecond portion56 of thesuture40 protruding from theskin58 are cut and discarded (FIG. 18).

It is understood that the method of the present invention shown inFIGS. 7-10 can be used to generate a similar stitch pattern if a second suture is used which is entered in the tissue to mirror the path of the first suture.

Another embodiment of the method according to the present invention for joining the

sides

64,70 of tissue in anopen wound60 is shown inFIGS. 19 and 20. In this embodiment, the surgeon inserts a first curved orstraight end46 of thesuture40, such as a needle, into the tissue at apoint62 on afirst side64 of thewound60 and laterally spaced from theface66 of thewound60 at thefirst side64. The surgeon advances theneedle46 through the tissue along a curvilinear path until theneedle46 emerges from the tissue on asecond side70 of the wound at anexit point72 laterally spaced from theface68 of thesecond side70 of thewound60 and longitudinally spaced in a first direction from the point ofinsertion62. This path subcutaneously passes through both faces66,68 of thewound60. The surgeon grips theneedle46 and pulls theneedle46 out of the tissue for drawing thefirst portion56 of thesuture40 through the tissue until thebarbs44 of thesecond portion56 engage the surface of theskin58 at theinsertion point62 preventing further advancement of thesuture40 into the tissue. The faces66,68 of thewound60 are approximated by pushing the

adjacent sides

64,70 of the tissue together along thebody42 of thesuture40 in the tissue. The length of thefirst portion54 of thebody42 of thesuture40 protruding from theskin58 is cut and discarded (FIG. 19).

The surgeon then inserts thesecond needle48 into the tissue at the point ofinsertion62 of thefirst needle46 at thefirst side64 of thewound60. The surgeon pushes theneedle48 through the tissue along a curvilinear path which substantially minors the passage of thefirst needle46 until theneedle48 emerges from the tissue at an exit point110 laterally spaced from the wound and longitudinally spaced in a second direction from the point ofinsertion62 such that the paths of the first and

second portions

54,56 of thesuture40 overlap. Again, the path of thesecond needle48 subcutaneously passes through the

faces

66,68 of thewound60. The surgeon grips thesecond needle48 and pulls theneedle48 from the tissue for drawing thesecond portion56 of thesuture40 into the tissue. The length of thesecond portion56 of thesuture40 protruding from theskin58 is cut and discarded, leaving a stitch in the tissue which resembles the Greek letter alpha (FIG. 20).

This stitch has its greatest benefit in small wound and incision closure. The alpha-shaped stitch can be placed quickly in tissue as compared with conventional loop sutures. Moreover, this stitch pattern has no blood constricting loops, leaves no stitch marks on the surface of the skin, and does not have to be removed from the patient if bio-absorbable material is used. Two or more of the alpha-shaped stitches may be used to close a larger wound.

A particular application of the alpha-stitch according to the method of the present invention is as a means of restricting bleeding from an arterial opening by constricting the tissue above and around the arterial opening. For example, the introduction and removal of catheters into the femoral artery is typically required when performing cardiac catheterization, percutaneous interventions, and other vascular procedures. These puncture wounds are typically self-sealing after several hours of sustained external pressure at and around the insertion site of the puncture wound.FIGS. 21 and 22 show the alpha-stitch according to a method of the present invention positioned for performing this function. Note that the path of the

suture portions

54,56 is curvilinear with the respect to theskin58 surface and that the deepest points of the arcs pass immediately above thepuncture site112 in theartery114. In this embodiment, the ends46,48 of thesuture40 are pulled to put tension in the tissue. As the ends46,48 of thesuture40 are pulled, the tissue embraced by the suture is pulled both inward from the areas lateral to theartery114 and downward from areas immediately above theartery114. This constriction of tissue increases the density of tissue around thearterial puncture site112 and imparts forces with vectors directed toward the arteriotomy site to limit bleeding. Further, this suture method avoids the need to traverse the artery wall or lumen, thus eliminating the risk of vessel wall dissection and promoting introgenic thrombogenesis.

The method of the present invention is also useful in binding together partially or completely severed tendons or other internal tissue repairs requiring considerable tensile strength. For example, referring toFIG. 23, afinger120 is shown with a portion of the outer layer of tissue cut-away to schematically show asevered tendon122. A Kessler suturing method for joining the two ends124,126 of thetendon122 is shown inFIG. 24. This method requires the surgeon to apply an intricate stitch pattern and to complete the tendon connection with one or two technicallychallenging knots128. No portion of thesuture knot128 may protrude from the outside surface of the repairedtendon122 where it could snag the surrounding tendon sheath and impede healing. Theknot128 also presents a particular dilemma since it must be tied between the two ends124,126 of thetendon122, where it can be a barrier between tendon sections that must appose in order to effectively heal. A further limitation of the conventional tendon repair method is that relatively small amounts of tension can stretch thetendon122, allowing it to slide along the smooth monofilament fiber and effectively disrupt, or in the case of greater amounts of tension, separate completely at the wound margin. This outcome substantially limits healing even though the suture material remains intact.

A method according to the present invention for joining the two ends124,126 of thetendon122 is shown inFIGS. 25-28. Referring toFIG. 25, the surgeon begins by inserting thefirst end46 of thesuture40, which may a straight or curved surgical needle, into oneend124 of thetendon122 and pushing theneedle46 through thetendon122 along a selected curvilinear path until thepoint50 of theneedle46 extends from anexit point130 in the periphery of thetendon122 longitudinally spaced from the one end of thetendon122. Thefirst needle46 is gripped and pulled out of the tendon for drawing thefirst portion54 of thesuture40 through thetendon122 leaving a length of thefirst portion54 of the suture in thetendon end124 between the end of thetendon122 and theexit point130. The surgeon reinserts theneedle46 into the periphery of thetendon122 at anentry point132 immediately adjacent theexit point130 and pushes theneedle46 along a selected curvilinear path until thepoint50 of theneedle46 exits the other side of the tendon at anexit point134 that is longitudinally spaced from theentry point132. It is understood that the surgeon could use theexit point130 as the next entry point for theneedle46 if desired. The surgeon pulls theneedle46 out of the tendon for drawing thefirst portion54 of thesuture40 through thetendon122, reinserts theneedle46 into the side of thetendon122 at anentry point136 immediately adjacent theexit point134 and pushes theneedle46 along a selected curvilinear path back out of the other side of thetendon122 at anexit point138 longitudinally spaced from theprevious entry point136. It is understood that the surgeon makes as many passes as deemed necessary for holding theend124 of thetendon122, or as the length or thickness of thetendon122 allows, and removes the remaining length of thefirst portion54 of thesuture40.

As seen inFIG. 26, these steps are repeated with thesecond portion56 of thesuture40 at theother end126 of thetendon122. The pattern of thesecond portion56 of thesuture40 in thesecond end126 of thetendon122 generally mirrors thefirst portion54 of thesuture40 in thefirst end124 of thetendon122, including exit points130a,134a,138aand entry points132a,136a.The ends124,126 of thetendon122 are brought together while maintaining tension on the free ends of the sutures.

Referring now toFIG. 27, a second suture40ais introduced at thesecond end126 of thetendon122. Thefirst needle46aof the second suture40ais inserted into theend126 of thetendon122 and pushed through thetendon122 along a selected curvilinear path until theneedle46aextends from anexit point140 in the periphery of thetendon122 substantially opposite the first exit point130aof thesecond portion56 of thefirst suture40. Theneedle46aof the second suture40ais pulled out of thetendon122 for drawing the first portion54aof the second suture40athrough thetendon122 leaving a length of the suture40ain thetendon122 between theend126 of thetendon122 and theexit point140. The surgeon repeats the steps. described above by reinserting theneedle46ainto thetendon122 at an entry point142 (FIG. 28) adjacent theexit point140 and pushing theneedle46aalong a selected curvilinear path until theneedle46aemerges from anexit point144 in the periphery of thetendon122 substantially opposite the second exit point134aof thesecond portion56 of thefirst suture40. In this manner, the surgeon advances longitudinally along theend126 of thetendon122 entering at146 and exiting at148. The previous steps are repeated at theother end124 of thetendon122 with the second portion56aof the second suture40a. The number of sutures used depends on the size, caliber, and length of the tendon to be repaired. Big tendons will require more than two sutures whereas one may suffice for very small tendons.

Tendon repair with two sutures according to the present invention exhibits equivalent or better holding power as the prior art technique. Moreover, tendons repaired according to the methods of the present invention maintain their original configuration, profile, contour, and form better when being stretched.

The method of the present invention may be embodied in many surgical procedures. The procedures include both open surgery as well as endoscopic and laparoscopic surgery. Further, the uses of embodiments of the present invention may include repair of wounds, fastening of tissue junctions formed by the procedures, and positioning of tissue. The surgical procedures described herein are known to those of ordinary skill in the art, and accordingly are described only to a level of detail required to convey the respective embodiments of the method of the present invention. InFIGS. 29-48, where various steps of insertion are omitted from a drawing, it should be understood that the description and accompanying text ofFIGS. 1-28 apply to inserting thesutures40.

FIG. 29 shows astomach200 prior to performance of a Nissen fundoplication. This procedure is performed on patients who suffer from gastroesophageal reflux disease and do not respond to medical treatment. As shown, thefirst portions54 of two respectivebarbed sutures40 are inserted into a proximal location of thefundus202 and into the serosal and muscularis layers, and the respectivesecond portions56 remain free. The stomach'sfundus202 is pulled behind and wrapped206 around theesophagus204. The respectivesecond portions56 are then advanced similarly into the apposingpart208 of thestomach200, as shown inFIG. 30.

The same result in fastening may be achieved by performing the procedure in a different order. Thefundus202 may be pulled and wrapped206 behind theesophagus204 first, and then temporarily clamped or stapled in placed while the first and

second portions

54,56 are inserted in the configuration shown inFIG. 30. Other sequences may also be used and remain within the scope of the present invention.

Thebarbed suture40 may also be inserted as shown inFIG. 31, in either a sinusoidal or coiled configuration as previously described. The curved insertion is performed subsequent to pulling and wrapping206 thefundus202 behind theesophagus204, and then clamping or stapling in place.

FIG. 32 shows alaparoscopic insertion device220 used to stabilize abowel structure222 in position in advance of performing an anastomosis, whereby an end-to-end surgical connection of hollow organs is conventionally performed. Thelaparoscopic insertion device220 comprises a tubular body in which thebarbed suture50 is disposed, with holes at the leading and trailing ends, similar to that disclosed in U.S. Pat. No. 5,342,376 to Ruff, the contents of which were previously incorporated by reference herein. Theinsertion device220 penetrates using thepoint50 of the suture to pierce theepidermis84,dermis86,fat88,fascia90,muscle92, and the peritoneum94 before passing into theabdominal cavity224. Theinsertion device220 then passes into thebowel structure222. A laparoscopic graspingtool226 is shown to be holding the bowel structure in position until the suture is in place. It should be noted that thebowel structure222 may also be stabilized by placement of abarbed suture40 from the inside of thestructure222.

InFIG. 33, the laparoscopic insertion device is removed by pulling it outward228, exposing thesuture40, while thepointed end50 of thesuture40 is retained by its barbs against the removal force of theinsertion device220. Thesuture40 is in place inFIG. 34. When the procedure that gave rise to the need to tie thebowel structure222 in place is complete, the suture may be cut at an exposedpoint229. As shown, the trailing end of thesuture40 extends through theepidermis84 at the point of initial insertion, and thesuture40 may be cut atpoint229 to allow that portion of thesuture40 to be removed by pulling on the trailing end.

Optionally, the barbed suture pointedend50 may continue through thebowel structure222 tissue, into theabdominal cavity224, and through any number of desired selected layers of the peritoneum94,muscle92,fascia90,fat88,dermis86, andepidermis84. If thesuture40 passes through theepidermis84 and is to be left in place, thesuture40 may be cut off such that the end of thesuture40 resides beneath theepidermis84. Alternatively, in a method similar to that described forFIG. 34, when the procedure that gave rise to the need to tie thebowel structure222 in place is complete, thesuture40 may be cut at the exposedpoint229 and in addition at another exposed point along thesuture40 on the opposite side of thebowel structure222, allowing removal of both ends of thesuture40.

A portion of the biliary system is shown inFIG. 35. Theliver230 is shown in partial section view, and thegallbladder232,bowel234, andstomach200 are the other organs that are shown. The barbed suture of the present invention may be used to perform a Rodney Smith procedure with Roux-en-Y for the anastomosis of thebowel234 to theliver230. In such an operation, thebile duct236 may be cut, for example, atpoint237 and anastomized to thebowel234 at an incision in thebowel234 atpoint238. Thesutures40 may be inserted as shown inFIG. 36 with either an insertion device or with needles as previously discussed. The remaining portion of thebile duct239 is removed and the wound at the end where it connects to thebowel234 is sutured closed, which may also be done withsutures40 of the present invention. In addition, barbed sutures can be placed in a curvilinear path, as shown inFIG. 37 by proceeding with the suture around thebile duct236 and the opening in the bowel. The first insertion point of the suture may be either in the bowel or the bile duct.

Theappendix240 is being removed from thececum242 of the large intestine inFIG. 38. Prior to cutting of theappendix240, thesuture40 must be placed so that it will be ready to tie off theappendiceal stump244. Thesuture40 may be placed using a curved insertion device (not shown), or with

curved needles

46,48. Thebarbed suture40 is placed around the base of theappendix240 by inserting the first end of the first portion of the suture at an insertion point62 (FIG. 39) and pushing thefirst portion54 in one direction through the muscularis and serosal layers of thececum242 around the base for at least one half of the circumference. Then thesecond portion56 is likewise placed by inserting at theinsertion point62 and pushing thesecond portion56 in the other direction through the muscularis and serosal layers of thececum242 around the base for at least until thesecond portion56 crosses the first portion54.Theappendix240 is then removed, and thestump244 is inverted while thesuture40 is pulled taut, similar to a purse-string as well as the alpha stitch shown inFIGS. 19-22.

AlthoughFIG. 38 shows both

needles

50,52 and respective

suture end portions

54,56 extending from thececum242, having both

end portions

54,56 extend from thececum242 is optional. With the use of an insertion device of the nature of that shown inFIG. 33, for example (device220), one end may be left embedded in thececum242 and the other end may be pulled to invert theappendiceal stump244 with the purse-string or alpha stitch.

FIGS. 40-42 show three stages of the procedure for a Zenker's Diverticulectomy. A Zenker'sDiverticulum260 is a sac that protrudes from theesophagus262 below thepharynx264. TheDiverticulum260 is the herniation of the mucosal sac between the fibers of the pharyngeal constrictor muscle and thecricopharyngeal muscle266. The Diverticulum forms anorifice268 to thelumen270 of theesophagus262, and is shown in its initial untreated position inFIG. 40.

InFIG. 41 theDiverticulum260 is inverted and pulled into theesophagus262 through theorifice268 using an endoscopicgrasping tool272. An endoscopic insertion device274, similar to thelaparoscopic insertion device220 ofFIGS. 32-34, is used as shown inFIG. 42 to insert thebarbed suture40 into thecricopharyngeal muscle266 above theorifice268, exiting at the orifice, and then again penetrating themuscle266. Themuscle266 on both sides of theorifice268 is approximated to close the orifice. TheDiverticulum260 is then endoscopically cut and removed (not shown). Alternatively, the stitch used to close theorifice268 may be a purse-string type or alpha type, as shown inFIGS. 38 and 39. Multiple sutures may be used to close the orifice. Further, the procedure of suturing closed the orifice may be performed in a similar manner without inverting theDiverticulum260 into theesophagus262. In this alternative the Diverticulum remains outside theesophagus262 and is not excised.

Theviscus structure300 shown inFIGS. 43-44 has anulcerative lesion302 on itsinside wall304. An endoscopic camera306 (scope) allows the procedure to be performed, and an endoscopic insertion device (not shown) in a separate tube within the scope inserts thesutures40 as previously described. Thescope306 may approach thelesion302 through the anus or the oropharynx. The tissue on each side of thelesion302 is approximated and the endoscopic devices are removed as shown inFIG. 44.

FIGS. 45 and 46 respectively show a closure of a cystostomy incision in aurinary bladder320. The closure is shown as having a curvilinear path, and may be inserted in such a curvilinear path similarly to the sinusoidal method (FIG. 45) or coil method (FIG. 46) previously discussed and shown byFIGS. 7-10 andFIGS. 12-15, respectively, although other methods discussed herein may also be used. Thesuture40 passes through the muscularis layer of the bladder in a bidirectional fashion.

Areplacement heart valve340 is shown inFIG. 47. Theannular cuff342 of theheart valve340 forms the periphery of the valve. Thecuff342 is joined tofibrous heart tissue344 that forms a ring in the location where thevalve340 is placed. Twosutures40a,40bare shown, respectively havingfirst portions54aand54bthat pass through thecuff342 andtissue344 in one direction andsecond portions56aand56bthat proceed in the other direction. Threading of thesutures40a,40bis performed similarly to the sinusoidal and coil methods previously discussed, and may start from either thecuff342 or thetissue344.

Various configurations may be used to install thevalve340 in accordance with the knowledge of one of ordinary skill in the art, such as only one suture for the full periphery of the valve, or multiple sutures that each include a portion of the valve's periphery, and providing redundancy of sutures as appropriate. The replacement heart valve may be a bioprosthetic valve or an artificial prosthetic mechanical valve. In addition, this method may be used on any foreign element that has a periphery and requires attachment to tissue, for example, a patch for closing a septal defect in the, heart.

The method according to the present invention may also be used to secure devices to tissue, both inside and outside of a body. Acentral line device360, as used for intravenous access, is shown inFIG. 48, and is attached to a person'sleg362. Examples of other devices that are required to be secured include catheters and monitors; tumor monitors in particular are an example of an internal device that may benefit from the method of the present invention.Eyelets364a,364bare provided on thedevice360 and thesuture40 passes through eacheyelet364a,364bbefore penetrating and passing through tissue of theleg362 in a manner similar to that previously described, and being pulled snug to secure thedevice360.

To facilitate removal of thebarbed suture40, thesuture40 may be cut at a point within thecentral portion366, separating the portions of thesuture40 with opposing barbs. Then the

separate sections

54,56 of thesuture40 may be removed by pulling on an exposed portion in the direction that the barbs allow movement of thesuture40 through the tissue. This method o removal is not limited to the use shown inFIG. 48, but may apply to any use of the barbed suture.

The barbed sutures of the present invention may also be used in a variety of cosmetic surgery applications. Such applications include but are not limited to facelifts, browlifts, breast lifts, and thigh lifts. In each of the procedures, once the sutures are in place and as tension is maintained on the free ends of the suture (not shown in the figures referenced below), the engaged tissues are manually grouped and advanced toward the insertion point to achieve the desired lifting effect. The tissue into which the sutures are inserted are soft tissue, meaning any tissue that is not an organ or a vessel. Multiple sutures may be used for further augmentation or maintenance of lift.

A facelift and two methods of browlifts are shown inFIG. 49. Oneend380 of abarbed suture382 is inserted using a needle (not shown) at the temporal, hairline atpoint384 and advanced through the subepidermal tissue underneath the scalp, exiting distally. Subepidermal tissue comprises the papillary dermis, reticular dermis, subcutaneous tissue, or any combination thereof. Theother end386 is inserted at the same location and extended towards thenasolabial fold388, engaging the subepidermal tissue, the superficial muscular aponeurotic system, or both, and exiting distally. As tension is maintained on the free ends (not shown) of thesuture382, the engaged tissues on thelower end386 are manually grouped and advanced toward theinsertion point384 to achieve the desired lifting effect. The procedure is repeated on the opposite side of the face. Similar procedures may be performed to provide the lifts made in other locations with

barbed sutures

390,400.

In addition, the barbed sutures may be applied with the use of an insertion device as previously discussed. For example, the

barbed sutures

382,390 shown inFIG. 49 may be put in place using an insertion device from either end of the respective suture.

One method of performing a browlift is shown with oneend408 of abarbed suture410 being inserted atpoint412 at the hairline (for nonreceding hairlines, as depicted) or at the midpoint between the hairline and the eyebrow (for receding hairlines, not shown). Thisend408 is advanced through the subepidermal tissue towards and on through the scalp. Theother end414 is inserted at the same point and advanced through the subepidermal tissue in the opposite direction, exiting at theinferior aspect416 of the brow. The procedure is repeated on the opposite side of the forehead, but for convenience herein a different method is shown in the same figure. Once again, thesuture410 may be put in place with the use of an insertion device from either end.

A second method of performing a browlift is shown inFIG. 49 with oneend420 of abarbed suture422 being inserted atpoint424 at the hairline (for nonreceding hairlines, as depicted) or between the hairline and the eyebrow (for receding hairlines, not shown). Thisend420 is advanced through the subepidermal tissue, exiting at theinferior aspect426 of the brow. Theother end428 is inserted at the same point and is also advanced through the subepidermal tissue, but at a slight angle to the path taken by thefirst end420 and also exiting at theinferior aspect426 of the brow. This results in the approximate inverted vee-shaped configuration shown. The procedure may be repeated across the forehead.

Barbed sutures of the present invention may similarly be used as a tissue-sculpting device to perform a thigh or breast lifting procedure. These procedures are similar to those shown for the facelift and browlift ofFIG. 49, and accordingly no additional drawings are required but respective descriptions are as follows.

To perform a thigh lift, multiple sutures are inserted by needle at the inguinal crease, spaced approximately 0.5-1.5 cm apart, beginning at the lateral aspect of the pubic triangle and extending medially approximately 180 degrees to the vicinity of the gluteal fold. The suture is advanced approximately 8 cm cranially through the subepidermal tissue. The opposite end of the suture is inserted in the same location and similarly advanced approximately 8 cm caudally. After exiting through the skin distally at each end, tension is maintained on the free ends of the suture, and the engaged tissues are manually grouped and advanced toward the insertion point to achieve the desired lifting effect. The process is repeated with multiple sutures around the semi-circumference of the thigh, and then repeated on the opposite thigh.

To perform a breast lift using a barbed suture of the present invention, one end of the barbed suture is inserted by needle into the skin at the upper aspect of the breast curvature. The needle is advanced such that the medial barbs engage the subcutaneous and dermal tissues, while the distal barbs engage the pectoralis muscle (and where possible, the periosteum of the clavicle), and then exit distally through the skin. The other end of the suture is inserted at the same point by needle, and advanced caudally through the fibrous and fatty tissues of the breast exiting at various points along the lower curvature of the breast. Additional sutures are similarly inserted at a variety of appropriately spaced locations along the breast. As tension is maintained on the free suture ends, the breast is lifted along the axis of the suture, with the barbs locking the lift into place. Lifting is continued until the desired effect is achieved. Results from such a procedure may benefit from the use of a barbed suture with longer barbs than may be necessary in other procedures, in order to grasp fatty breast tissue effectively.

InFIG. 50, aninsertion device500 is shown in a procedure to close an axial wound in a blood vessel, such as an artery or vein. Thewound112 is similar to that shown inFIG. 22, but the method is different in that the method ofFIG. 22 uses needles and does not penetrate theartery114, rather constricting the tissue above and around the arterial opening. Theinsertion device500 ofFIG. 50 comprises a tubular body in which thebarbed suture50 is disposed. Thewound112 may be a puncture in anartery114 as occurs as the result of the introduction and removal of catheters, as discussed in the text accompanyingFIG. 22. The sharppointed end50 of thesuture40 is pushed with the leading end of theinsertion device500 through theskin58 andtissue70 on one side of theartery114, through the artery wall on one side of thewound112, into theinterior504 of theblood vessel114, through the artery wall on the other side of thewound112, and into thetissue64 on the other side of thewound112. The trailing end of theinsertion device500 is then pulled on to remove theinsertion device500, leaving thesuture40 in place.

Two embodiments of a suture left in place by an insertion device are shown inFIGS. 51 and 52. InFIG. 51, theportion506 of thesuture40 in theinterior504 of theartery114 has barbs. The embodiment ofFIG. 52 omits barbs in theinterior504 of theartery114, and the barbs are omitted for aportion508 that extends into theartery114 wall. Theportion508 without barbs could extend less or more than shown, and into the

tissue

70,64, so long as there are no barbs inside theartery114. To reduce the chance of clotting of blood on or around the suture, an antithrombotic agent may be applied on the suture. AlthoughFIGS. 50-51 show thesuture40 with thepointed end50 embedded in

tissue

70,64, thesuture40 may also be put into place with thepointed end50, or both ends, extending out of theskin58, where the end or ends may be cut.

The invention is further illustrated by the following non-limiting examples.

Example 1

A straight incision wound, about 1.5 cm deep, was created in each of four samples of cadaveric porcine skin tissue. The tissue samples measured 4 cm by 10 cm. Each incision was centered on the skin sample so that the wound was 4 cm long from end to end.

Each wound was closed according to a different suture method using identical barbed sutures made from monofilament PDS (polydioxanone)size 0. One wound was closed according to the method shown in U.S. Pat. Nos. 5,342,376 and 6,241,747, without using the inserting device (the Ruff method). Seven sutures were placed along the length of the wound and running generally perpendicularly to the faces of the wound. When placed, the sutures dipped below the incision line thus engaging subcutaneous tissue below the incision and the ends of the sutures engaged some dermis. A second wound was closed using seven needle-tipped sutures placed along the length of the wound in the dermis and running generally perpendicularly to the faces of the wound similar to the method shown in U.S. Pat. No. 5,931,855 (the Buncke method). In both methods, the length of each suture buried under the skin was approximately 6 cm. A third wound was closed using the zigzag stitch pattern in the dermis as described above and shown inFIGS. 3-6. The number of passes resulted in four entry/exit points on each side of the wound. A fourth wound was closed using the corkscrew-shaped stitch pattern described above and shown inFIGS. 12-15. The number of passes resulted in seven complete loops with the tops of the loops engaged in the dermis. The tissues were held together only by the sutures.

Biomechanical strength testing was carried out as follows. Each sample was positioned so that the surface of the tissue sample was substantially vertical and the incision was generally horizontal. The bottom edge of the sample was immovably secured. The upper edge of the sample was attached to a Berkley digital fish scale (0-50 lb.) The scale was then raised vertically generating tension across the wound. The scale was raised until the tissues totally separated. The peak force required to separate the incision was recorded as the breaking strength.

	TABLE 1

	Suture Method	Breaking Strength(lbs)

	Ruff Method	4.5
	Buncke Method	8.5
	Zigzag Method	18.3
	Corkscrew Method	16.5

Example 2

Seven incisions were made at various locations on each of three dogs. The length of the incisions ranged from ½ inch to 4 inches and the depth of the incisions from the dermis to the muscular level. The incisions were closed with barbed sutures made from monofilament PDS (polydioxanone)size 0 and conventional sutures' according to the following scheme with the locations randomized:

TABLE 2

	Barbed
	Suture
Tissue Level	Method	Conventional Suture Method

Dermis	Alpha,	Simple interrupted loop stitches [2-0 nylon,
	Zigzag	2-0 silk]
Subcuticular	Corkscrew	Simple continuous loop stitches [3-0 PDS]
Subcutaneous	Corkscrew	Simple continuous loop stitches [3-0 PDS]
Muscular	Corkscrew	Simple continuous loop stitches [3-0 PDS]

More than one alpha-shaped stitch was used for longer incisions.

The dogs were housed for two weeks. Daily clinical and necropsy observations were performed on all surgical sites. With the exception that three of six sites closed by nylon sutures had some sutures chewed out by the dog, all incisions healed normally and no dehiscence occurred. The other three sites closed with nylon sutures had a railroad-tile appearance, one site in particular being very pronounced. None of the topical skin sites closed with barbed sutures had such an appearance. This example shows the efficacy of barbed sutures in an in vivo model.

The methods of the present invention have a number of advantages, including improving the biomechanical performance of barbed sutures. The curvilinear placement paths of the suture, as contrasted with linear insertion, provide substantially increased strength for holding the edges of a wound together. Moreover, the insertion of a single suture with curvilinear techniques replaces the insertion of a plurality of sutures. The new methods provide an efficient means for a surgeon to close a wound, reducing the time necessary to place the suture and the trauma to the patient. Surgeons can quickly and easily utilize the suturing methods during any type of surgery to quickly join the edges of a wound in tissue without threading and tying numerous individual stitches. The new suture methods are performed in a manner similar to conventional suturing thus realizing the advantages thereof. The methods minimize damage to tissue when inserted and minimize scarring or tissue necrosis across the wound. The sutures can be placed in the tissue in a manner to control and adjust the tension on the suture or the compression of the tissue.

Although the present invention has been shown and described in considerable detail with respect to only a few exemplary embodiments thereof, it should be understood by those skilled in the art that we do not intend to limit the invention to the embodiments since various modifications, omissions and additions may be made to the disclosed embodiments without materially departing from the novel teachings and advantages of the invention, particularly in light of the foregoing teachings. For example, the methods of the present invention can be used alone or with other closure methods, such as topical skin adhesives to aid in holding the position of the tissue. Accordingly, we intend to cover all such modifications, omission, additions and equivalents as may be included within the spirit and scope of the invention as defined by the following claims.