fig1 and 2 show a surgical suturing tool 12 constructed according to the invention and particularly adapted to suture an epicardial pacer electrode 18 to a heart . the tool 12 has a generally elongated body 14 preferably formed of a rigid molded plastic such as polycarbonate . one end 12a of the tool has a pistol - like handle 16 that allows a surgeon to grip the tool comfortably , guide it accurately and operate it easily during the suturing procedure . the other distal end or head 12b of the tool is adapted to hold the epicardial pacer electrode 18 and guide it to the desired attachment point on the heart . a hand operated plunger 20 slides axially in a recess 22 within handle 16 . the plunger travels between a retracted position and a full forward position . during a first portion of its forward travel ( to the right as shown ) the plunger sutures the electrode to the heart . during a second portion of its forward travel , the plunger detaches the electrode and its electrical lead 40 from the tool 12 . the plunger 20 has two extension arms 24 , 24 which slide axially in die passages 26 , 26 . the die passages 26 , 26 are circular in cross section and extend the full length of the body 14 from the handle 16 to the end face 12c . they may be formed of stainless steel hypodermic tubing . these passages closely guide the extension arms 24 , 24 as well as pusher wires 28 , 28 and suture elements 30 , 30 held in the die passages . the pusher wires 28 , 28 are relatively stiff , preferably formed of 0 . 010 diameter stainless steel . the suture elements 30 , 30 are formed of a suitable malleable material which will retain a set after being stressed byond its elastic limit , preferably half - hard elgiloy . each extension arm 24 is associated with and axially aligned with one pusher wire 28 and one suture 30 . these elements are in end - abutting relationship so that a forward movement of the plunger from its retracted position is translated into a corresponding movement of the associated wire and suture within the surrounding die passage 26 . with particular reference to fig6 - 10 , the distal ends 26a , 26a of the die passages 26 , 26 within the head portion 12b of the tool are curved so that suture elements 30 , 30 emerge from the die passages 26 , 26 following an arcuate path 31 whose curvature is determined by the curvature of the die passages ends 26a , 26a . the curvature of the ends 26a , 26a is selected so that operation of the plunger drives the suture elements to penetrate heart tissue first at 32 ( fig6 ), then at 34 , and finally through notches 36 ( fig6 and 12 ) in pacer electrode 18 . the lengths of suture elements are sufficient to form closed - loop circular sutures that reliably secure the electrode to the heart with a projecting electrical stimulation electrode 38 of the electrode 18 implanted in the heart tissue . the projecting electrode 38 is of conventional design and includes a cutting member 38a and a coiled conductor 38b that supports the cutting member and transmits a heart stimulating electrical signal from a pacer ( not shown ) to the heart muscle . an electrical lead 40 transmits the signal from an implanted pacer ( not shown ) to the projecting electrode 38 . it should be noted that a significant advantage of this invention is that the trauma caused by suturing is isolated from the point of electrical stimulation . another significant advantage is that the invention in its preferred form forms two closed - loop sutures to secure the electrode to the heart with a high degree of reliability . the electrode is releasably secured on the inclined end face 12c of the tool head 12b . the tool 12 is therefore useful not only in suturing , but also in guiding the electrode to the proper location on the heart , usually following a path under the rib cage from an incision in the abdomen where the pacer is implanted . the overall geometry of the tool 12 is also so that it facilitates this insertion procedure . the length is selected so that the handle 16 and the plunger 20 are readily grasped and manipulated when the electrode is positioned on the heart . the cross - sectional width of the tool body is greater than the height ( fig5 and 9 ) to slide under the rib cage . the head 12b and the electrode 18 mounted flush against the end face of the head are tilted downwardly so that the electrode 18 is generally abuts the adjacent heart tissue at the implantation site . this tilt also slants the electrode lead 40 projecting from the lower edge of the electrode 18 to facilitate the insertion of the electrode . the handle 16 is horizontally oriented to minimize its interference with the insertion . with particular reference to fig7 and 11 , the electrode 18 has a resilient protrustion 42 with an enlarged , generally cylindrical end portion 42a adapted to seat in a generally cylindrical recess 44 formed in the head 12b of the tool . the electrode is secured on the tool by pressing the protrusion 42 into a narrowed distal end 46a of a central channel 46 in the body 14 until the portion 42a seats in the recess 44 . a separating element or rod 48 , preferably formed of a rigid molded plastic , slides axially in the channel 46 which extends from the recess 22 in the handle 16 to the end face 12c of the tool lead . as shown in fig1 and 2 , one end 48a of the rod is adapted to engage the plunger 20 . the other end 48b is of reduced width and adapted to engage the resilient protrusion 42 of the electrode when it is seated in the recess 44 . during the first portion of the travel of the plunger from the fully retracted position , it acts through the extensions 24 , 24 and the pusher wires 28 , 28 to drive and eject the circular sutures . at the end of the second portion of the travel the rod pushes the protrusion 42 out of the recess 44 and thereby detaches the electrode 18 from the tool 12 . the last portion of the travel also completes the ejection of the sutures . the initial position of the rod 48 is shown in solid lines in fig3 and the full forward position is shown in phantom . with reference to fig2 - 4 , the rod 48 also operates to detach the lead 40 which is held in part in a slot 50 defined by an opening 52 in the bottom wall of the body 14 and a recess 54 formed in the rod 46 . when the plunger is fully retracted , the recess 54 overlies the slot 52 . they together receive a portion 40a ( fig2 and 5 ) of the lead . the side walls 52a , 52a of the opening 52 are upwardly narrowing to promote the insertion of the lead into the slot but block its movement out of the slot once it is fully inserted as is best seen in fig5 . this immobilizes the lead during insertion and minimizes the likelihood that it will interfere with the insertion or suturing operations . when the suturing is completed , the forward sliding movement of the rod 48 causes a sloped cam surface 56 at the rear of the recess 54 to engage the lead and drive it out of the slot 50 . the lead is thus released from the tool just before the electrode is detached . to prepare the suturing tool 12 for operation , the plunger 20 is removed and the suture elements 30 , 30 are each inserted into one of the die passages 26 , 26 through the handle recess 22 . next , the pusher wires 28 , 28 are inserted into the passages 26 , 26 in the same manner . the separating rod 48 is inserted into the channel 46 with the recess 54 aligned with the slot 52 in the tool body . the plunger 20 is replaced in the recess 22 . finally , the pacer electrode is fixed on the head 12b and the head portion 40a is jammed into the slot 50 . the tool is then ready for use . using a small incision below the rib cage , the tool carrying the electrode is inserted into the body and guides the electrode to the heart by mediastinoscopy . when the electrode is in the proper location , the plunger is pushed forward . the first portion of its travel ejects and forms the suture elements 30 , 30 into closed - loop circular sutures that permanently attach the electrode to the heart . in the last portion of its travel , the separating rod ejects the electrode and its leads from the suturing tool . the tool is then withdrawn , leaving the pacer electrode attached to the heart . prior to actually applying the electrode to the heart , the tool with the probe can be utilized for exploring or mapping the heart with regard to sensitivity . this is advantageous as compared with mapping initially with a separate probe because of the difficulty of returning exactly to the same spot with a separate electrode . there has been described a surgical tool that sutures an epicardial pacer electrode to the heart without the need of directly exposing the heart by a thoracotomy which is a substantially more hazardous procedure than a small incision below the rib cage . also , the present invention sutures the pacer electrode to the heart with the sutures spaced from the point of electrical contact with heart tissue to minimize trauma . furthermore , these objects and advantages are achieved by means of a tool of simple and inexpensive construction . although the suture forming tool disclosed herein has particular utility in attaching an epicardial pacer electrode to the heart , it should be understood that the tool may be advantageously applied to other medical procedures since the tool allows the formation of closed loop sutures at remote locations within the body . a tissue tear may be repaired , for example , without the necessity of fully exposing the site as would be required with conventional suturing techniques . also , while the invention has been described with reference to a tool for forming a pair of sutures , it can readily be adapted to form only one or more than two sutures . these and other modifications of the invention will occur to those skilled in the art from the foregoing detailed description and the accompanying drawings . such modifications are intended to fall within the scope of the appended claims .
a suture forming surgical tool particularly useful in attaching an epicardial pacer electrode to the heart . the tool has an elongate body and a manually operable plunger slidable in the body . the electrode is releasably secured to a distal end of the tool . in a first portion of its travel , the plunger acts on a pair of pusher wires that each drive lengths of malleable sutures through tubular dies that have curved central bores which impart curvatures of essentially predetermined radii to the sutures . as the curved sutures are ejected from the dies they pass through the adjacent heart tissue and form circular loops which securely attach the electrode to the heart . in a second portion of its travel , the plunger detaches the electrode and its lead wire from the tool .