JP4594953B2 - Endoscopic treatment tool and sewing device - Google Patents

Description

The present invention relates to an endoscope treatment tool and a sewing instrument that are used by being incorporated in an endoscope, for example, for sewing a perforation generated in a digestive tract or the like.

In general, when a perforation occurs in the digestive tract such as the esophagus or stomach for some reason, a laparotomy is performed to close the perforation. However, since this method performs laparotomy regardless of the size of the perforation, it places a heavy burden on the patient and takes time to recover after surgery.
Therefore, several methods for closing the perforation without performing a laparotomy are provided. One of them is a method in which a clip formed so as to open and close like a hook with a springy material is used to draw and bind tissue around the perforation.
JP 2005-13539 A

However, the method using the clip described in Patent Document 1 still has the following problems.
Even if the tip of the clip is opened to the maximum, the width dimension cannot be made large, so when the size of the perforation is large, the left and right tissue parts corresponding to the diameter part of the perforation are directly bound. I can't. For this reason, using a plurality of clips, a method of gradually narrowing the perforation by binding the tissues on the left and right of the perforation in order while spacing from the end of the perforation toward the center is used. Is the actual situation.
With such a method, only one clip can be bound by one procedure using the endoscope treatment tool, and eventually, a plurality of procedures using the endoscope treatment tool are repeated. In addition, in the middle of the procedure, it is not possible to directly observe whether the clip tip engages with the tissue around the perforation and is ready for binding. There was a problem of being very troublesome.
In addition, the procedure time until the perforation is closed is increased, and accordingly, there is a problem that the possibility of causing complications such as peritonitis becomes high.

The present invention has been made in view of the above-mentioned problems of the prior art, and its purpose is to eliminate the need for laparotomy and the need to open a hole in the abdominal wall, and to quickly and reliably perforate the digestive tract. Furthermore, it is an object of the present invention to provide an endoscopic treatment tool and a crimping instrument that can be sewn by an easy operation.

The present invention employs the following means in order to solve the above problems.
An endoscopic treatment tool according to the present invention includes a sheath, an operation wire that is inserted into the sheath and is relatively movable along the axial direction of the sheath, and is detachably engaged with the operation wire. the endoscopic treatment instrument comprising: a plication instrument is locked, wherein the plication device comprises at least two elastically deformable arm portion is engaged with the proximal end side to the operating wire, and A first arm that binds the arm part and is slidable in the length direction of the arm part, and the arm part is inserted into the sheath at the base end side and the first arm extends forward of the sheath. parts through a second arm portion extending from the distal end of the arm portion of the first back toward the proximal end of the first arm portion, with respect to provided a biological tissue on the tip of the second arm portion an anchor portion to be inserted into the through-hole hole capable to form Characterized in that it.

According to this endoscope treatment instrument, for example, the distal end of the sheath and the sewing instrument are inserted into a perforation formed in the digestive tract, and in this state, the suture instrument is pulled together with the sheath toward the proximal end side of the endoscope. . At this time, the anchor part at the tip of the arm part penetrates the living tissue around the perforation and is locked there. Next, the stopper originally locked at the intermediate position of the first arm portion is moved to the distal end side in the length direction of the arm portion. Along with this, the anchor part at the tip of the arm part and the biological tissue part penetrated by the anchor part are pulled toward each other. As a result, the perforation is sewn. Thereafter, the sewing device can be left in the body by unlocking the operation wire and the sewing device .

The endoscope treatment tool according to the present invention includes a stopper moving means for moving the stopper toward the distal end side in the length direction of the arm portion.
According to this endoscope treatment tool, the stopper can be moved to the distal end side in the longitudinal direction of the arm portion by the stopper moving means, and therefore, after the sewing instrument is placed, another treatment tool for endoscope is used. Compared to moving the stopper, the procedure is simple and the procedure time can be shortened.

The endoscope treatment tool according to the present invention is characterized in that the arm portion and the stopper can be accommodated in the sheath, respectively.
According to this endoscope treatment instrument, the arm portion and the stopper can be accommodated in the sheath. For example, when the sewing instrument is transferred to a predetermined position inside the digestive tract through the channel of the endoscope. The arm and stopper can be moved while they are housed in the sheath, and the outer periphery of the anchor and stopper is inadvertently placed on the inner periphery of the endoscope channel and digestive tract when moving. It is possible to avoid problems that are caught on.

In the endoscope treatment tool according to the present invention, the arm portion is elastically deformed so that the first arm portion and the second arm portion overlap with each other, and is housed in the sheath. It is characterized by.
According to this endoscopic treatment tool, the arm portions can be stored overlapping each other, so that the arm storage space required in the sheath is relatively small, and the arm portion is operated by operating the operation wire. When exposing from the distal end of the sheath, the operation amount of the operation wire can be shortened. Furthermore, since the anchor portion is not exposed in the process of exposing the arm portion, it is possible to prevent the surrounding living tissue from being damaged.

In the endoscope treatment tool according to the present invention, the arm portion is elastically deformed so that the first arm portion and the second arm portion are linear, and is accommodated in the sheath. It is characterized by that.
According to this endoscope treatment instrument, since the plurality of arm portions are accommodated so as to be linear, the arm portion can be accommodated in the sheath even when the inner diameter of the sheath is relatively small. .

In the endoscope treatment tool according to the present invention, the diameter of a virtual circle obtained by connecting the anchor portions of the at least two arm portions is set to be larger than the outer diameter of the sheath. It is characterized by that.
According to this endoscope treatment tool, since the anchor portion is located outside the outer shape of the sheath, without merely controlling the posture of the sheath, simply pulling the sheath toward the proximal end of the endoscope, The anchor part at the tip of the arm part can penetrate the living tissue around the perforation.

Further, plication device according to the present invention is a plication instrument is locked detachably engaged with the movable operating wire is inserted into the sheath and along the axial direction of the sheath, the proximal end side The arm having at least two deformable arm portions that are locked to the wire, and a stopper that is locked in a state of straddling the arm portion and is slidable in the length direction of the arm portion; A first arm portion whose proximal end is inserted into the sheath and whose distal end extends forward of the sheath, and returns from the distal end of the first arm portion to the proximal end side of the first arm portion. a second arm portion extending, and having an anchor portion to be inserted into the said through hole can form a through-hole with respect to provided the biological tissue to the tip of the second arm portion. Here, the cross-sectional shape of the arm portion may be any of a rectangle, a circle, and a polygon, and the shape is not limited.
According to this sewing instrument , the perforation can be placed in the body in a state where the perforation is stitched by the method using the endoscope treatment tool described above.

  According to the present invention, when the anchor portion at the distal end of the arm portion is pierced into the living tissue around the perforated portion, the distal end of the anchor portion faces the sheath side. Can be confirmed using a mirror. In addition, the perforation can be closed by a single operation using the endoscope treatment tool. As a result, the perforation generated in the digestive tract can be sewn quickly, reliably, and easily. Further, as described above, since the perforation can be closed by a single operation, the procedure time is shortened and the possibility of causing complications such as peritonitis is reduced.

Embodiments according to the present invention will be described below.
1 to 14 show an embodiment of an endoscopic treatment tool and a sewing device according to the present invention. In these drawings, FIG. 1 is a perspective view showing a state in which an endoscope treatment tool is incorporated in an endoscope, FIG. 2 is a cross-sectional view of a main part of the endoscope treatment tool, and FIG. 3 is an endoscope. FIG. 4 is a cross-sectional view illustrating a stopper of the treatment tool, FIG. 4 is a diagram illustrating the stopper, and FIGS. 5 to 13 are process diagrams illustrating a method of closing a perforation using the endoscope treatment tool. In the present embodiment, as an example of the perforation H generated in the digestive tract, a case where the perforation H occurs in the stomach wall X will be described as an example.

The endoscope treatment tool 1 according to this embodiment is used by being incorporated in an endoscope 2 as shown in FIG. As shown in FIGS. 1 and 2, the endoscope treatment tool 1 is made of a flexible sheath such as a coil sheath that is inserted into a treatment tool channel 2 b formed in an insertion portion 2 a of the endoscope 2. A sheath 3, an operation wire 4 that is inserted into the sheath 3 and that can move relative to the sheath 3 along the axial direction thereof, and a hook portion 4 a provided at the distal end of the operation wire 4 are detachably locked. The sewing instrument 5 is provided, and an operation unit 6 for operating the sewing instrument 5 to advance and retreat via the operation wire 4.

The sewing device 5 is provided on the base end side (here, the sheath is used as a reference, the operation portion side of the sheath is the base end side, and the opposite side is the front end side) and is detachably engaged with the hook portion 4a. A locking ring 10 to be stopped, at least two deformable arm portions 11 extending from the locking ring 10 toward the distal end side, and a stopper capable of bundling the arm portions 11 and slidable in the length direction of the arm portions 11 The tool 12 is provided.
In this embodiment, an example in which there are two arm parts 11 is shown. These two arm portions 11 have the same configuration, and the arm portions 11 are attached to the locking ring 10 so as to be symmetrical with each other.

  As shown in FIG. 2, the arm portion 11 includes a first arm portion 11a having a proximal end inserted into the sheath 3 and a distal end extending forward of the sheath 3, and a first arm portion 11a extending from the distal end of the first arm portion 11a. The second arm portion 11b extends so as to return to the proximal end side of the arm portion 11a, and the anchor portion 11c is provided at the distal end of the second arm portion 11b and can be pierced into a living tissue such as a stomach wall.

  Further, in this embodiment, the arm portion 11 is formed in a substantially V shape as shown in FIG. 2 in a natural state where no load is applied from the outside. The shape may be a W shape. In short, as described above, the diameter of the imaginary circle obtained by connecting the anchor portions 11c provided at the tip of the second arm portion, including the first arm 11a and the second arm portion 11b. It is sufficient if La is set larger than the outer diameter Lb of the sheath 3. Further, the diameter La of the virtual circle can be changed by moving the position of the stopper 12 with respect to the arm 11.

  Further, as shown in FIG. 5, the arm portion 11 has elasticity that can be folded so that the first arm portion 11a and the second arm portion 11b overlap when stored in the sheath 3. In addition, as shown in FIGS. 7 and 8, when the proximal end side is inserted into the sheath 3 and pulled toward the proximal end side of the endoscope, the anchor portion 11c is inserted into the living tissue. It is made of a material having such a rigidity that it can be used, such as stainless steel, a superelastic alloy, a shape memory alloy, or a resin.

In addition, the anchor portion 11c is formed in a twisted shape in FIG. 2, but it is not necessarily formed in a twisted shape, and when the anchor portion 11c is inserted into a living tissue, the anchor portion 11c does not come out easily. Any shape that can maintain that state is sufficient. Therefore, for example, the shape may be slightly inclined while maintaining the same diameter as the second arm portion.
Further, as shown in FIG. 2, when only the proximal end side of the arm portion 11 is accommodated in the sheath 3, the anchor portion 11c is substantially parallel to the axis of the sheath 3 or slightly inclined inward. Is formed.

As shown in FIG. 4, the stopper 12 includes a cylindrical stopper main body 12 a and a movable locking piece 12 b that is attached to the left and right outwards of the stopper main body 12 a. As shown in FIG. 3, the movable locking piece 12b is rotatable about a base end portion attached to the lower end portion of the stopper main body 12a in FIG. Sometimes, as shown in FIG. 3 (b), the diameter is increased to be larger than the outer diameter of the sheath 3, and when the sheath 3 is housed in the sheath 3, as shown in FIG. Then, the diameter of the stopper main body 12a is reduced so as to be accommodated in the storage groove 12c.
The stopper 12 is made of a material having elasticity as appropriate, for example, rubber or silicon-based material. The arm portion 11 of the sewing instrument 5 is inserted into the stopper main body 12a. The locking position of the stopper 12 with the arm portion 11 is not easily shifted by the stopper main body 12a sandwiching the arm portion 11 by its own elastic action.

Further, the endoscope treatment tool 1 is provided with a stopper moving means 14 for moving the stopper 12 toward the distal end side in the length direction of the arm portion 11. The stopper moving means 14 includes a locking portion that locks the stopper 12 to the distal end of the sheath 3, and the operation wire 4 and the operation portion 6 that moves the operation wire 4 back and forth.
In this embodiment, the locking portion is provided on the stopper 12 and is constituted by the movable locking piece 12b. However, the locking portion is not necessarily provided on the stopper side 12, and may be provided on the sheath 3 side. Alternatively, it may be provided across the stopper 12 and the sheath 3.

  Further, as shown in FIG. 1, the proximal end side of the sheath 3 is connected to the operation portion main body 15. A guide groove 16 is formed in an intermediate portion of the operation unit main body 15 in the axial direction. A slide portion 17 that slides along the guide groove 16 is attached to the operation portion main body 15, and the proximal end side of the operation wire 4 is fixed to the slide portion 17.

For this reason, when the slide part 17 is advanced and retracted, the hook part 4a can be moved toward the distal end of the sheath 3 as shown in FIG. It is like that. As a result, after the sewing device 5 is pushed out, retracted, or pushed out of the sheath 3, the hook portion 4a and the locking ring 10 can be unlocked and released.
That is, the operation unit main body 15 and the slider unit 17 operate the advancement / retraction operation of the operation wire 4 to advance / retreat the stored shrinkage instrument 5 in the axial direction of the sheath 3, and push out the shrinkage instrument 5 from the sheath 3. Thus, the operation portion 6 is configured to release the locking between the hook portion 4a and the locking ring 10 at an arbitrary timing.

Next, a perforation / stitching method in which the perforation H generated in the stomach wall X is sewn with the endoscope treatment tool and the sewing device having the above-described configuration will be described.
First, as shown in FIG. 5, the sewing device 5 is housed in the sheath 3 with the arm portion 11 folded. At this time, the hook portion 4 a provided at the tip of the operation wire 4 is kept in a state of being engaged with the engagement ring 10. Subsequently, the insertion portion 2a of the endoscope 2 is orally introduced and guided to the inside of the stomach, and the perforated H portion is confirmed by an endoscopic image. After confirming the perforation H location, the sheath 3 is inserted into the treatment instrument channel 2b of the endoscope 2 as shown in FIG. Subsequently, the sheath 3 is projected from the distal end of the insertion portion 2a while confirming with an endoscopic image.

Subsequently, as shown in FIG. 6, the distal end of the sheath 3 is inserted into the perforation H formed in the stomach wall X from the mucous membrane side P1 side. In this state, the operation portion 6 is operated to advance the hook portion 4a, and the sewing device 5 is pushed out from the distal end of the sheath 3 by a predetermined amount. Specifically, the distal end portion of the arm portion 11, that is, the entire anchor portion 11b and the second arm 11b and the middle portion on the distal end side of the first arm 11a are exposed outward from the distal end of the sheath 3.
Then, as shown in FIG. 7, the arm portion 11 is in a natural state by being opened radially outward by its own elastic action without the anchor portion 11 c being restrained by the inner wall of the sheath 3. At this time, the anchor part 11c is located on the serosa side P2 of the stomach wall X.

While maintaining this state, the crimping instrument 5 together with the sheath 3 is pulled to the proximal end side of the endoscope via the operation unit 6. Then, as shown in FIG. 8, the anchor portion 11 c penetrates the stomach wall X in the vicinity of the perforation H, and the tip thereof reaches the mucosa side P <b> 1 of the stomach wall X.

Next, as shown in FIG. 9, by operating the operation portion 6, only the sheath 3 is retracted while the position of the hook portion 4 a is maintained, and the stopper 12 is exposed from the distal end of the sheath 3. When the stopper 12 is exposed from the distal end of the sheath 3, the movable locking piece 12 b is enlarged in diameter by its own elastic action as shown in FIG. 3B, and can be locked to the distal end of the sheath 3.
Next, as shown in FIG. 10, only the sheath 3 is advanced while maintaining the position of the hook portion 4 a, and the distal end of the sheath 3 is inserted into the perforation H again. At this time, the stopper 12 is locked to the distal end of the sheath 3 and moves to the serosa side P2 integrally with the sheath 3 in this state. As a result, the stopper 12 moves relative to the distal end side with respect to the arm portion 11.

  Next, as shown in FIG. 11, the sheath 3 is pulled toward the proximal end side of the endoscope via the operation unit 6, and the distal end of the sheath 3 is pulled out from the perforation H. At the same time, the hook portion 4a is pulled to the proximal end side of the endoscope via the operation wire 4, and the stopper 12 is moved relative to the distal end side with respect to the arm portion 11. As a result, the distance between the two anchor portions 11c is shortened, whereby the stomach wall X is pulled and the perforation H is gradually narrowed. Finally, the perforation H is in the squeezed state on the mucosa side P1 of the stomach. Can be blocked.

Next, as shown in FIG. 12, only the sheath 3 is retracted while maintaining the position of the hook portion 4 a, and the entire stopper 12 and the hook portion 4 a are exposed from the distal end of the sheath 3. Then, as shown in FIG. 13, the hook portion 4 a and the locking ring are unlocked while being confirmed by an endoscope.
Thereafter, the other members of the endoscope treatment tool are pulled out of the body together with the endoscope while the sewing device 5 remains in the body. Incidentally, the arm portion 11 of the cerclage instrument 5 may cut an unnecessary portion with scissors forceps or the like (not shown).

As described above, by using the endoscope treatment tool 1 of the present embodiment, the perforation H generated in the stomach wall X can be performed on the mucosa side P1 side without performing a laparotomy or opening a hole in the abdominal wall. Can be sewn and sealed reliably.
Further, when the anchor portion 11c at the distal end of the arm portion 11 is inserted into the stomach wall X around the perforated portion, since the distal end of the anchor portion 11c faces the sheath 3, whether the anchor portion 11c penetrates the stomach wall X or not. Can be confirmed using an endoscope, and the anchor portion 11c can be locked through the stomach wall X even in the subsequent operation of moving the stopper 12 toward the distal end side of the arm portion 11 and sewing the perforation H. It can be confirmed whether or not Further, the perforation H can be closed by a single operation using the endoscope treatment tool. As a result, the perforation H generated in the digestive tract can be sewn quickly, reliably, and easily.
Further, as described above, since the perforation can be closed by a single operation, the procedure time is shortened and the possibility of causing complications such as peritonitis can be reduced. If necessary, by using a clip as described supplementarily in the background, it may elaborate stitching the ends of the perforations H of the plication in the plication device 5.

Further, the endoscope treatment tool of the present embodiment is provided with the stopper moving means 14 for moving the stopper 12 to the distal end side in the length direction of the arm portion 11, so that the anchor portion 11 c of the sewing device 5 is attached to the stomach wall X. Since the stopper 12 can be moved to the distal end side in the length direction of the arm portion 11 as it is, the surgical instrument 5 is temporarily placed on the stomach wall X, and then the treatment tool is temporarily removed from the endoscope channel. Instead of pulling out, instead of inserting another dedicated treatment instrument into the endoscope channel and moving the stopper, the procedure becomes simpler and the procedure time can be shortened.

The present invention is not limited to the above-described embodiment, and can be appropriately changed in design without departing from the spirit of the invention.
For example, in the above-described embodiment, the arm portion 11 of the treatment instrument 5 is folded and housed in a V shape so as to be housed in the sheath 3, but is not limited thereto, as shown in FIG. The elasticity of the portion 11 may be used to extend and store in a straight line.
Moreover, in the said embodiment, when the front-end | tip part of the arm part 11 is exposed from the front-end | tip of the sheath 3, it deform | transforms so that the distance of the anchor parts 11c may each expand according to the elastic effect | action of the arm part 11 itself, Without being limited thereto, the arm portion 11 may be deformed into a desired shape by using a shape memory alloy and utilizing a human body temperature.
Moreover, in the said embodiment, although the arm part 11 of the sewing implement 5 is made into two, it is not restricted to this, You may make the arm part 11 into three or more. You may comprise the two arm parts 11 by bending one arm from the center.

  Moreover, in the said embodiment, although the stopper 12 exposed from the front-end | tip of the sheath 3 is made into the structure which provides the movable locking piece 12b in the stopper 12 in order to lock the sheath 3, it is restricted to this. Instead, the stopper 12 has a simple cylindrical shape or a truncated cone shape made of an elastic material, and the outer diameter thereof is set to be the same as or slightly larger than the inner diameter of the sheath 3, so that it can be accommodated in the sheath 3. In this case, the diameter may be reduced to the same level as the inner diameter of the sheath 3, and when exposed from the sheath 3, the diameter may be increased by its own elasticity so that the sheath 3 can be locked.

<Additional notes>
A step of inserting a sheath that houses the sewing device locked to the tip of the operation wire into the perforated portion of the living tissue;
Projecting a plurality of arms of the crimping instrument from the distal end of the sheath;
Piercing the biological tissue with anchors provided at the distal ends of the arms facing the proximal end of the arms,
Moving a stopper for bundling the arm toward the distal end side of the arm, approaching the anchor, and closing the perforated part;
Separating the crimping instrument from the operating wire;
Medical practice with.

It is a perspective view which shows the state by which the treatment tool for endoscopes and the sewing implement which concern on embodiment of this invention were assembled | attached to the endoscope. It is sectional drawing which shows the principal part of the treatment tool for endoscopes. (A) is sectional drawing which shows the state in which the stopper of the treatment tool for endoscopes was accommodated in the sheath, (b) is sectional drawing which shows the state in which the stopper was latched by the front-end | tip of a sheath. . (A) is a top view of the stopper of the endoscope treatment tool, (b) is a side view of the stopper, and (c) is a bottom view of the stopper. It is sectional drawing explaining an effect | action of the treatment tool for endoscopes which concerns on embodiment of this invention. It is sectional drawing explaining an effect | action of the treatment tool for endoscopes which concerns on embodiment of this invention. It is sectional drawing explaining an effect | action of the treatment tool for endoscopes which concerns on embodiment of this invention. It is sectional drawing explaining an effect | action of the treatment tool for endoscopes which concerns on embodiment of this invention. It is sectional drawing explaining an effect | action of the treatment tool for endoscopes which concerns on embodiment of this invention. It is sectional drawing explaining an effect | action of the treatment tool for endoscopes which concerns on embodiment of this invention. It is sectional drawing explaining an effect | action of the treatment tool for endoscopes which concerns on embodiment of this invention. It is sectional drawing explaining an effect | action of the treatment tool for endoscopes which concerns on embodiment of this invention. It is sectional drawing explaining an effect | action of the treatment tool for endoscopes which concerns on embodiment of this invention. It is sectional drawing of the principal part which shows the modification of the treatment tool for endoscopes which concerns on embodiment of this invention.

DESCRIPTION OF SYMBOLS 1 ... Endoscope treatment tool, 2 ... Endoscope, 3 ... Sheath, 4 ... Operation wire, 4a ... Hook part, 5 ... Sewing instrument , 6 ... Operation part, 10 ... Locking ring, 11 ... Arm part 11a ... 1st arm part, 11b ... 2nd arm part, 11c ... Anchor part, 12 stopper, 12b ... Movable locking piece (locking part) 14 ... Stopper moving means,

Claims (7)

Endoscopic comprising a sheath, an operation wire relatively movable along its axial direction relative to the sheath while being inserted into the sheath, and plication instrument is locked detachably engaged with the operation wire, the A mirror treatment tool,
The sewing device includes at least two elastically deformable arm portions whose proximal ends are locked to the operation wire, and a stopper that binds the arm portions and is slidable in the length direction of the arm portions. Have
The arm portion includes a first arm portion whose proximal end is inserted into the sheath and a distal end extending forward of the sheath, and returns from the distal end of the first arm portion to the proximal end side of the first arm portion. a second arm portion extending manner, endoscope, characterized by having an anchor portion provided at the tip of the second arm portion is inserted into the through-hole can be a through-hole with respect to the biological tissue Mirror treatment tool.   The treatment instrument for an endoscope according to claim 1, further comprising a stopper moving means for moving the stopper toward the distal end side in the length direction of the arm portion.   The treatment instrument for an endoscope according to claim 1 or 2, wherein the arm portion and the stopper can be accommodated in the sheath, respectively.   4. The endoscope according to claim 3, wherein the arm portion is elastically deformed so that the first arm portion and the second arm portion overlap with each other, and is housed in the sheath. 5. Treatment tool.   The internal view according to claim 3, wherein the arm portion is elastically deformed so that the first arm portion and the second arm portion are linear, and is housed in the sheath. Mirror treatment tool.   The diameter of a virtual circle obtained by connecting the anchor portions of the at least two arm portions is set larger than the outer diameter of the sheath. The endoscopic treatment tool according to Item. A sewing instrument that is inserted into a sheath and is detachably locked to an operation wire that is movable along the axial direction of the sheath,
At least two elastically deformable arm portions that are locked to the wire on the proximal end side, and a stopper that is locked in a state of straddling the arm portion and that can slide in the length direction of the arm portion. Have
The arm portion includes a first arm portion whose proximal end is inserted into the sheath and a distal end extending forward of the sheath, and returns from the distal end of the first arm portion to the proximal end side of the first arm portion. a second arm portion extending manner, plication characterized by having an anchoring portion to be inserted into the said through hole can form a through-hole with respect to provided the biological tissue to the tip of the second arm portion Instruments .

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