Endoscope suture cutter

Abstract

A method for cutting a suture. The method provides a drive wire coupled with the cutter. The cutter has a first blade defining a first plane and a second blade defining a second plane that is not parallel to the first plane. The first blade and the second blade define an opening. The method hooks the suture into the opening. The method cuts the suture by pulling the drive wire in a proximal direction.

Description

[0001] priority

[0002] This patent application claims priority to provisional U.S. patent application No. 63 / 399,987 filed on August 22, 2022, the disclosure of which is incorporated herein by reference in its entirety. Technical Field

[0003] The illustrative embodiments of the present invention relate generally to endoscopic devices, and more particularly, various embodiments of the present invention relate to suture cutters delivered through a working channel of an endoscope. Background Art

[0004] After an endoscopic surgical procedure, sutures are often used to secure closed perforations or wounds and promote healing. Certain types of sutures, such as absorbable sutures, remain in the body to decompose over time, while other types of sutures, such as non-absorbable sutures, need to be removed at each subsequent time. For example, sutures that need to be removed include monofilament or braided sutures made of polyester, polypropylene, or coated with plastic.

[0005] Endoscopic scissors are a type of surgical scissors used for dissecting tissue and placing sutures during endoscopic and laparoscopic medical procedures. Endoscopic scissors have many blade configurations, including curved, curved, hooked, large, small, and straight configurations, to give the surgeon a variety of options to choose from when planning a surgical cutting strategy. Traditional "Mayo" scissors are heavy duty scissors, while "Metzenbaum" scissors are smaller, finer blade scissors designed for open surgery. Summary of the invention

[0006] According to one embodiment of the present invention, a method cuts a suture. The method positions a flexible insertion tube of an endoscope within a patient. A cutter coupled to a drive wire moves through a working channel of the flexible insertion tube. The drive wire is configured to move the cutter along a central axis of the working channel. The cutter has a suture receiving portion facing proximally toward a sharp blade. The method extends the cutter out of the working channel of the insertion tube. Positions the suture adjacent to the sharp blade. The suture is then cut by pulling the drive wire proximally.

[0007] Pulling the drive wire proximally applies tension to the suture using a cutter, particularly one or more sharp blades of the cutter. In order to position the suture adjacent to the sharp blade, the method can allow the suture to pass through a suture receiving portion. To this end, the suture receiving portion can be positioned distally of a portion of the suture. A portion of the suture can be aligned with the suture receiving portion. The suture receiving portion is then moved proximally to receive the aligned portion of the suture in the suture receiving portion.

[0008] The method can be repeated. For example, the sharp blade can be positioned adjacent to the second suture. The second suture can be cut by pulling the cutter proximally. In various embodiments, the flexible insertion tube can be angled as the cutter moves through the flexible insertion tube. In particular, the flexible insertion tube can be angled near the distal end. To facilitate movement through the insertion tube, the cutter can have a rigid longitudinal traversal length L of less than about 8 mm, preferably less than 5 mm. In some embodiments, the cutter can have a rigid longitudinal traversal length L greater than about 0.9 mm.

[0009] In various embodiments, the cutter can be retracted into the working channel and / or the delivery shaft or cutting device. The drive wire can be coupled to a retraction feature that is configured to position and orient the cutter to reduce or prevent interference with the delivery shaft. In various embodiments, the drive wire can be coupled to an inner surface of the retraction feature. The retraction feature can include a hypodermic tube, etc. The size of the hypodermic tube can be smaller than the size of the inner diameter of the delivery shaft.

[0010] According to another embodiment, a suture cutting device includes a drive wire coupled to a cutter. The cutter has a first blade defining a first plane and a second blade defining a second plane that is non-parallel to the first plane.

[0011] The first blade and the second blade are non-movable. In addition, the first blade and the second blade may define a suture receiving portion. The drive wire has a proximal end and a distal end, and the suture receiving portion may substantially face the proximal end. In addition, the first blade and the second blade may provide a passive cutting mechanism.

[0012] According to another embodiment, a method cuts a suture. The method provides a drive wire coupled to a cutter. The cutter has a first blade defining a first plane and a second blade defining a second plane that is not parallel to the first plane. The first blade and the second blade define an opening. The method hooks the suture into the opening. The method cuts the suture by pulling the drive wire in a proximal direction.

[0013] In some embodiments, the cutter can face a substantially distally facing direction. In particular, some embodiments can have a suture receiving portion facing distally. Thus, some embodiments can simply push the cutter toward the suture to cut the suture. Of course, some other embodiments can position the cutter in a proximally facing direction so that the cutter can be pulled to cut the suture.

[0014] According to yet another embodiment, a suture cutting system includes an endoscope having an insertion tube. The insertion tube has at least one working channel. The system includes a cutting device. The cutting device includes a handle movably connected to a flexible drive wire. The handle is configured to enable the drive wire to move proximally or distally within the working channel of the endoscope. A cutter is connected to the distal end of the drive wire. Movement of the drive wire in the distal direction causes movement of the cutter in the distal direction. The cutter has a rigid longitudinal traversal length L of less than about 8 mm. BRIEF DESCRIPTION OF THE DRAWINGS

[0015] Those skilled in the art will more fully appreciate the advantages of the various embodiments of the present invention from the following “Detailed Description” discussed with reference to the accompanying drawings summarized immediately below.

[0016] Figure 1 A patient is schematically shown lying on an operating table in a hospital environment, according to an illustrative embodiment of the invention.

[0017] Figure 2A An endoscope according to an illustrative embodiment of the invention is schematically shown.

[0018] Figure 2B A partially exposed view of an insertion tube is schematically depicted in accordance with an illustrative embodiment.

[0019] Figure 2C The distal end of an insertion tube is schematically shown according to an illustrative embodiment of the invention.

[0020] Figure 2D Schematically shows Figure 2A An endoscope in which the insertion tube is straight at the distal end.

[0021] Figure 2E Schematically shows Figure 2A An endoscope in which the insertion tube is angled near the distal end.

[0022] Figure 2F Schematically shows Figure 2A An endoscope in which the insertion tube is curved near the distal end.

[0023] Figure 3A A cutting device according to an illustrative embodiment is schematically shown.

[0024] FIG. 3B to FIG. 3F A detailed view of a cutter according to an illustrative embodiment of the invention is schematically shown.

[0025] Figure 4 A process of cutting a suture is shown according to an illustrative embodiment of the invention.

[0026] Figure 5 A delivery shaft is schematically shown positioned in an accessory port according to an illustrative embodiment of the invention.

[0027] FIG. 6A to FIG. 6B A suture cutter is schematically shown transitioning from being located inside a delivery shaft to extending outside of the delivery shaft, according to an illustrative embodiment of the invention.

[0028] Figure 7 A perspective view of a suture cutter extending from a working channel of an endoscope is shown in accordance with an illustrative embodiment of the invention.

[0029] FIG. 8A to FIG. 8C A suture is schematically shown positioned in a suture-receiving portion according to an illustrative embodiment of the invention.

[0030] Fig. 9 The rotating features of a cutting device according to an illustrative embodiment of the invention are schematically shown.

[0031] FIG. 10A to FIG. 10B A process of applying tension to a suture according to an illustrative embodiment of the invention is schematically shown.

[0032] FIG. 11A to FIG. 11B A further retracted cutter is schematically shown according to an illustrative embodiment of the invention.

[0033] FIG. 12A to FIG. 12B A suture is schematically shown being cut inside a delivery shaft, according to an illustrative embodiment of the invention.

[0034] FIG. 13A to FIG. 13B A suture cut externally of a delivery shaft is schematically shown in accordance with an illustrative embodiment of the invention.

[0035] Fig.14A A cutter is schematically shown interfering with a delivery shaft according to an illustrative embodiment of the invention.

[0036] Fig. 14B A cutter is schematically shown that does not interfere with a delivery shaft, according to an illustrative embodiment of the invention.

[0037] Fig. 14C A retraction feature is schematically shown in accordance with an illustrative embodiment of the invention.

[0038] FIG. 15A to FIG. 15G Various cross-sections of various embodiments having a retraction feature are schematically shown, according to illustrative embodiments of the invention.

[0039] Figures 16 to 18 An alternative embodiment of a suture cutter according to an illustrative embodiment of the invention is schematically shown.

[0040] It should be noted that the aforementioned figures and the elements depicted therein are not necessarily drawn to consistent scale or any scale. Unless the context indicates otherwise, the same elements are indicated by the same numbers. The drawings are primarily for illustrative purposes and are not intended to limit the scope of the inventive subject matter described herein. DETAILED DESCRIPTION

[0041] In an illustrative embodiment, an endoscope has a flexible insertion tube having a working channel through which a drive wire connected to a suture cutter extends. The suture cutter has a relatively small profile and length so that it can be passed through the working channel of the endoscope during medical surgery. Advantageously, the illustrative embodiment is configured to be deployed through the working channel even when the insertion tube forms a tortuous or winding path. In various embodiments, the suture cutter provides a passive cutting mechanism that does not require active movement and / or independent control of one or more cutting blades. The cutter has a suture receiving portion that leads to the cutting edge of the blade. The suture receiving portion is substantially facing the proximal direction (also referred to as facing the proximal side) so that the physician can capture the suture by pulling the cutter in the proximal direction (pulling the cutter proximally). After capturing the suture, the physician can cut the suture by applying tension on the suture by further pulling the cutter proximally. The details of the illustrative embodiment are discussed below.

[0042] In the currently available flexible endoscopic suture cutters known to the inventors, the suture is cut using a conventional scissor mechanism with one or two movable blades. Such devices require the blade to be positioned adjacent to the suture and the operation of the blade to be manually controlled. In addition, the cutter tool with a manually movable blade typically has a long rigid distal end (e.g., the cutter tool is about 1 inch long), which makes it difficult for the cutter to pass through the flexible insertion tube, especially when the insertion tube forms a tortuous or winding path. In contrast, the illustrative embodiment captures the suture with a cutter and cuts the suture using tension, which advantageously reduces the number of moving parts and provides a shorter distal end that is better for smooth passage through the insertion tube.

[0043] Figure 1 A patient 12 is schematically shown lying on an operating table or examination table in a hospital environment 10 according to an illustrative embodiment of the present invention. The environment 10 may be, for example, within an endoscopy unit of a hospital. The endoscopy unit may include a physician 14 (e.g., a gastroenterologist or surgeon), a trained nurse 16, and various medical devices. For example, the medical devices may include an endoscope 18, a video display 20, and other equipment. Procedures performed within the endoscopy unit may include gastrointestinal endoscopy (such as gastroscopy, colonoscopy, ERCP, and endoscopic ultrasound), bronchoscopy, cystoscopy, or other more specialized procedures.

[0044] FIG. 2A to FIG. 2E An endoscope 18 according to an illustrative embodiment of the present invention is schematically shown. As known to those skilled in the art, a flexible endoscope 18 (e.g., a colonoscope, a gastroscope) is positioned into the body of a patient 12 through a natural orifice (e.g., mouth, anus). To this end, the endoscope 18 has a long and flexible insertion tube 22 that is adjustable relative to the natural passages in the body. In addition, the endoscope 18 has a plurality of channels extending through the flexible insertion tube 22. One of these channels is a working channel through which tools can be advanced to the distal end 23 of the insertion tube 22.

[0045] The endoscope 18 can be contrasted with other devices (such as laparoscopes) that are not inserted into the natural orifices of the patient 12. Instead, the laparoscope is inserted into one of the access holes formed in the patient 12 during laparoscopic surgery. Typically, three access holes are made for laparoscopic surgery, one for the rigid scope, and two ports for tools, such as forceps, scissors, sutures, etc. The laparoscope has a non-flexible, rigid, and short insertion tube that is delivered to the body through one of the access holes. Typically, a laparoscope does not have a working channel for passing tools therethrough. In contrast, the insertion tube 22 of the endoscope 18 (colonoscope, gastroscope) is flexible to travel through the natural orifices of the body and has a working channel. Various embodiments can be used with various endoscopes (e.g., laparoscopes). However, a preferred embodiment is used with a flexible insertion tube 22.

[0046] The endoscope 18 has a control portion 26 to help guide the insertion tube 22 through the body passages (e.g., the tortuous gastrointestinal tract) of the patient 12. To this end, the endoscope 18 includes a control dial 26 that allows the position and orientation of the insertion tube 22 to be controlled (e.g., the distal end 23 is bent upward or downward and to the right or left). Like many endoscopes, the endoscope 18 can have multiple imaging controls, such as an image freeze button and an image capture button. There can also be a control chromoendoscopy button that can change the color of the video in the display 20. The control portion 26 can also include a suction button 28 and an air / water button 30. The endoscope 18 can be connected to a light source via a light guide 31, to an air source via an air supply connector 32, to a water source via a water supply connector 34, and to a suction source via a suction connector 36. Therefore, light, air, water and / or suction can be delivered to the distal end 23 of the insertion tube 22 through various aforementioned channels through an umbilical hose 35.

[0047] Water, air, suction and other functions can be selectively applied at the distal end 23 via separate channels within the insertion tube 22. For example, the user can press the water button 30 to selectively spray water out of the distal end 23. To this end, water is drawn from an external water source through a water supply connector 34, passes through an umbilical hose 35 of the endoscope 18, and then flows along the insertion tube 22 to the distal end 23 and is discharged. For other functions, including light and suction, a similar process is followed. Each of these functions can have a dedicated channel within the endoscope 18.

[0048] Figure 2B A partially exposed view of an insertion tube 22 according to an illustrative embodiment is schematically shown. The insertion tube 22 has a plurality of channels 38 to 41 and wires 42 to 45 within the insertion tube 22, which are configured to provide various functions to the endoscope 18. For example, the insertion tube 22 includes a biopsy channel 38, an air channel 39, a water channel 40, and a water jet channel 41. The insertion tube 22 may also include an optical fiber 42, a wire 43 for adjustable stiffness, an angled wire 44, and a CCD signal wire 45, among others. These channels 38 to 41 and wires 42 to 45 are within the housing of the insertion tube 22. The housing of the insertion tube 22 may include an outer polymer top coating 46 and a base layer. Below the polymer top coating 46 may be a stainless steel wire mesh 47 and an outer spiral metal band 48 and an inner spiral metal band 49.

[0049] Figure 2C The distal end 23 of the insertion tube 22 is schematically shown with a tool 50 extending out of the working channel 38 according to an illustrative embodiment of the present invention. The tool 50 can be inserted through the accessory port 37 ( Figure 2A As shown) and positioned in the working channel 38. For example, Figure 2C Biopsy forceps 50 are schematically shown extending out of working channel 38. Various embodiments use a cutting device 54 to deliver a suture cutter 64 through working channel 38. Cutting device 54 may also be referred to as a cutter delivery device 54.

[0050] Figure 2D Schematically shows Figure 2A An endoscope in which the endoscope is substantially straight near the distal end 23 of the insertion tube 22. Figure 2E Schematically shows Figure 2Aendoscope in which the position and orientation of the insertion tube 22 are adjusted (e.g., angled). In particular, the control portion 26 is used to bend the distal end 23. In practice, the physician 14 controls the bending of the insertion tube 22 to properly orient the distal end 23 within the patient 12 during surgery. For example, the insertion tube 22 can be bent in various ways to pass through the gastrointestinal tract. When the distal end 23 is close to the desired position, the orientation of the distal end 23 is manipulated (e.g., to obtain a specific biopsy sample, capture a specific suture, etc.). When the distal end 23 is properly oriented, the tool 50 can extend out of the working channel 38. However, when the distal end 23 of the tool 50 (e.g., a cutter, biopsy forceps, scissors, etc.) is rigid, it is difficult to advance the tool 50, especially when the distal end of the endoscope 18 is angled, such as when the distal end of the endoscope 18 is angled. Figure 2E and Figure 2F shown.

[0051] Figure 2F Schematically shows Figure 2A The endoscope of FIG. 1 is a diagram of an endoscope in which the curved portion 21 of the insertion tube 22 is near the distal end 23. In some use cases, the insertion tube 22 can be significantly curved, particularly near the distal end 23, to achieve a desired orientation relative to the patient 12 and / or the suture 68. When the desired orientation is achieved, one or more tools 50A and 50B can be pushed out of one or more working channels 38. For example, as shown in FIG. Figure 2F As shown, the tools 50 may be endoscopic scissors 50B and endoscopic snares 50A, etc. However, various embodiments may push other tools 50, such as biopsy forceps and / or endoscopic clips, out of the working channel 38. When the tools 50 are advanced through the insertion tube 22 and / or out of the working channel 38, each of the tools 50 may be referred to as having a rigid longitudinal traversal length L. However, as described below, some tools 50 may have a negligible rigid length.

[0052] For example, the endoscopic scissors 50B have a rigid longitudinal traversal length L as they traverse the insertion tube 22 and are advanced out of the working channel 38. The rigid longitudinal traversal length L of the scissors 50B is defined by the rigid length of the tool 50 as the tool 50 is advanced through the insertion tube 22. For example, the scissors 50B traversal length L is determined when the blades are closed (as the scissors 50B are advanced through the insertion tube 22 with the blades closed).

[0053] As another example, a snare tool 50A is another tool 50 that can be used with the various embodiments. The snare tool 50A includes a flexible snare portion 68 that extends out of a flexible delivery housing 69. The snare portion 68 is flexible during normal operation of the endoscope 18 and therefore includes negligible rigid components. After the delivery device 69 extends out of the working channel 38, the snare portion 68 extends out of the flexible delivery device 69. Because the delivery device 69 is flexible, it also has a negligible rigid length when passing through the insertion tube 22. In other words, the delivery device 69 and the snare portion 68 flex to adapt to the shape of the insertion tube 22 as they travel inside the insertion tube 22. Therefore, during normal use, the physician 14 does not have to adjust the shape of the insertion tube 22 to allow the snare tool 50A to pass.

[0054] As yet another example of a tool 50, some embodiments may include a suture cinch tool 50, such as described in US Patent Application No. 17 / 991,526, which is incorporated herein by reference.

[0055] Those skilled in the art will appreciate that a longer rigid length L makes it more difficult for the tool 50 to pass through the flexible insertion tube 22 and / or exit the distal end 23. Depending on the curvature / angle of the insertion tube 22, some longer rigid lengths L may not be possible to pass through the insertion tube 22 (e.g., exit the distal end 23). Therefore, various embodiments advantageously provide a tool 50 having a small rigid length L. For example, the rigid length L of the endoscopic suture cutter 64 is small (about 0.1 inches to about 0.3 inches), thereby allowing easier device advancement and better access when the distal end 23 of the endoscope is not in a straight orientation. This is in contrast to the rigid length L of the endoscopic scissors (0.5 inches to about 1.0 inches). When the distal end 23 of the endoscope 18 is angled, it is difficult and sometimes impossible to advance the scissors in the working channel 38 at the angled region. Instead, the physician 14 needs to straighten the tip of the endoscope 18 to advance the scissors in the working channel. The illustrative embodiment allows the physician 14 to advance the cutter 64 in the working channel 38 at the angled region.

[0056] Figure 3AA cutting device 54 according to an illustrative embodiment is schematically shown. The cutting device 54 includes a cutter deployment system 62, which is configured to be positioned within the insertion tube 22 and to move the cutter 64 through the insertion tube 22. As described below, the cutter deployment system 62 includes, among other things, a delivery shaft 74, a drive wire 60 within the delivery shaft 74, and a cutter 64 coupled to the drive wire 60. The cutter deployment system 62 is controlled externally to the insertion tube 22. To this end, the cutting device 54 includes a handle slide 56 having an opening configured to receive a physician's thumb finger. During use, the handle slide 56 slides along the handle frame 58. Movement of the handle slide 56 relative to the handle frame 58 causes the drive wire 60 within the delivery shaft 74 to move proximally or distally along the delivery shaft 74. As shown in FIG. Fig. 9 As shown, the handle frame 58 and the handle slide 56 may be rotated to rotate the cutter 64 .

[0057] In various embodiments, the drive wire 60 (also referred to as the pull wire 60) can move in an axial direction (e.g., substantially along A1) within the delivery shaft 74. Axis A1 is a central longitudinal axis extending through the working channel 38. The drive wire 60 can be a long pull wire 60 supported within the delivery shaft 74. In some embodiments, the drive wire 60 can include a long pull wire 60, such as a solid wire, a stranded wire, or a combination of both. In some embodiments, the drive wire 60 can include a long pull wire 60 supported inside the spring guide 65 and / or the delivery shaft 74. The spring guide 65 can be inside the delivery shaft 74 and support the pull wire 60. In some embodiments, the delivery shaft 74 can include a long catheter without any spring guide 65. The pull wire 60 has a small diameter and may not have structural support itself. In various embodiments, the delivery shaft 74 or / and the spring guide 65 provide structural support for the pull wire 60 when the pull wire passes through the working channel 38, etc. (when passing through the working channel, etc.).

[0058] In various embodiments, the pull wire 60 is inside the delivery shaft 74 (e.g., catheter). Therefore, some embodiments may not include the Bowden coil 65. Some embodiments may use a coil instead of a catheter, or use both a coil and a sheath. As previously described, the pull wire 60 has a small diameter and generally does not have structural support itself. Therefore, in various embodiments, the pull wire 60 may be supported by a delivery catheter, a delivery coil, and / or a delivery coil (catheter) with a sheath.

[0059] It should be understood that although the axis A1 is shown as a straight axis, in various embodiments, the delivery shaft 74 is configured to bend and / or twist in a manner similar to the insertion tube 22, and therefore the axis A1 may also be curved, bent and / or twisted. Therefore, in various embodiments, moving the drive wire 60 and / or the cutter 64 along the axis A1 may not be a straight axial movement. In addition, in some embodiments, the distal end of the drive wire 60 may be bent so that the drive wire 60 forms a central cutter axis B1 that deviates from the central axis A1 of the insertion tube 22. When the cutter axis B1 deviates from the central axis A1, the pulling wire 60 may be forced against the inner diameter of the delivery shaft 74. This provides the maximum space for the cutter 64 to move proximally and distally in the delivery shaft 74. In addition, the deviated cutter axis B1 allows the cutter 64 to rotate into an arc when extending distally. This enables the cutter 64 to reach a larger area to capture the suture 78.

[0060] FIG. 3B to FIG. 3F A detailed view of a cutter 64 according to an illustrative embodiment of the present invention is schematically shown. The cutter 64 is configured to cut one or more sutures that have been sutured in the patient 12 (e.g., in the gastrointestinal tract). To this end, the cutter 64 has a suture receiving portion 76 that is configured to guide or lead the suture to one or more sharp blades 70. Figure 3B , the cutter 64 has four sharp edges 70. Two sharp edges 70 are used to cut sutures. The sharp edges 70 can each be part of a cutting blade 72A and 72B. In some embodiments, the first cutting blade 72A can be in a plane with the body 80 of the cutter 64. For example, the cutting blade 72A can be formed by the body 80. The second cutting blade 72B can be out of plane (e.g., offset upward) relative to the first cutting blade 72A and / or the body 80, so that the suture receiving portion 76 is formed by the blades 72A and 72B. In some embodiments, the first blade 72A defines a first plane, and the second blade 72B defines a second plane that is not parallel to the first plane. In some embodiments, the first blade 72A, the second blade 72B, and the body 80 can all have substantially non-parallel planes (e.g., Figure 3E and Figure 3F shown).

[0061] When the suture 78 is positioned in the suture receiving portion 76, the cutter 64 can be pulled in the proximal direction to achieve the cutting of the suture 78. Specifically, the suture 78 can be cut by applying tension on the suture 78 using the blades 72A and 72B (e.g., by the user pulling the handle 56 to move the wire 60 coupled to the cutter 64 in the proximal direction). The sharp blades 72A and 72B are forced against the suture 78 to cut the suture 78.

[0062] It should be clear that, although various embodiments show and describe two blades 72A and 72B, this is not intended to limit various embodiments of the present invention. Some embodiments may only have a single blade 72 with a sharp edge 70. For example, some embodiments may only have a planar blade 72A. Some other embodiments may only have a plane outer blade 72B. The embodiment with a single blade 72 can still form a suture receiving portion 76 (for example, using a second blunt blade instead of a second sharp edge 70). For example, some embodiments may include one or more arcuate or semicircular blades 72. Therefore, the discussion of a single blade 72 or a plurality of blades 72 is not intended to limit various embodiments of the present invention. For example, a suture receiving portion 76 can be formed by one or both of blades 72A and 72B.

[0063] Cutter 64 advantageously operates as a passive tension cutter, i.e., no user control or active movement of blades 72A and 72B is required to cut suture 78. Instead, suture 78 is cut by tensioning suture 78 against sharpened edge 70. In various embodiments, out-of-plane blade 72B may be biased upward (e.g., elastically) or rigidly formed.

[0064] In various embodiments, the cutter 64 can be formed (e.g., stamped, electro-discharged) from a thin sheet of material (e.g., metal or plastic). In some embodiments, the thickness T of the material of the cutter 64 is 1 mm or less (e.g., T1 and T2 are each less than 1 mm). In addition, the out-of-plane blade 72B can give the cutter 64 a total height H greater than the thickness T. In various embodiments, the height H of the cutter is between about 1.3 mm and 3.5 mm. The total width W of the cutter 64 can be between about 1 mm and about 2 mm. The total rigid length L of the cutter 64 can be between about 4 mm and about 8 mm. Preferably, the outer blade 75 (e.g., distal blade or proximal blade) of the cutter 64 is blunt or rounded to prevent accidental cutting of the patient 12. The opening O of the suture receiving portion 76 (e.g., formed by two blades 72) allows the cutter 64 to grasp and receive the suture 78. If the opening O is too small, it is difficult to capture or properly place the suture 78 between the two blades 72. If the opening O is too large, it becomes difficult to retract the blade 72 into the delivery shaft 74 (see, for example, Fig.14A ). Preferably, the opening O is between 0.9 mm and 3.1 mm. For clarity, the range between the endpoints X and Y is considered to include the endpoints X and Y.

[0065] In various embodiments, the non-moving cutting blades 70A and 70B meet at a cutting point 71, which provides effective cutting of the suture 78, rather than a conventional scissor-type cutter in which two opposing blades move against each other to produce a moving cutting point. In various embodiments, the two blades 72A and 72B do not move to cut. Preferably, the blades 72 are rigid and short enough so that they do not move when they are regularly used to cut the suture 78. Therefore, the blades 72A and 72B can be considered to be static blades 72A and 72B. Although the static blade 72A can be formed of a deformable or ductile material when sufficient force is applied (i.e., under non-normal use), the blades 72A and 72B are still considered to be static / non-moving during normal use by the physician 14 (e.g., when a force sufficient to cut the suture 78 is applied).

[0066] In various embodiments, depending on the thickness of the suture 78, the suture 78 may be cut at the cutting area 73 formed between the cutting edges 70A and 70B of the two blades 72. In some embodiments, the suture 78 may reach the cutting point 71. However, in some other embodiments, the suture 78 may be cut within the cutting area 73 formed by the blades 72.

[0067] Figure 4 A process 400 for cutting a suture 78 according to an illustrative embodiment of the present invention is shown. It should be noted that the process is simplified from a longer process that is typically used to cut a suture 78. Therefore, the process 400 for cutting a suture 78 may have many steps that one skilled in the art may use. Furthermore, some steps may be performed in a different order than shown. Additionally or alternatively, some steps may be performed simultaneously. Therefore, one skilled in the art may modify the process 400 appropriately.

[0068] Process 400 begins at step 402, where the physician 14 sews up a perforation in the patient 12. For example, during a medical procedure, the physician 14 may perform a biopsy from the patient 12 to remove a polyp by using a biopsy tool 50 (e.g., a biopsy forceps). The biopsy tool 50 may be placed within the working channel 38 of the endoscope 18. The physician 14 may then use any suturing tool 50 to sew up the perforation. In various embodiments, the suturing tool may be attached to the exterior of the distal end 23 of the insertion tube 22. Various embodiments of the endoscope 18 may include one or more working channels 38.

[0069] The process of suturing perforation is known in the art, so it is not described in detail here. Generally, the process involves grasping tissue near the perforation (for example, using tissue grasping tool 50), retracting tissue, driving the needle connected to suture 78 to pass through tissue, and repeating suturing as needed. Therefore, in the above example, suture 78 has two ends: the first end connected to the needle and the second free end. Various embodiments can tighten the free end of suture and / or the first end connected to the needle together or separate. In some other embodiments, suture is connected to the needle as a part of the needle assembly (for example, it passes through tissue and clamps tissue). Therefore, suture can be considered to have a single free end and a second anchoring end. Suture can be formed by any material commonly used for surgical sutures, such as stainless steel, nitinol, nylon, braided polyester, polypropylene and / or silk. Some can also be used for cutting suture 78 with two free ends.

[0070] The process proceeds to step 404, which provides an endoscopic suture cutting device 54, such as FIG. 3A to FIG. 3B The device 54 shown. The device 54 can be provided to the physician 14 during and / or after a medical procedure (e.g., a polypectomy). The illustrative embodiments work with various sutures and / or endoscopic suturing devices. Advantageously, the suture cutting device 54 can be used to cut sutures that were previously applied to the patient 12 (e.g., applied to a perforation) using an integrated or separate suturing tool.

[0071] The process proceeds to step 406, which positions the cutter deployment system 62 into the working channel 38 of the endoscope 18. To remove the suture 78 in the gastrointestinal tract, the patient 12 may be intubated with the endoscope 18. After positioning the endoscope 18 within the patient 12 and positioning the suture 78 to be cut, the physician 14 inserts the deployment system 62 into the accessory port 37 of the endoscope 18. Alternatively, the deployment system 62 may be positioned in the accessory port 37 prior to positioning the endoscope 18.

[0072] Specifically, the distal end of the delivery shaft 74 may first be positioned within the accessory port 37 of the endoscope 18 . Figure 5 Cutter deployment system 62 is schematically shown positioned in accessory port 37. In particular, delivery shaft 74 is driven into accessory port 37. Delivery shaft 74 can advantageously flex in a manner corresponding to the shape of insertion tube 22.

[0073] At step 408 , the suture cutter 64 is extended from the working channel 38 of the endoscope 18 . FIG. 6A to FIG. 6B The suture cutter 64 is schematically shown transitioning from being located inside the delivery shaft 74 to extending outside the delivery shaft 74 in accordance with an illustrative embodiment of the present invention.

[0074] In particular, Fig. 6AThe cutter 64 is shown inside the delivery shaft 74. From the perspective of the physician 14, the handle 56 is in the retracted position. To extend the suture cutter 64 from the working channel 38, after the delivery shaft 74 is outside the working channel 38 of the endoscope 18, the handle 56 is moved forward, as shown in FIG. Figure 6B shown.

[0075] Figure 7 A perspective view of a suture cutter 64 extending from the working channel 38 of the endoscope 18 is shown according to an illustrative embodiment of the present invention. In contrast to many prior art cutting tools, in various embodiments of the cutter 64, the suture receiving portion 76 defines an opening or gap that faces substantially in the proximal direction (i.e., facing the working channel 38 and / or the distal end 23 of the endoscope 18).

[0076] In some embodiments, the puller wire 60 can be configured to extend the cutter 64 straight out of the delivery shaft 74. However, in some other embodiments, and as Figure 7 As shown, the puller wire 60 can be configured to bend when it leaves the delivery shaft 75. Therefore, the central axis B1 of the cutter 64 can form an axis B1 that deviates from the central axis A1 by an angle θ1. In various embodiments, the angle θ1 can be between about 5 degrees and about 30 degrees, or between about 10 degrees and about 20 degrees.

[0077] Advantageously, the proximally facing suture receiving portion 76 allows the physician 14 to hook the suture 78 with the suture receiving portion 76 and cut the suture 78 by a simple retraction of the cutter 64 (e.g., pulling the drive wire 60 in the proximal direction). In addition, the cutter 64 does not need to independently and actively control the blades 72A and 72B. Instead, as described below, the suture 78 is positioned in the suture receiving portion 76 and then cut by the blade 72 using the tension on the suture 78. Because the blades 72A and 72B do not move against each other, a pivot mechanism is not required. However, some embodiments may still have some offset / movement of the passive blade 72. Therefore, the illustrative embodiment provides a passive / static cutting mechanism using a passive planar blade 72A and / or an out-of-plane (e.g., offset) blade 72B. Therefore, the cutter 64 is advantageously much shorter and thinner than many prior art cutters and is easy to pass through the insertion tube 22.

[0078] After the suture cutter 64 is extended, the suture 78 is positioned in the suture receiving portion at step 410 . FIG. 8A to FIG. 8C A suture 78 is schematically shown positioned in a suture receiving portion 76 according to an illustrative embodiment of the invention. FIG. 8A to FIG. 8BAs shown, the cutter 64 is advanced until it is located distal to the suture 78. A portion of the opening of the suture receiving portion 76 is aligned with at least a portion of the suture 78 (eg, Figure 8B ). The handle 56 can be manipulated until the suture 78 is positioned (eg, hooked) into the suture receiving portion 76. Figure 8C Schematically depicted is a close-up view of a suture 78 positioned in a suture receiving portion 76, in accordance with an illustrative embodiment of the present invention. At this point, it can be said that the suture 78 is "captured" or "hooked" by the cutter 64.

[0079] In various embodiments, it may be necessary to rotate cutter 64 to properly align the opening of receiving portion 76 with suture 78 . Fig. 9 The rotation feature of the cutting device 54 according to an illustrative embodiment of the present invention is schematically shown. As previously described, the cutting device 54 can be coupled to the endoscope 18. In the illustrative embodiment, the handle 56 can be rotated to rotate the cutter 64. Therefore, the receiving portion 76 is advantageously rotatable to allow easy alignment and capture of the suture 78. For example, the rotation allows the receiving portion 76 to be repositioned to an ideal position to capture the suture 78. To this end, in various embodiments, the pulling wire 60 is coupled to the handle slide 56, and the delivery shaft 74 is coupled to the coupling 61 (such as Figure 3A This allows for relative rotation of the drive wire 60, and therefore the cutter 64, relative to the flexible tube 22 and the delivery shaft 74.

[0080] In various embodiments, the handle 56 is external to the accessory port 37 and is manipulated by the physician 14. To pass through the working channel 38, the delivery shaft 74 is preferably longer for endoscopic procedures (eg, about 150 cm to about 250 cm).

[0081] The process then proceeds to step 412 where tension is applied to cut the suture 78 with the suture cutter 64 . FIG. 10A to FIG. 10B The process of applying tension to suture 78 is schematically shown in accordance with an illustrative embodiment of the invention. Fig. 10B Shows Fig. 10A Detailed view of. In various embodiments, tension can be applied by retracting the suture cutter 64. To do this, the handle 56 is pulled proximally (as shown by the arrow). Figures 10A to 10B The suture cutter 64 is schematically shown retracted with the suture 78 captured according to an illustrative embodiment. As the suture cutter 64 is retracted, the suture 78 is tensioned. When sufficient tension is applied, the suture 78 is cut by the blade 72A or 72B. Depending on the type of suture 78, additional tension may be required. The captured suture 78 can be further tensioned by further pulling the suture cutter 64 and / or the entire cutter deployment system 62 proximally. FIG. 11A to FIG. 11B Cutter (64) is schematically shown further retracted in accordance with an illustrative embodiment.

[0082] Various embodiments advantageously cut the suture 78 by pulling substantially in the proximal direction. Because the physician 14 pulls in the proximal direction (away from the tissue) to cut the suture 78, the illustrative embodiments advantageously provide additional safety compared to conventional endoscopic scissors. With endoscopic scissors, the physician 14 cuts the suture toward the tissue (distal), which may undesirably cut the tissue (e.g., accidentally cut the tissue if the blade tip is close to the tissue). In the illustrative embodiments, the physician 14 cuts the suture 78 by pulling away from the tissue (i.e., by pulling the cutter toward the proximal direction), which reduces the likelihood of cutting and damaging the tissue.

[0083] Based on testing, the inventors have determined that when the correct amount of tension is applied, the suture 78 is cut outside or inside the delivery shaft 74. Based on the type of suture 78 (e.g., smaller sized sutures are easier to cut than larger sized sutures) and the amount of sutures under tension during surgery, the suture 78 may be cut before it is pulled into the delivery shaft 74, or the handle may need to retract the blade 72 and suture 78 further into the delivery shaft 74 to apply a higher tension on the suture to cut the suture. The more the cutter 64 is retracted into the delivery shaft 74, the greater the tension applied to the suture 78.

[0084] However, in some embodiments, the cutter 64 can face in a substantially distal direction, such that the suture receiving portion 68 faces substantially distally. Thus, some embodiments can simply push the cutter 64 toward the suture 78 to cut the suture 78 (e.g., by pressing the handle distally). Of course, some other embodiments can position the cutter 64 in a proximal-facing direction, such that the cutter 64 can be pulled to cut the suture 78.

[0085] FIG. 12A to FIG. 12B Suture 78 is schematically shown cut within a delivery shaft 74, in accordance with an illustrative embodiment of the invention. FIG. 13A to FIG. 13B Suture 78 is schematically shown cut externally of delivery shaft 74, in accordance with an illustrative embodiment of the invention.

[0086] The process proceeds to step 414, which asks if there are more sutures to be cut? If so, the process returns to step 410, which positions the suture 78 in the suture receiving portion 76 of the cutter 64. In some embodiments, the suture cutting device can be removed from the working channel 38, and the suture 78 can be cut using endoscopic scissors. The process 400 is then repeated substantially as described above until the suture 78 is cut.

[0087] When there are no more sutures 78 to cut, the process proceeds to step 416, which removes the suture cutter 64 from the endoscope 18. To remove the suture cutter 64, the suture cutter 64 is retracted into the delivery shaft 74 and through the insertion tube 22. The inventors have determined that removal of the suture cutter 64 may be difficult in various embodiments due to interference with the delivery shaft 74. FIG. 14A to FIG. 14B A distal end view of cutter (64) retracted toward delivery shaft (74) is schematically illustrated. Fig.14A and Fig. 14B Two different results of retracting the blade 72 toward the delivery shaft 74 are shown.

[0088] like Fig.14A As shown, cutter 64, particularly offset blade 72B, may interfere with delivery shaft 74 and thereby become stuck on delivery shaft 74 (e.g., particularly at the point of maximum height H of cutter 64). Delivery shaft 74 may be undesirably positioned, for example, within receiving portion 76. This requires further manipulation by physician 14 to remove shaft 74 from receiving portion 76 and then attempt to properly position cutter 64 within the lumen of shaft 74, such as Fig. 14B In particular, Fig. 14B It is shown that there is no interference between the blade 72B and the inner wall 74A of the delivery shaft 74.

[0089] In various embodiments, the distal end of the puller wire 60 is curved to assist in retracting the blade 72 into the delivery shaft 74. In particular, the curve reduces the likelihood that the blade 72 will become stuck on the delivery shaft 72 when being pulled toward the delivery shaft 74.

[0090] Fig. 14C The retraction feature 82 of the cutting device 54 according to the illustrative embodiment is schematically shown. The retraction feature 82 is configured to position and orient the cutter 64 so that when the cutter 64 is retracted into the delivery shaft 74, there is minimal or no interference between the one or more blades 72 and the delivery shaft 74 (e.g., Fig. 14B ). In some other embodiments, the retraction feature 82 includes a hypodermic injection tube 82 (e.g., having a length 83 of about 5 mm to about 9 mm) that is coupled (e.g., welded, glued, integrally formed) to the wire 60 near the distal end of the wire 60 to force the wire 60 to approach or abut against the inner wall 74A of the delivery shaft 74. This ensures that there is enough space for the blade 64 to retract into the delivery shaft 74 (e.g., catheter). Thus, the retraction feature 82 minimizes or eliminates interference between one or more blades 72A and the delivery shaft 74. To this end, the retraction feature 82 can be sized to be just smaller than the inner diameter of the delivery shaft 74 (to push the wire 60 toward the inner wall of the delivery shaft 74 without causing excessive resistance to the movement of the feature 82).

[0091] In some embodiments, the pull wire 60 may be coupled to the inner or outer surface of the hypodermic tube 82 so that the pull wire 60 remains against or in close proximity to the inner surface 74A of the delivery shaft 74. The retraction feature 82 may be rigidly fixed to the pull wire 60 so that the cutter 64 is rotationally and movably fixed to the retraction feature 82. Therefore, when the cutter 64 moves proximally or distally, the retraction feature 82 moves proximally or distally in a corresponding manner. Similarly, when the cutter 64 rotates, the retraction feature 82 also rotates. Preferably, the retraction feature 82 is coupled to the pull wire 60 so that the cutter 64 is oriented and positioned to avoid interference with the shaft 74.

[0092] FIG. 15A to FIG. 15G Various cross-sections of various embodiments having a retraction feature 82 are schematically shown. In particular, the cross-sections show the cutter 64 and the delivery shaft 74. It should be understood that the retraction feature 82 is not shown in this cross-section because the retraction feature 82 can be located proximal to the cutter 64 (e.g., see FIG. Fig. 14C ).

[0093] As an example, an imaginary plane P1 can be drawn through the maximum diameter of the delivery shaft 74 and the rotation axis 88 of the cutter 64. An imaginary plane P2 can also be defined along the maximum height of the cutter 64. An angle α1 is defined between P1 and P2. In various embodiments, certain angles α1 orient the cutter 64 so that there is no interference with the delivery shaft 74 (e.g., at FIG. 15A to FIG. 15C However, certain other angles α1 orient the cutter 64 so that there is interference with the delivery axis 74 (e.g., FIG. 15D to FIG. 15G ). In some embodiments, angle α1 is preferably selected so that interference between the maximum height H of cutter 64 and shaft 74 is minimized or eliminated.

[0094] although FIG. 15A to FIG. 15G Various angles relative to the puller wire 60 are mentioned, but it should be understood that the puller wire 60 can be coupled at various points along the cutter 64 (e.g., on different ends of the cutter 64, on opposite sides, etc.). However, the illustrative embodiments advantageously couple the wire 60 eccentrically from the cutter 64 so that the suture 68 can easily enter the receiving portion 76.

[0095] In addition, the size of the cutter 64, the pull wire 60 and / or the delivery shaft 74 can be different from the examples shown herein. Therefore, various embodiments are not limited to the angles described herein. These examples are provided only to illustrate certain orientations and positions that can be operated using the retraction feature 82. Those skilled in the art can determine how to appropriately determine the size and orientation of the cutter 64, the pull wire 60 and the retraction feature 82 relative to each other, so as to ensure that the cutter 64 has limited interference or no interference with the delivery shaft 74 during retraction. Process 400 then ends.

[0096] Figures 16 to 18 An alternative embodiment of a suture cutter 64 is schematically shown in accordance with an illustrative embodiment of the invention. Fig.16 A suture cutter 64 is schematically shown having two planar blades 72. The receiving portion 76 can be formed in part by the actuation wire 60.

[0097] Fig.17 A suture cutter 64 is schematically shown having a single blade 72. The blade edge 70 may face substantially in the proximal direction. Fig.16 , the receiving portion 76 can be formed by the driving wire 60.

[0098] Fig.18 Schematically shows a pre-receiving section 84 Fig.17 The suture cutter 64 of the present invention. The pre-receiving portion 84 can be formed by the drive wire 60, or can be formed separately. The pre-receiving portion 84 allows the physician 14 to initially capture the suture 78 by pushing the cutter 64 in the distal direction (e.g., substantially along the axis A1). Then, as shown by the movement of the arrows, the suture 78 can be brought into the suture receiving portion 76 leading to the blade 72 by aligning the suture 78 with the receiving portion 76 and pulling the cutter 64 in the proximal direction.

[0099] It will be apparent to one skilled in the art that the illustrative embodiments provide numerous advantages to the physician 14 and the patient 12. Specifically, the illustrative embodiments advantageously provide a cutter 64 having a small rigid profile (e.g., length L) that allows for easy movement through the angled insertion tube 22. In addition, the illustrative embodiments provide a device having a reduced profile without a moving blade 72. Thus, no active control mechanism for the blade 72 (e.g., a control mechanism for rotating the blade around a pin as in conventional scissors) is required. In addition, due to the orientation of the cutter 64 relative to the device 54, the illustrative embodiments enable the physician 14 to cut the suture 78 using a pulling motion. The pulling motion can be performed using the same handle 56 used to position the cutter 64. The simplified hooking and cutting motion using a single handle 56 advantageously simplifies the medical procedure for the physician 14.

[0100] Although various inventive embodiments have been described and illustrated herein, a person of ordinary skill in the art will readily appreciate various other means and / or structures for performing functions and / or obtaining results and / or one or more advantages described herein, and each of these changes and / or modifications is considered to be within the scope of the inventive embodiments described herein. More generally, it will be readily understood by those skilled in the art that all parameters, dimensions, materials, and configurations described herein are intended to be exemplary, and that actual parameters, dimensions, materials, and / or configurations will depend on one or more specific applications for which the present invention is taught. Those skilled in the art will recognize or be able to determine many equivalents of the specific inventive embodiments described herein using no more than routine experiments. Therefore, it should be understood that the foregoing embodiments are presented only by way of example, and within the scope of the appended claims and their equivalents, embodiments of the present invention may be practiced in a manner different from that specifically described and claimed. The inventive embodiments of the present disclosure relate to each individual feature, system, article, material, kit, and / or method described herein. In addition, if two or more such features, systems, articles, materials, kits, and / or methods are not inconsistent with each other, any combination of these features, systems, articles, materials, kits, and / or methods is included within the scope of the invention disclosed herein.

[0101] Various inventive concepts may be embodied as one or more methods, examples of which have been provided. The actions performed as part of a method may be ordered in any suitable manner. Thus, embodiments may be constructed in which the actions are performed in an order different from that shown, which may include performing some actions simultaneously, even though shown as sequential actions in an illustrative embodiment.

[0102] Although the subject matter contained herein has been described in detail for purposes of illustration, it should be understood that such detail is intended for that purpose only and that the present disclosure is not limited to the disclosed embodiments, but on the contrary is intended to cover modifications and equivalent arrangements within the spirit and scope of the appended claims. For example, it should be understood that the present disclosure contemplates that, to the extent possible, one or more features of any embodiment may be combined with one or more features of any other embodiment.

[0103] Although the above discussion discloses various exemplary embodiments of the present invention, it should be apparent that those skilled in the art can make various modifications that will achieve some of the advantages of the present invention without departing from the true scope of the invention.

Claims

1. A method for cutting a suture, the method comprising: positioning a flexible insertion tube of the endoscope within the patient; moving a passive cutter coupled to a drive wire through a working channel of the flexible insertion tube, the drive wire being configured to move the cutter along a central axis of the working channel, the cutter having a proximally facing suture receiving portion leading to a sharpened blade; extending the cutter out of the working channel of the insertion tube; positioning the sharp blade adjacent to a suture; as well as The suture is cut by pulling the actuation wire proximally.

2. The method according to claim 1, wherein: Positioning the suture adjacent to the sharpened blade includes: The suture is passed through the suture-receiving portion.

3. The method according to claim 2, wherein: Passing the suture through the suture-receiving portion includes: moving the suture-receiving portion distally of a portion of the suture; aligning the portion of the suture with the suture-receiving portion; The suture-receiving portion is moved proximally to receive the aligned portion of the suture within the suture-receiving portion.

4. A method according to any one of the preceding claims, wherein: The cutter has a rigid longitudinal penetration length L of less than about 8 mm.

5. The method according to any one of the preceding claims, further comprising: positioning the sharpened blade adjacent to a second suture; and The second suture is cut by pulling the cutter proximally.

6. A method according to any one of the preceding claims, wherein: The flexible insertion tube is angled near the distal end.

7. A method according to any one of the preceding claims, wherein: The cutter has at least one blade forming a suture-receiving portion.

8. The method of claim 1, further comprising retracting the cutter into the working channel.

9. The method of claim 8, further comprising retracting the cutter into a delivery shaft, wherein: The drive wire is coupled to a retraction feature configured to position and orient the cutter to reduce or prevent interference with the delivery shaft.

10. A suture cutting device, comprising: a drive wire connected to the cutter; The cutter has at least one blade defining a suture-receiving portion.

11. The suture cutting device according to claim 10, wherein: The cutter has a first blade defining a first plane and a second blade defining a second plane that is non-parallel to the first plane.

12. The suture cutting device according to any one of the preceding claims, wherein: The first blade and the second blade are non-moving.

13. The suture cutting device according to any one of the preceding claims, wherein: The actuation wire has a proximal end and a distal end, with the suture-receiving portion generally facing the proximal end.

14. The suture cutting device according to any one of the preceding claims, wherein: The cutter has a rigid longitudinal penetration length L of less than about 8 mm.

15. The suture cutting device of any of the preceding claims, further comprising a retraction feature configured to position and orient the cutter to reduce or prevent interference with the delivery shaft.

16. The suture cutting device according to claim 15, wherein: The retraction feature is a hypodermic injection tube.

17. A method of cutting a suture, the method comprising: supply: a drive wire coupled to a cutter having a central axis, wherein the drive wire is offset from the central axis; The cutter has a first blade defining a first plane and a second blade defining a second plane non-parallel to the first plane, the first blade and the second blade defining an opening; hooking a suture into the opening; The suture is cut by pulling the actuation wire in a proximal direction.

18. A suture cutting system, the suture cutting system comprising: an endoscope having an insertion tube having at least one working channel; A cutting device, comprising: a handle, the handle being movably coupled to the flexible drive wire, the handle being configured to move the drive wire proximally or distally within the delivery shaft; A cutter is coupled to the distal end of the actuation wire, wherein movement of the actuation wire in a distal direction causes movement of the cutter in a distal direction, the cutter having a rigid longitudinal traverse length L of less than about 8 mm.

19. The suture cutting system of any one of the preceding claims, wherein: The cutter has a rigid longitudinal penetration length L of less than about 8 mm.

20. The suture cutting system of any one of the preceding claims, wherein: The cutter has a rigid longitudinal penetration length L greater than about 4 mm.

Images