U.S. patent application number 11/273198 was filed with the patent office on 2007-05-17 for perforation suturing method.
This patent application is currently assigned to OLYMPUS MEDICAL SYSTEMS CORP.. Invention is credited to Masayuki Iwasaka, Kunihide Kaji, Takayasu Mikkaichi.
Application Number | 20070112362 11/273198 |
Document ID | / |
Family ID | 38041893 |
Filed Date | 2007-05-17 |
United States Patent
Application |
20070112362 |
Kind Code |
A1 |
Mikkaichi; Takayasu ; et
al. |
May 17, 2007 |
Perforation suturing method
Abstract
A perforation suturing method has the steps of: inserting a
needle into a wall of a hollow organ at a periphery of the
perforation formed in the hollow organ, and piercing the wall;
withdrawing the needle from the wall after delivery of an anchor
attaching suture thread from the needle, and having the suture
thread transit the wall; and tightening the suture thread so that
the mated insertion points at the time of insertion of the needle
into the wall approximately coincide after having the needle pierce
the wall at the periphery of the perforation a plurality of times,
and making surfaces of the wall where the insertion points are
formed coincide with each other.
Inventors: |
Mikkaichi; Takayasu; (Tokyo,
JP) ; Iwasaka; Masayuki; (Tokyo, JP) ; Kaji;
Kunihide; (Tokyo, JP) |
Correspondence
Address: |
SCULLY SCOTT MURPHY & PRESSER, PC
400 GARDEN CITY PLAZA
SUITE 300
GARDEN CITY
NY
11530
US
|
Assignee: |
OLYMPUS MEDICAL SYSTEMS
CORP.
TOKYO
JP
|
Family ID: |
38041893 |
Appl. No.: |
11/273198 |
Filed: |
November 14, 2005 |
Current U.S.
Class: |
606/153 |
Current CPC
Class: |
A61B 17/0401 20130101;
A61B 2017/00637 20130101; A61B 2017/0458 20130101; A61B 2017/0464
20130101; A61B 17/29 20130101; A61B 2017/0417 20130101; A61B
17/0487 20130101; A61B 2017/0454 20130101; A61B 2017/0496 20130101;
A61B 2017/0409 20130101 |
Class at
Publication: |
606/153 |
International
Class: |
A61B 17/08 20060101
A61B017/08 |
Claims
1. A perforation suturing method comprising, the steps of:
inserting a needle into a wall of a hollow organ at a periphery of
the perforation formed in the hollow organ, and piercing the wall;
withdrawing the needle from the wall after delivery of an anchor
attaching suture thread from the needle, and having the suture
thread transit the wall; and tightening the suture thread so that
the mated insertion points at the time of insertion of the needle
into the wall approximately coincide after having the needle pierce
the wall at the periphery of the perforation a plurality of times,
and making surfaces of the wall where the insertion points are
formed coincide with each other.
2. The perforation suturing method according to claim 1, wherein
the needle is inserted into the hollow organ via a tool that is
inserted from a natural orifice in a living body.
3. The perforation suturing method according to claim 1, wherein
the hollow organ is a digestive organ, and the needle is inserted
from the mucous membrane side of the digestive organ.
4. The perforation suturing method according to claim 1, wherein
the insertion point is formed in a muscular layer exposed on an
inner circumferential surface of the perforation, and the needle
pierces the muscular layer diagonally relative to the inner
circumferential surface of the perforation.
5. The perforation suturing method according to claim 1, further
comprising a step of resecting a mucous membrane of the inner
surface of the hollow organ, wherein the step in which the suture
thread is made to transit the wall includes a step of inserting the
needle into a surface on an interior side of a muscular layer
exposed by resection of the mucous membrane.
Description
BACKGROUND OF THE INVENTION
[0001] 1. Field of the Invention
[0002] This invention relates to a suturing method using an
endoscope. For example, it relates to a method of suturing
perforation formed in a wall of a hollow organ.
[0003] 2. Description of Related Art
[0004] When conducting procedures on the interior of the body of a
patient, one may cite cases of incisions in the body of the patient
by surgical operation, as well as transoral and transrectal
endoscopic procedures. As a method of suturing perforations in the
abdominal region by surgical operation, there is the method shown
in FIG. 6a-6c of U.S. Pat. No. 6,066,146. This suturing method is
used when closing incisions in the abdominal cavity. A needle is
inserted into the muscular layer of the opening in the abdominal
wall, and an anchor attaching suture thread is pushed out from the
needle. The suture thread attached to the anchor is tied with the
proximal side, and suturing is conducted. Endoscopic procedures are
conducted by passing forceps, high-frequency treatment instruments,
incision instruments, sutures and the like through the channel of
an endoscope. For example, in cases where medical treatment is
conducted in the abdominal cavity using an endoscope inserted into
a duct or cavity via a natural orifice in the living body such as
the mouth, anus or the like, tissue is resected from the abdominal
cavity or cut open, forming a perforation, and the medical
treatment is conducted by accessing the interior of the abdominal
cavity from the interior of the duct or cavity via this
perforation. After conducting the medical treatment, the formed
perforation is sutured with a suture.
SUMMARY OF THE INVENTION
[0005] The perforation suturing method of the present invention
includes the steps of: inserting a needle into a wall of a hollow
organ at a periphery of the perforation formed in the hollow organ,
and piercing the wall; withdrawing the needle from the wall after
delivery of an anchor attaching suture thread from the needle, and
having the suture thread transit the wall; and tightening the
suture thread so that the mated insertion points at the time of
insertion of the needle into the wall approximately coincide after
having the needle pierce the wall at the periphery of the
perforation a plurality of times, and making surfaces of the wall
where the insertion points are formed coincide with each other.
BRIEF DESCRIPTION OF THE DRAWINGS
[0006] FIG. 1 is a view showing the schematic configuration of an
endoscope and a suturing apparatus.
[0007] FIG. 2 is a sectional view of the suturing apparatus and the
distal end of the endoscope.
[0008] FIG. 3 is an oblique view of the suturing apparatus and the
distal end of the endscope.
[0009] FIG. 4 is a view showing the configuration of the
suture.
[0010] FIG. 5 is a view showing the step of inserting the endoscope
into the abdomen of the patient, and observing the planned incision
position from inside the abdomen.
[0011] FIG. 6 is a view showing the step of conducting a procedure
in the abdominal cavity via a perforation.
[0012] FIG. 7 is a view showing the needle insertion position.
[0013] FIG. 8 is a view of the delivery of the anchor after the
needle has bored through.
[0014] FIG. 9 is a view of the attachment of the suture.
[0015] FIG. 10 is a view showing the forceps that tighten the
suture.
[0016] FIG. 11 is a view showing the step of tightening the suture
with the outer sheath of the forceps.
[0017] FIG. 12 is a view showing the state where the perforation
has been closed to the extent of the tightening of the suture.
[0018] FIG. 13 is a view where the suture has been tightened, and
the insertion points have been made to approximately coincide.
[0019] FIG. 14 is a view where the suture has been tightened, and
the insertion points have been made to approximately coincide.
[0020] FIG. 15 is a view where the anchors are stationed between
the mucous membrane and the muscular layer.
[0021] FIG. 16 is a view showing the process of tightening the
suture from the state of FIG. 15.
[0022] FIG. 17 is a view where the suture is tightened, and the
insertion points are made to approximately coincide.
[0023] FIG. 18 is a view showing the step of diagonal insertion of
the needle into the inner circumferential surface of the
perforation.
[0024] FIG. 19 is a view of the delivery of an anchor after the
needle has passed through.
[0025] FIG. 20 is a view of the attachment of the suture.
[0026] FIG. 21 is a view showing forceps for tightening the
suture.
[0027] FIG. 22 is a view where the suture has been tightened, and
the insertion points are made to approximately coincide.
[0028] FIG. 23 is a view where the mucous membrane on the abdomen
interior side is resected in the vicinity of the perforation.
[0029] FIG. 24 is a view showing the step of inserting the needle
into the surface exposed by the resection of the mucous
membrane.
[0030] FIG. 25 is a view of the attachment of the suture.
[0031] FIG. 26 is a view where the suture has been tightened, and
the insertion points are made to approximately coincide.
[0032] FIG. 27 is a schematic view showing one example of the
combination of an endoscope and a suturing apparatus.
PREFERRED EMBODIMENTS
[0033] (First Embodiment)
[0034] FIG. 1 shows the endoscope and suturing apparatus used in
the present embodiment. An endoscope 1 (flexible endoscope) has an
endoscope control section 2 that is controlled by the operator. The
endoscope control section 2 is connected to a control device by a
universal cable 3, and is provided with various types of switches 4
and angle knobs 5. A flexible, elongated endoscope insertion
section 6 extends from the distal end of the endoscope control
section 2. The distal end of the endoscope insertion section 6 is
provided with an observation device 7 for obtaining images of the
interior of the body, an illumination device 8, the distal openings
of channels 9, and so on. The observation device 7 uses an imaging
device provided with a CCD (charge coupled device), optical fiber,
and so on. The illumination device 8 has optical fiber that guides
the light from a light source. The channels 9 run through the
endoscope insertion section 6, and open at a side part 2a of the
endoscope control section 2. A cover 10 is attached to the opening
of the side part 2a. An insertion aperture is formed in the cover
10, and instruments for medical procedures such as a suturing
apparatus 11 are inserted into the channel 9 from this insertion
aperture. In short, the endoscope 1 and channel 9 are used as tools
for inserting instruments for medical procedures such as the
suturing apparatus 11 into a duct or cavity from a natural orifice
in the living body.
[0035] As shown in FIG. 1 to FIG. 3, a freely movable flexible
inner sheath 13 runs through the interior of an outer sheath 12 of
the suturing apparatus 11. A needle 14 is fixed to the distal end
of the inner sheath 13. A slit 15 extends in the lengthwise
direction from the distal end of the needle 14. A suture 16 is
housed inside the needle 14. The respective lengths of the outer
sheath 12 and the inner sheath 13 are longer than the channel 9 of
the endoscope 1. A control section 17 is attached to the base of
the inner sheath 13. The control section 17 has a freely slideable
handle 19 relative to a control section body 18. The base of a
pusher 20 is fixed to the handle 19. The pusher 20 runs through the
interior of the inner sheath 13, and extends to the interior of the
needle 14. A distal end 21 of the pusher 20 contacts the suture
16.
[0036] As shown in FIG. 4, the suture 16 is provided with suture
threads 25. The suture threads 25 are largely folded in two, and a
knot 31 is formed in the vicinity of the folding point.
Furthermore, the suture threads 25 run through a stopper 26 that is
approximately triangular in the state where its two ends are bound
together. One anchor 27 each is fixed to the respective ends of the
suture threads 25. The anchors 27 have a cylindrical shape, and
suture thread 25 is affixed to approximately the center of each
anchor 27 in the lengthwise direction. The stopper 26 has an
aperture 28 at the center in the lengthwise direction of its long
plate member through which the suture threads 25 pass. Two ends 29
in the lengthwise direction of the stopper 26 diagonally fold back
into each other, sandwiching the suture threads 25. The two ends 29
in the lengthwise direction of the stopper 26 are cut into
triangular sections 30. In the stopper 26, the two ends 29 are
diagonally folded back so that the sections 30 intersect, and the
suture threads 25 are sandwiched in between. Consequently, the
suture threads 25 do not fall out from between the ends 29. When
the knot 31 of the suture threads 25 is pulled in the direction
away from the stopper 26, the two ends 29 of the stopper 26 are
slightly opened. Accordingly, the stopper 26 allows movement of the
suture threads 25 in this direction. On the other hand, when the
ends of the suture threads 25 on the anchor 27 side are pulled, the
suture threads 25 move in the direction shown by the arrow mark in
FIG. 4. However, at this time, the two ends 29 of the stopper 26
close, and bind the suture threads 25, with the result that the
suture threads 25 do not move. As shown in FIG. 3, two anchors 27
are sequentially housed in the interior aperture of the needle 14
of the suture 16. The suture threads 25 are drawn out from the slit
15 in the needle 14. As shown in FIG. 2, the stopper 26 is housed
more toward the distal end than the needle 14 inside the outer
sheath 12. The number of anchors 27 and the shape of the stopper 26
are not limited to the illustrated mode.
[0037] Next, the suturing method of this embodiment is described
primarily with reference to FIG. 5 to FIG. 12. FIG. 5 to FIG. 12
are typical views that serve to explain the technique, and the
abdomen (the stomach) is shown as one example of a hollow
organ.
[0038] As shown in FIG. 5, the endoscope insertion section 6 is
inserted from the mouth of a patient to which a mouthpiece 40 is
attached, and the distal end of the endoscope insertion section 6
is curved by the angle knob 5. A perforation is formed in a wall of
an abdomen 43 by a needle-like knife which is a high-frequency
resection instrument in the channel 9 of the endoscope insertion
section 6. As shown in FIG. 6, the endoscope insertion section 6 is
directed into an abdominal cavity 44 via a perforation 42. Forceps
54 are passed through the channel 9, and the procedure pertaining
to an abdominal cavity 44 is conducted with the forceps 54.
[0039] When the procedure is completed, the suturing apparatus 11
is passed through the channel 9 in place of the forceps 54. The
distal end of the endoscope insertion section 6 is curved, the
distal opening of the channel 9 is oriented toward a wall 45 in the
vicinity of the perforation 42 from the outer side (abdominal
cavity 44 side) of the abdomen 43, and the needle 14 of the
suturing apparatus 11 is projected outward from the outer sheath 12
toward the wall 45. The stopper 26 falls into the abdominal cavity
44 side. As shown in FIG. 7, the needle 14 is inserted at an
insertion point 46 at a prescribed distance from the
circumferential edge of the perforation 42. When the needle 14
pierces the wall 45 of the abdomen 43 in the sequence of muscular
layer 47 and mucous membrane 48, the pusher 20 (see FIG. 2) moves
forward. As shown in FIG. 8, first anchor 27 is pushed out from the
distal end of the needle 14 to the interior of the abdomen 43. When
the needle 14 is withdrawn from the wall 45, the first anchor 27
remains in the interior of the abdomen 43, while the suture thread
25 passes through the wall 45, and is pulled out to the outer side
of the abdomen 43.
[0040] Similarly, as shown in FIG. 7, an insertion point 49 is set
at a position that is symmetrical with the insertion point 46 and
that sandwiches the perforation 42, and the needle 14 is again
inserted at this insertion point 49. When the needle 14 transits
the wall 45, a second anchor 27 is pushed out from the needle 14.
When the needle 14 is withdrawn, as shown in FIG. 9, the suture 16
is attached in the vicinity of the perforation 42.
[0041] Next, as shown in FIG. 10, the endoscope insertion section 6
is brought back to the interior side of the abdomen 43, and the
suture 16 is tightened with the forceps 60. With regard to the
forceps 60, an inner sheath 62 freely passes backward and forward
in an outer sheath 61 which has a larger external diameter than the
anchors 27. At the distal end of the inner sheath 62, a pair of
clasps 64 are supported by a support member 63 so as to freely open
and shut. These clasps 64 clasp the knot 31 of the suture thread 25
of the suture 16. When the outer sheath 61 is moved forward, the
distal end of the outer sheath 61 strikes against the stopper 26. A
shown in FIG. 11, when the outer sheath 61 is moved further
forward, the stopper 26 is pushed inward toward the wall 45. As the
stopper 26 is configured to be movable in this direction, the
stopper 26 is moved toward the wall 45. As the position of the pair
of clasps 64 does not change, the stopper 26 moves forward relative
to the suture thread 25. As a result, the distance between the
stopper 26 and the anchors 27 diminishes, and the suture thread 25
is tightened.
[0042] As shown in FIG. 12, the process of binding the tissue with
the suture thread 25 pulls the tissue between the insertion points
46 and 49 into the interior side of the abdomen 43. Consequently,
the muscular layer 47 is sealed with the mated external surfaces
(of the abdominal cavity 44 side). The mated insertion points 46
and 49 are brought into proximity so that they approximately
coincide on the abdominal cavity 44 side. Finally, as shown in FIG.
13, the tissue between the insertion points 46 and 49 is pulled
further into the interior side of the abdomen 43, and the mated
insertion points 46 and 49 approximately coincide on the interior
side of the abdomen 43. Consequently, the perforation 42 is
sutured. The mode for making the insertion points 46 and 49 to
coincide is subject to various differences according to the type of
the wall 45, the position of the insertion points 46 and 49, and
the shape of the stopper 26. FIG. 14 illustrates the case where the
stopper 26 is rotated approximately 90.degree. around the suture
thread 25, and is vertical. In this state, the stopper 26 is
interposed between the tissue that is pulled into the interior
side. Even in this case, the mated insertion points 46 and 49
approximately coincide, and the muscular layer 47 is sealed by the
mated external surfaces (of the abdominal cavity 44 side).
[0043] When suturing of the perforation 42 is completed, the clasps
64 are opened after the outer sheath 61 is withdrawn. The suture
thread 25 separates from the clasps 64. The end of the stopper 26
allows movement in the direction of tightening the tissue by the
suture thread 25, but works so that the suture thread 25 is
tightened in the direction of loosening the suture thread 25.
Accordingly, when the suture 16 is stationed inside the abdomen 43,
the suture thread 25 maintains the sutured state without
loosening.
[0044] In this embodiment, the endoscope 1 and the working channel
9 are used as tools through which the needle 14 is passed, the
needle 14 inserted via a natural orifice in the living body is
inserted into the wall 45 from the abdominal cavity 44 side, and
the suture thread 25 is tightened so that these insertion points 46
and 49 are approximately coincided, with the result that it is
possible to seal the mated muscular layers. As the mated muscular
layers 47 knit together more easily than the mucous membrane 48,
the perforation 42 can be rapidly and reliably closed. In the case
where the perforation of a hollow organ such as the abdomen 43 is
sutured, whereas the knitting of the mated muscular layers takes
time with conventional suturing methods, the mated muscular layers
47 knit more reliably, and the perforation 42 is sealed in the
present embodiment. As a result, knitting progresses quickly, and
healing is quick.
[0045] As a modified example of this embodiment, there is the
suturing method shown in FIG. 15 to FIG. 17. As shown in FIG. 15,
the needle 14 pierces the muscular layer 47 from the insertion
points 46 and 49, and stations the anchors 27 between the muscular
layer 47 and the mucous membrane 48. The suture thread 25 transits
only the muscular layer 47, and is attached to the wall 45. As
shown in FIG. 16, when the suture thread 25 is tightened, the mated
insertion points 46 and 49 are brought into proximity, the tissue
is pulled into the interior side of the abdomen 43, and the
muscular layer 47 is sealed by the mated external surfaces. As
shown in FIG. 17, when the mated insertion points 46 and 49 are
made to approximately coincide, the perforation 42 is closed. As
the anchors 27 are stationed between the muscular layer 47 and
mucous membrane 48, leaks from the interior of the abdomen 43 to
the abdominal cavity 44 that pass through the hole formed in the
wall 45 due to insertion of the suture thread 25 are prevented.
Moreover, as the anchors 27 are not exposed on the interior side of
the abdomen 43, the anchors 27 are protected from gastric juices.
Furthermore, as the anchors 27 are not exposed to the interior side
of the abdomen 43, the anchors 27 can be preserved in an almost
sterile state. In this case, healing is promoted.
[0046] (Second Embodiment)
[0047] A second embodiment of this invention is described with
reference to drawings. Description of components and operations
identical to those of the first embodiment is omitted.
[0048] As shown in FIG. 18, the suturing apparatus 11 is passed
through the channel of the endoscope insertion section 6. The
needle 14 is diagonally inserted at the prescribed insertion point
71 of the muscular layer 47 that is exposed on the inner
circumferential surface of the perforation 42. As shown in FIG. 19,
when the needle 14 inserted from the insertion point 71 diagonally
pierces the muscular layer, and when the distal end of the needle
14 is exposed on the abdominal cavity 44 side, first anchor 27 is
pushed out onto the abdominal cavity 44 side. The needle 14 is
withdrawn, and is then diagonally inserted at the prescribed
insertion point 72 of the muscular layer 47 that is exposed on the
inner circumferential of the opposite side of the perforation 42 as
shown in FIG. 18. It is preferable that insertion point 71 and
insertion point 72 be at approximately identical positions in the
thickness direction of the wall 45. When the needle 14 diagonally
pierces the abdominal cavity 44 side from the inner circumferential
side of the perforation 42, the second anchor 27 is pushed out onto
the abdominal cavity 44 side. When the needle 14 is subsequently
withdrawn from the wall 45, as shown in FIG. 20, the second anchor
27 is stationed on the abdominal cavity 44 side in the same way as
the first anchor 27. After the suture thread 25 has diagonally
pierced the muscular layer 47, it transits the interior side of the
perforation 42, and is drawn into the abdomen 43.
[0049] The suture 16 is tightened as shown in FIG. 21. With the
clasps 64 of the forceps 60 clasping the knot 31, the stopper 26 is
pushed against the tissue by the outer sheath 61. The suture thread
25 is relatively pulled by the movement of the stopper 26.
Consequently, the inner circumferential surfaces of the perforation
42 are drawn together and sealed. The suture thread 25 is pulled
until the mated insertion points 71 and 72 coincide. As shown in
FIG. 22, the mated muscular layers 47 and mated mucous membranes 48
exposed on the inner periphery of the perforation 42 are sealed,
and the perforation 42 is closed.
[0050] In the present embodiment, the needle is diagonally inserted
through the muscular layer 47 exposed on the inner periphery of the
perforation 42, and the tissue is tightened by the suture thread 25
so that the insertion points 71 and 72 coincide after the anchors
27 have been stationed on the abdominal cavity 44 side, with the
result that it is possible to reliably seal the mated muscular
layers 47. Accordingly, the muscular layer 47 reliably knits
together, and the perforation 42 can be rapidly closed. Holes are
not formed in the mucous membrane from piercing by the suture
thread 25.
[0051] (Third embodiment)
[0052] A third embodiment of this invention is described with
reference to drawings. Description of components and operations
identical to those of the first embodiment is omitted.
[0053] As shown in FIG. 23, a surgical instrument 80 such as, for
example, a snare is passed through the channel 9 of the endoscope
insertion section 6, and the mucous membrane 48 in the vicinity of
the perforation 42 is resected. When the mucous membrane 48 is
resected, a suture 16 is attached by the suturing apparatus 11. As
shown in FIG. 24, the needle 14 is inserted at the prescribed
position (insertion point 81) of the inner surface 47a of the
muscular layer 47 exposed by resection of the mucous membrane 48.
When the needle 14 has pierced the muscular layer 47, and has
projected into the abdominal cavity 44, the anchor 27 is pushed
out. When the needle 14 is withdrawn from the muscular layer 47,
the suture thread 25 runs through the muscular layer 47, and the
anchor 27 is stationed on the abdominal cavity 44 side. In a
similar manner, the needle 14 is again inserted at an approximately
symmetrical position that sandwiches the perforation 42. The
insertion point 82 in this instance is set at a place where the
inner surface 47a of the muscular layer 47 is exposed by the
resection of the mucous membrane 48. The muscular layer 47 is
pierced by the needle 14 from the inner surface side (the interior
side of the abdomen 43) to the outer surface side (the exterior
side of the abdomen 43), and the second anchor 27 is pushed out. As
shown in FIG. 25, when the needle 14 is pulled out, the suture 16
is attached so that it straddles the perforation 42.
[0054] This suture 16 is tightened as in the second embodiment. The
inner circumferential surfaces of the perforation 42 are drawn
together and sealed by pulling the suture thread 25. The suture
thread 25 is pulled until the insertion points 81 and 82
approximately coincide. At this time, the mated end points 47b of
the muscular layer 47 initially make contact on the inner side of
the abdomen 43. With the point of origin set here, the mated inner
surfaces 47a are drawn together. As shown in FIG. 26, the tissue is
pushed outward so that the inner circumferential surfaces of the
perforation 42 are oriented toward the exterior side of the abdomen
43, and the mated inner surfaces 47a of the muscular layer 47
exposed by resection of the mucous membrane 48 are sealed.
[0055] In this embodiment, the inner surfaces 47a of the muscular
layer 47 at the periphery of the perforation 42 are exposed, the
insertion points 81 and 82 are formed on these inner surfaces 47a,
and the tissue is tightened by the suture 16 so that the insertion
points 81 and 82 approximately coincide, with the result that it is
possible to reliably seal the mated inner surfaces 47a of the
muscular layer 47. Accordingly, the muscular layer 47 rapidly
knits, and the perforation 42 can be reliably closed.
[0056] The present invention is not limited to the respective
foregoing embodiments, and may be widely applied.
[0057] For example, the endoscope 1 may be inserted from the anus
into the colon which is one example of a hollow organ. In this
case, perforations in the colon or the like are sutured.
[0058] In the first and second embodiments, the needle 14 is almost
vertically inserted relative to the muscular layer 47, but it may
also be inserted with a prescribed angle of inclination. The suture
thread 25 then pierces the muscular layer 47 diagonally relative to
the axis of the perforation 42. In this case, as well, the same
effects are obtained.
[0059] As shown in FIG. 27, in the case where the endoscope
insertion section 6 is provided with two channels 9, it is also
acceptable to run one suturing apparatus 11 each through the
respective channels 9. In this case, one each of the anchors 27 of
the suture 16 is housed in the respective needles 14 of each
suturing apparatus 11.
* * * * *