CA2192471C - Endoscopic ligating instrument - Google Patents

Abstract

An endoscopic instrument for ligating multiple lesions within a hollow body organ. A plurality of cords (103) are laid over the tube (101) to extend longitudinally thereon and be folded over the distal end of the tube. A plurality of elastic rings (50) are mounted on the tube (101) in stretched condition and overlaying the cords (103). The segment of each cord (103) between each pair of adjacent rings (50) is in slack condition and of a length which equals or exceeds the distance of the tube's distal end to the furthest ring of the pair. By a trip cord (105) threaded through a working channel (19) of the endoscope and connected to the cords (103), a pull can be exerted thereon to simultaneously retract the cords (103) and dislodge each of the rings in controlled stepped sequence in a procedure wherein only one elastic ring at a time moves over the tube in the process of its dislodgement to ligate a lesion which has been suctioned part way into the tube (101).

Description

,~ 61211-1247 ENDOSCOPIC LIGATING INSTRUMENT
FIELD OF INVENTION
The invention relates to an instrument for ligating lesions, and more particularly to an endoscopic instrument for ligating mucosal and subwucosal lesions witluin a hollow organ of the body, such as the alimentary tract.
BACKGROUND OF THE INVENTION
The endoscopic treatment of lesions presently encompasses a variety of techniques such as electrocauterization, laser photocoagulation, heat therapy by the application of heat probes, and sclerotherapy which involves the injection of ~uedicine into a target varix by a needle passed through the working channel of the endoscope. A further, wide7.y used and increasingly promising teclunique involves the ligation of lesions, wherein mucosal and submucosal tissue is strangulated by an elastic ligature.
A variety of instrnmenls for effecting the ligation of body tissue by the application of an elastic ring are well )crown in the prior art. Some of these instruments, because of their rigidity and size are suited only for treatment of lesions that are in the external regions of the Lody or in the shallow body cavities. Others are particularly suited WO 95134244 ~ ~ ~'~ ~ ~ ~ PCTlI1595IOk305 for the ligatian of tissue in the abdominal cavity, such as for tubal ligation, when the abdominal cavity has been opened ' surgically.
U.S. Patent No. 3,760,810 to Van Hoorn discloses an ' encloscape-equipped instrument comprising a device with two tubes mounted one insirO> the other, with the inner tube protruding at the front of the outer tube. Means are included to move the outer tube forwardly relative to the inner tube and cause an elastic cord to be dislodged and Placed about the tissue to be ligated. In U.S. Patent No.
4,257,419, there is disclosed an instrument for ligating hemorrhoids wherein a suction tube fitted inside a proctoscape provides means for sucking the hemorrhoid into a suction cavity where a ligating ring is applied. Both of these instruments are rigid devices suited for treating lesions close to the external regions, and both are equipped with only a single elastic ring for treating a single lesion.
There are also instruments in the prior art which employ laparascope-assisted means for ring ligation such as shown in U.S. Patent No. 4,257,420 an 4,471,766, wherein the instruments are eacka equipped with a single elastic band and utilize forceps to position the tissue for ring ligation.
In U.S. Patent No. 3,870,048, there is disclosed a ring applicator device having forceps slidably mounted in a cYli.nder for grasping the fallopian tube and including means for displacing an elastic ring to effect a ligation of tissue. While this device can be equipped with a plurality of elastic rings, its rigidity precludes its use with a flexible endoscope for treating the deeper regions of an internal organ, such as the alimentary tract. , A flexible endoscopic instrument used for li.gation pur~soses and disclosed in U.S. Patent No. 4,735,194 comprises , a fl~~xibl<~ fiber optic endoscope on the end of which is secured an outer tube and an inner tube reciprocally movable therein. A trip Wire is fastened to the inner tube to ~i~~~~~~
WO 95/3424~! PCTJUS95/01305 provide rearward motion to the inner tube to cause an ~ elastic ring fitted about the inner tube to slide off and effect ligation. While this instrument is suitable for ~ ligating Jesions steep within the alimentary tract, it can only be used to treat but one lesion during a single insertion of the instrument.
In many instances, huwever, there are a number of lesion:
present in the organ being treated, such as the esophagus, stomach or colon. If an endoscopic instrument equipped with only one elastic ring is used, the treatment of multiple lesions in the same organ requires the extraction of the endoscope after tire placing of each elastic ring about a lesion and reinsertion of the endoscope into the organ to repeat the procedure far placing arr elastic ligating ring about each of tire lesions. In addition to being time consuming and an associated concern for blood loss when there are bleeding lesions, there are other disadvantages associated with the repetitions of this procedure. The instrument, when withdrawn from the body, is usually covered Zp with blood and mucous. Furthermore, each time the instrument is reinserted into the organ, it becomes necessary to relocate a lesion to be treated and to orient the instrument witkr respect thereto. In some cases where considerable blood and mucous are present, the relocating of the instrument is a tedious and difficult task.

W 0 95f3424~t PCTIUS95l01305 SUMMAI?Y OP TIIE INVENTION
A flexible endoscopic instrument is provided with a plurality of elastic ligating rings mounted on one tube of a pair of tubular members which are affixed in coaxial relation to the insertion end of an endoscope. The rings are adapted to be dislodged therefrom in sequence at selectively controlled times far treating multiple lesions during a single insertion of the endoscope into a body organ. The endoscope is equipped with illumination and viewing means to facilitate orientation of the instrument in the body organ, and longitudinally extending tubular gassages comprisincl a channel through which objects may be passed and suction applied for drawing the lesion tissue into the tubular end of the endoscope to facilitate ligation of a lesion, arid a IS working channel through which a flexible actuating cable is inserted. The cable is connected to one of the tubular members and serves as a means for imparting relative motion between the pair of tubular members to sequentially dislodge the elastic rings from the endoscope at controlled times.
Eackr of the elastic rings can be dislodged from the endoscope and placed in ligating relation to a lesion when lesion tissue is drawn into tire innermost of the tubular members by a suction force applied through the suction channel and each of the rings can be applied to a different one of the 2S multiple lesions in tire body organ during a single insertion of the endoscope.
In one embodiment of the invention, a tubular member is provided with a helical groove in its inner wall and with means at one end for fitting the tubular member onto the insertion end of the endascope. A plurality of elastic l.igating rings are mounted in stretched condition about tire periphery of a second tubular member which, when inserted into the first tubular member with a twisting motion, causes ~~~2~7~

the greater part of each of the elastic rings to be placed in a different one of tire coils of the helical groove. By a drive gear connection between the flexible cable and the inner tubular member, rotary motion of the cable is imparted to the inner tubular member whereby the elastic rings are adapted to be dislodged one at a time to effect the ligation of multiple lesions during a single insertion of the endoscope.
In a second embodiment, a first rigid tubular member is fitted to tyre insertion end of tire endoscope in coaxial relation thereto. A second tubular member of flexible material is glaced on the rigid tubular member with a first outer portion thereof sleeved aver the rigid tubular member and a second portion inserted within the first tubular member by folding over the free end of the rigid tubular member.
The elastic rings are placed in stretched condition about the outer portion of the flexible tubular member in side-by-side spaced relation to one another. By direct connection of the flexible cable to tire inner second portion of the flexible tubular member, the cable can be retracted to pull most of the outer sleeve portion over the free end of the rigid tube and iota the interior of the rigid tubular member thereby causing the elastic rings to be dislodged from the endoscope one at a time as they pass over the end of the rigid tubular member at times controlled by the retraction of the flexible cable.
In a third embodiment, a rigid tubular member is fitted to the insertion end of the endoscope and a plurality of cards connected together at the same point inside the tube, are each folded over its distal end with the free end portion thereof extending in the longitudinal direction of the tube and augularly spaced relative to one another with respect to tyre axis of tire tube. A plurality of elastic rings are placed in stretched condition about the tube at longitudinally spaced locations thereorr and also over the cords which lay over the tube. Each cord is provided with knots at predetermined spaced locations thereon against each of which an elastic ring is placed. By means of a trip wire or trip line threaded through a working channel of the endoscope and connecting to the cords at this mutual connecting point, the cords can be simultaneously retracted to pull the rings over the distal end of the tube in controlled sequence. By also providing a slack length of the cord between each pair of adjacent elastic rings, which slack length equals or exceeds the distance of the tube's distal end to the furthermost ring of the pair a small pulling force is required to dislodge a ring from the tube.
Thus, in a broad aspect the invention provides a flexible endoscopic instrument for ligating a multiplicity of lesions within a hollow body organ, such as the alimentary tract, said instrument comprising: (a) a flexible fiber optic endoscope having a forward insertion end and a rearward end, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion end, and a working channel; (b) a tubular member having a forward distal end, a rearward end and a longitudinal axis, said rearward end having means for providing attachment to the insertion end of the endoscope; (c) a plurality of string-like cords of flexible substantially inelastic material, each said cord being folded over the distal end of the tubular member with a first portion of each said cord overlaying a part of the exterior of said tubular member and a second portion thereof being disposed internally of said tubular member, said cords being oriented in angular spacing about the longitudinal axis of said tubular member; (d) a plurality of elastic ligating rings removably mounted in stretched condition on said tubular member in coaxial - 6a -relation thereto and in overlying relation to said cords, said rings being spaced from one another in the longitudinal direction of the tubular member at successively greater different distances from the distal end of the tubular member; and (e) means for imparting relative sliding motion between said cords and said tubular member to dislodge each of the elastic rings in controlled sequence during a single insertion of the endoscope into the body organ whereby each of the elastic rings can be dislodged from the endoscope and placed in ligating relation to a lesion when lesion tissue is drawn into the tubular member by said suction means with each ring being applied to a different one of multiple lesions present in the body organ, said means comprising a flexible line element threaded through the working channel of the endoscope and connecting at one end to said cords disposed within said tubular member and exiting the endoscope at the rearward end thereof whereby a pulling force may be exerted on the other end of the line element to cause sliding movement of the cords over said tubular member, each said cord being arranged in slack condition between each pair of adjacent elastic rings.
In another aspect the invention provides a flexible endoscopic instrument for ligating a multiplicity of lesions within a hollow body organ, such as the alimentary tract, said instrument comprising: (a) a flexible fiber optic endoscope having a forward insertion end and a rearward end, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion end, and a working channel; (b) a tubular member having a forward distal end, a rearward end and a longitudinal axis, said rearward end having means for providing attachment to the insertion end of the endoscope; (c) a plurality of string-si2i1-124 - 6b -like cords of flexible substantially inelastic material, each said cord being folded over the distal end of the tubular member with a first portion of each said cord overlaying a part of the exterior of said tubular member and a second portion thereof being disposed internally of said tubular member, said cords being oriented in angular spacing about the longitudinal axis of said tubular member; (d) a plurality of elastic ligating rings removably mounted in stretched condition on said tubular member in coaxial relation thereto and in overlying relation to said cords, said rings being spaced from one another in the longitudinal direction of the tubular member and between at least one pair of adjacent elastic rings each of said cords having a slack segment of cord of a length which is at least equal to the distance between the distal end of the tubular member and the ring of said pair which is furthest from said distal end; and (e) means for imparting relative sliding motion between said cords and said tubular member to dislodge each of the elastic rings in controlled sequence during a single insertion of the endoscope into the body organ whereby each of the elastic rings can be dislodged from the endoscope and placed in ligating relation to a lesion when lesion tissue is drawn into the tubular member by said suction means with each ring being applied to a different one of multiple lesions present in the body organ, said means comprising a flexible line element threaded through the working channel of the endoscope and connecting at one end to said cords disposed within said tubular member and exiting the endoscope at the rearward end thereof whereby a pulling force may be exerted on the other end of the line element to cause sliding movement of the cords over said tubular member, each said cord being arranged in slack condition between each pair of adjacent elastic rings.

- 6c -In another aspect the invention provides a flexible endoscopic instrument for multiple ligation, said instrument comprising: (a) a flexible endoscope having a forward insertion portion, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion portion, and a working channel; (b) a hollow support member having a forward distal end and a rearward portion, said rearward portion being connectable to the insertion portion of the endoscope; (c) at least two string-like cords of flexible substantially inelastic material, each of said cords having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and (d) a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in overlying contacting relation to each of said cords, said rings being spaced from one another along said support member at successively greater different distances from said distal end of said support member; wherein a pulling force may be exerted on each of said cords to cause movement of each of said cords relative to said support member to dislodge one or more of said rings in controlled sequence from said support member, each of said cords being arranged in slack condition between each pair of adjacent elastic rings.
In another aspect the invention provides use of a ligation apparatus for ligating tissue, said ligation apparatus including: a hollow support member having a forward distal end and a rearward portion; at least two string-like cords of flexible substantially inelastic material, each of said cords having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member;

- 6d -and a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in overlying contacting relation to each of said cords, each of said cords being arranged in slack condition between each pair of adjacent elastic rings, wherein: said rearward portion of said support member is capable of connection to a forward insertion end of an endoscope; said forward end of said support member is capable of insertion into a body organ and placement adjacent tissue to be ligated; said ligation apparatus is capable of drawing tissue within said support member; and said ligation apparatus is capable of dislodging one of said rings from said support member to ligate tissue drawn within said support member upon exertion of a pulling force on each of said cords.
In another aspect the invention provides a flexible endoscopic instrument for multiple ligation, said instrument comprising: (a) a flexible endoscope having a forward insertion portion, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion portion, and a working channel; (b) a hollow support member having a forward distal end and a rearward portion, said rearward portion being connectable to the insertion portion of the endoscope; (c) at least two string-like cords of flexible substantially inelastic material, each of said cords having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and (d) a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in contacting relation to each of said cords, said rings being spaced from one another along said support member at successively - 6e -greater different distances from said distal end of said support member; wherein a pulling force may be exerted on each of said cords to cause movement of each of said cords relative to said support member to dislodge one or more of said rings in controlled sequence from said support member, each of said cords being arranged in slack condition between each pair of adjacent elastic rings.
In another aspect the invention provides a flexible endoscopic instrument for multiple ligation, said instrument comprising: (a) a flexible endoscope having a forward insertion portion, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion portion, and a working channel; (b) a hollow support member having a forward distal end and a rearward portion, said rearward portion being connectable to the insertion portion of the endoscope; (c) at least one string-like cord of flexible substantially inelastic material, each said cord having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and (d) a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in overlying contacting relation to each said cord, said rings being spaced from one another along said support member at successively greater different distances from said distal end of said support member; wherein a pulling force may be exerted on each said cord to cause movement of each said cord relative to said support member to dislodge one or more of said rings in controlled sequence from said support member, each said cord being arranged in slack condition between each pair of adjacent elastic rings.

- 6f -In another aspect the invention provides use of a ligation apparatus for ligating tissue, said ligation apparatus including: a hollow support member having a forward distal end and a rearward portion; at least one string-like cord of flexible substantially inelastic material, each said cord having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in overlying contacting relation to each said cord, each said cord being arranged in slack condition between each pair of adjacent elastic rings, wherein: said rearward portion of said support member is capable of connection to a forward insertion end of an endoscope; said forward end of said support member is capable of insertion into a body organ and placement adjacent tissue to be ligated; said ligation apparatus is capable of drawing tissue adjacent to said forward end, within said support member; and said ligation apparatus is capable of dislodging one of said rings from said support member to ligate tissue drawn within said support member upon exertion of a pulling force on each said cord.
In another aspect the invention provides a flexible endoscopic instrument for multiple ligation, said instrument comprising: (a) a flexible endoscope having a forward insertion portion, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion portion, and a working channel; (b) a hollow support member having a forward distal end and a rearward portion, said rearward portion being connectable to the insertion portion of the endoscope; (c) at least one string-like cord of flexible - 6g -substantially inelastic material, each said cord having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and (d) a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in contacting relation to each said cord, said rings being spaced from one another along said support member at successively greater different distances from said distal end of said support member; wherein a pulling force may be exerted on each said cord to cause movement of each said cord relative to said support member to dislodge one or more of said rings in controlled sequence from said support member, each said cord being arranged in slack condition between each pair of adjacent elastic rings.
In another aspect the invention provides an endoscopic ligating apparatus, comprising: a hollow barrel defining a barrel proximal end, a barrel distal end, a hollow interior and an outer surface; at least one elastic ligating band stretched around said barrel outer surface;
and at least one piece of flexible material having a material proximal end and a material distal end, said at least one piece of flexible material extending through said hollow interior, folding over said barrel distal end, and lying between at least a portion of said at least one ligating band and said outer surface; wherein pulling said material proximal end in a proximal direction is operative to pull said material distal end toward said barrel distal end, thereby pulling said at least one ligating band off of said barrel distal end.
In another aspect the invention provides an endoscopic ligating apparatus, comprising: a hollow barrel defining a barrel proximal end, a barrel distal end, a - 6h -hollow interior and an outer surface; at least one elastic ligating band stretched around said barrel outer surface;
and at least one piece of flexible material having a material proximal end and a material distal end, said at least one piece of flexible material extending through said hollow interior, folding over said barrel distal end, and lying between at least a portion of said at least one ligating band and said outer surface; wherein pulling said material proximal end in a proximal direction is operative to pull said at least one ligating band off of said barrel distal end.
In another aspect the invention provides an endoscopic ligating apparatus for use with a flexible endoscope, said endoscope having an endoscope distal end, said endoscopic ligating apparatus comprising: a hollow barrel defining a barrel proximal end, a barrel distal end, a hollow interior having an annular shoulder formed therein, and an outer surface; at least one elastic ligating band stretched around said barrel outer surface; and at least one piece of flexible material having a material proximal end and a material distal end, said at least one piece of flexible material extending through said hollow interior, folding over said barrel distal end, and lying between at least a portion of said at least one ligating band and said outer surface; wherein said hollow interior at said barrel proximal end is sized to mount over said endoscope distal end such that said endoscope distal end abuts said annular shoulder; and wherein pulling said material proximal end in a proximal direction is operative to pull said material distal end toward said barrel distal end, thereby pulling said at least one ligating band off of said barrel distal end.

- 6i -In another aspect the invention provides an endoscopic ligating apparatus, comprising: a hollow barrel defining a barrel proximal end, a barrel distal end, a hollow interior having an annular shoulder formed therein, and an outer surface; at least one elastic ligating band stretched around said barrel outer surface; and at least one piece of flexible material having a material proximal end and a material distal end, said at least one piece of flexible material extending through said hollow interior, folding over said barrel distal end, and lying between at least a portion of said at least one ligating band and said outer surface; wherein said hollow interior at said barrel proximal end is sized to mount over said endoscope distal end such that said endoscope distal end abuts said annular shoulder; and wherein pulling said material proximal end in a proximal direction is operative to pull said at least one ligating band off of said barrel distal end.
In another aspect the invention provides an endoscopic ligating apparatus, comprising: a support member defining a support member proximal end, a support member distal end, a hollow interior and an outer surface; at least one elastic ligating band stretched around said support member outer surface; and at least one piece of flexible material having a material proximal end and a material distal end, said at least one piece of flexible material lying between at least a portion of said at least one ligating band and said outer surface, wherein pulling said material proximal end in a proximal direction is operative to pull said at least one ligating band distally off of said support member distal end.
In another aspect the invention provides an endoscopic ligating apparatus for use with a flexible endoscope having an endoscope distal end, said endoscopic - 6j -ligating apparatus comprising: a support member defining a support member proximal end, a support member distal end, a hollow interior, and an outer surface; at least one elastic ligating band stretched around said support member outer surface; and at least one piece of flexible material having a material proximal end and a material distal end, said at least one piece of flexible material lying between at least a portion of said at least one ligating band and said outer surface; wherein said support member proximal end is adapted to contact a portion of said endoscope distal end; and wherein pulling said at least one piece of flexible material is operative to pull said at least one ligating band distally off of said support member distal end.

~~~~~7~

-FIG. 1 is a longitudinal view, partly in section of an endoscopic ligating instrument representing a preferred embodiment of the invention;
FIG. 2 is a frontal plan view of the insertion end of the endoscopic Iigating instrument of FIG. 1;
FIG. 3 is a section view through the end portion of the instrument as taken along the section line 3-3 in FIG. 2;
FIG. 4 is a fragmentary view in crass-section showing details of the end portion of the flexible actuating cable at its connection with a planetary gear in a tubular member in an assembly of tubular members affixed to the insertion end of the endoscope;
FIG. 5 is a section view through the insertion end of the endoscope as taken along the section line 5-S in FIG. 3;
FIG. 6 is an exploded view of a tubular assembly which is affixed to the insertion end of the endoscope;
FIG. 7 is a fragmentary view, partly in section, showing the insertion end of the instrument of the invention applied z0 to a lesion with lesion tissue drawn by suction into an inner tubular member on tile end of the instrument;
FIG. 8 is a view similar to FIG. 7, but showing an elastic ligating ring applied about a lesion after its dislodgement front he end of the endoscopic instrument of tire invention;
FIG. 9 shows a lesion with an elastic ligating ring applied in strangulating relationship hereto;
FIG. 10 is a block plan view showing an endoscopic instrument as shown in FIG. 1 which is provided with a stem-motor for selectively and automatically controlling the rotation of the flexible cable;
FIG. 11 is a fragmentary view in longitudinal cross-section of a modified form of tubular assembly which is connectable to the insertion end of the endoscope of the 2I~~4"~~
W0 95134244 PCTlU59SI(113Q5 _ g _ invention;
FIG. 12 is a sectional view as taken along tire section line 12-12 in FIG. 11;
FIG. 13 is an enlarged fragmentary view of the tubular assembly of FIG. 11 which shows the nature and direction of the relative mavement which is imposed between the paired tubular member of the assembly for effecting the discharge of an elastic ligatiny ring;
FIG. 14 is a view similar to FIG. 13 but showing a modified form of ribbing which is provided on the exterior of a textile member of the tubular assembly of FIG. 11; acrd FIG. 15 is a plan view of an embodiment of tire invention as illustrated in FIGS. 11 - 14.
FIG. 16 is a perspective fragmentary view of a further iS embodiment of the invention showing tyre insertion end of an endascope with elastic rings displaceably mounted on a rigid tube affixed thereto;
FIG. 17 is a (rant view of the apparatus attached to the insertion end of the endascape of F'IG. 16;
FIG. 18 is a longitudinal sectional view of the endascope apparatus as taken along the section line 18-18 in FIG. 17 showing the arrarrgement of elastic rings on the rigid tube connected to the end of the endoscope;
FIG. 19 is an enlarged fragmentary view showing the distal end of the tubular member fitted to the end of the endoscoge in FIG. 16; and FIG. 20 is a longitudinal sectional view similar to FIG.
18 but showing a suctioned lesion ligated by an elastic ring which has been dislodged from tire tube.

21~~47~.
W095l34244 PCTIUS95/01305 _ g _ DETAlI~ED DESCRIPTION OF T1IE INVENTION
Referring more particularly to the drawings, there is skrown in FIG. 1 a flexible endoscopic instrument 10 of a length which permits access to the deeper regions of a hollow body organ, such as the alimentary tract. The instrument 10 comprises a conventional endoscope with an operating controls section 11 of rigid construction and a flexible section 12 which extends therefrom and is a length sufficient to reach the deeper regions of the alimentary tract. The distal end of the flexible section 12 is the insertion end 13 of the endoscope and the viewing end 14 of the endoscope is at the end of the rigid operating controls section 11 remote from the end thereof which connects to the flexible section 12.
Tkre endoscope is provided with passages 16-21 which extend longitudinally therein from its insertion end 13 to exit ports near the viewing end o~ the endoscope. The passages comprise an illumination channel 16 through which is inserted a fiber optic cable for the transmission of light from a light source, a viewing channel 17 which is also provided witlx a fiber optic cable for viewing purposes, and a channel through which objects may be passed or suction applied 18. The illumination channel and suction channel exit laterally through a lateral extension 22 of the side wall of the endoscope at a location on the operating controls section 11 near the viewing end 14. At their exit location, the fiber optic cable from channel 16 and the channel 18 are connectable through an umbilical cable 23 to a control device (not shown) which is adaptable for supplying illumination to the transmission optic cable and for connecting the channel 18 to an appropriate means for applying a suction therethrough. The fiber optic viewing channel 17 extends to the viewing end 14 of tare endoscope which may Le provided with a viewing lens acrd an adapter for mounting a camera thereon, if desired.

WO 9513d244 ~ ~ ~ PCIYU995/1)1305 ~, Tire endoscope is also provided with a working channel 19 which extends through the endascope from its insertion end il to an exit in the lateral extension 22. The working channel 19 includes a branch 19a which extends tlxrough an angularl.y extending protuberance 24 to a second exit near the viewing end of the endoscope.
Additional channels 20 and 21, shown in FIG. 2, may be utilized for delivering pressurized air or a jet stream of water for cleaning the lens.
In the embodirnent of lire invention shown in FIGS. 1-6, tire insertion end of the endoscope is fitted with an assembly of caaxially arranged tubes 25, 26, the outer tube 26 of which is secured in coaxial relation thereto preferably by a tubular adapter 27 which provides a friction fit as shown in FIG. 3 although ether fastening means such as a threaded connection might be suitaLly employed. Ttre tube 26 is preferably of transparent plastic material for enhancing the illumination and field of vision from the insertion end of the endascope, although ether inert material might also be suitable including stainless steel. The tube Z6 is provided at .its attaching end with an external frusta-conical bevel surface 28 to facilitate the placement of the tubular adapter 27 thereover. The adapter 27 is preferably of a flexible material such as plastic and is provided with an internal diameter which allows it to be sleeved tightly over the tube 26. For further enhancing the connection, the adapter 27 is provided with an internal annular flange 31 which is adapted to seat in an accanunodatirrg annular groove 32 from externally about ttte surface of the tube 26, thereby locking the adaptez 27 to the tube 26.
At its other end, the inner wall of the adapter 27 is formed with a succession of outwardly diverging frusto-comical grooved surfaces 34 which provide teeth-like edges for enhancing its grip an the endoscope when sleeved aver the end thereof. In addition, it is provided with am zm~~~~.

internal annular latching flange 36 which is adapted to seat in a latching groove 37 formed about the exterior of the endoscope.
The inner wall of outer tube 26 is formed with a helical groove 40 which extends from its distal end for the greater part of its length. Near its attaching end, the inner wall of auger tube 26 is formed with an internal annular flange 41.
The inner tubular member 25 has a forward end 42 and a rearward end 43 and comprises a first elongate section 94 and au adjoining shorter section 45 of circular cylinder configuration and larger radial dimensions. The tubular member 25 has au external annular shoulder 46 formed at tire junction of the elongate LuLular section 49 with the larger diameter section 45. The tubular member 25 is also provided an internal annular radial shoulder 47, which is formed at the junction of the bare of section 45 with the smaller bore of the elongate section 94.
The elongate section 44 has a radial cross section in the configuration of a segmented circle and an external cylindrical surface characterized by an elongate planar surface section 48 which extends from the forward end 92 of the tubular member 25 to the radial shoulder 46.
The inner tubular member 25 serves as a carrier for a plurality of elastic ligating rings 50 which are placed in stretched condition about the elongate section 44 and mounted thereon in side-by-side relation to one another and in sleeved relation to the section 44. The elastic rings 50 are typically of rubber material or an inert non-toxic plastic composition.
The tubular member 25 is also provided with a circular planetary gear 52 which is seated in tire bore of the circular section 45 in the coaxial reaction therewith. The gear 52 may be fabricated as an integral part of tire tubular member 25 or it could be separately formed and bonded to the radial shoulder 47 and the inner cylindrical wall of circular ~~~N~~~
WO 95I342d4 PCTIU595I01305 section 45 by an appropriate adhesive although other fastening means could also be used. An opening 49 is also provided in the radial shoulder 47 to insure full cannnunication of the interiors of the tubular members 25 and 26 with the suction channel 18.
When completely assembled as shown in FIG. 3, the gear teeth of planetary gear S2 are in meshing engagement with a drive gear 53 which is mounted by a connecting adapter 54 orr tire encl of a flexible steel cable 55, preferably a single wire, which is inserted through the working channel 19 0~ tyre endascope. The cable 55 extends through the working channel.
section 19a where it is fitted with a rotary control means such as knob 56 for manually effecting axial rotation of the cable 55.
The adapter 54 comprises a shaft 57 enlarged at one end which is provided with a socket 58 characterized by a socket cavity of rectangular transverse crass-section which receives the squared end of the cable 55. At its other end, the shaft 57 is journaled far rotation on a transverse support 60 2p fitted internally of tube 25. The shaft 57 is also fitted with a drive gear 53 which is fixed an the shaft 57 in coaxial relation thereto by a press fit or any suitable banding means. Also sleeved about the shaft 57 is a plastic spacer 59 which is in abutting engagement with the drive gear 53 and one end of the socket 58.
Also shown in FIG. 3, a retaining ring 61 is also fitted into the end of the inner tubular member 25 in coaxial relation therewith and in abutting engagement with both the rearward end of the tubular member 25 and the planetary gear 52. The retaining ring 61 is provided in its outer surface with a circumferential groove 62 which receives the arrnular flarrqe 91 of the tubular member 25 and latches the retaining rrnq 61 in position.
In assembly of the instrument 10 of the elastic ligatinq rings 50 must be placed onto the inner tubular member 25 R'Q 95/34244 PC7YUS95d01305 before it is inserted in the outer tubular member 26. This is also done before the tubular members 25, 26 are fitted onto the endoscope. The elastic ligating rings 50, when in the relaxed state are of a diameter less than that of the insertion end of tire endoscope, which for representative endoscopes, is in the range of approximately 9nrm to l3mm.
The rings 50 are placed in stretched condition onto the elongate section 44 of the tubular member 25 in side-by-side relation to one another and in sleeved relation to the section 44. The tubular member 25 is then inserted with an axially twisting motion Lhrough the attaching end of the outer tubular member 26 whereby each elastic ring, except for the portion thereof which rests atog the planar surface of the inner tubular member 25, is placed in a coil of the helical groove 40 in spaced relation to the adjacent elastic ring in the next adjacent coil of the helical groove.
Tfxe tubular assembly, comprising tubular member 25 and 26 w hat tubular adapter 27 secured to tire member 26, is then sleeved onto the insertion end of the endoscope such that the planetary gear 52 and drive gear 53 are in meshed driving engagement with one another and the attaching end of the tubular member 26 abuts the insertion end of the endoscope.
When treating a patient, the endoscopic instrument of the invention is first inserted into the affected organ, such as the alimentary tract, to place the insertion end of the endoscope in the vicinity of lesions in the alimentary tract. In some instances, however, it may be preferred that insertion of.the instrument be preceded by the insertion of an endoscopic overtube (not shown) into the alimentary tract and the instrument then be inserted through the overtube. In either case, the instrument is then oriented for sighting of a target lesion, such as lesion 77 shown in F1G. 7, and the instrument advanced under the control of a human operator until the distal end of the tubular member 25 contacts the lesion area and is placed in surrounding relation to the target lesion.

A suction force is then applied #~Hrough the suction channel 18 to completely draw tkae lesion tissue into the inner tubular member 25 as shown 'in FIG. 7. The operator then manually initiates axial rotation of tire cable 55 and the inner tubular member 25 in the spirally forward direction of the helical groove 40 whereby the elastic rings 50 are driven alone the surface of the tubular member 25 by the walls of the helical groove 40 until one of the elastic rings is dislodged from the instrument and placed in ligating relation about the base of the target lesion as shown in FIG.
8. fhe end of tire instrument lU is then withdrawn from around the lesion tissue, as shown in FTG. 9.
It is to be appreciated that by continuing the axial rotation of the tubular rnenrber 25, more of the elastic ring.>
can be dislodged from the instrument. Accordingly, the enc7ascopic instrument of the invention permits the successive ligation of multiple lesions during a single insertion of the instrument. With patients who are not bleeding, the ligation treatment is started at the most distal point in the alimentary tract and then continued proximally so that elastic bands which are placed about the lesion tissue are not disturbed by movement of the instrument. The instrument therefore facilitates the treatment of multiple lesions and alleviates the need for repeated removal and reinsertion of the instrument and reloading of an elastic ring for treating each lesion.
In sarne instances, particularly where vision is obscured, the instrument operator may have difficulty in ascertaininc, the precise amount of rotation of the flexible cable 55 drat is necessary for dislodging one and only one elastic ring 5U
when ligating a single target lesion. In thi.> respect, a rnod.ifi.ed form of the invention, which enables the axial rotation of the cable 55 in steps of precise amounts, is represented by the endascopic instrument 7U as shown in schematic form in FIG. 10. The instrument 70 is identical in ~ 2~~~~~~~.

all respects to the instrument 10 except for the means of imparting axial rotation to tire flexible cable 55 and identical components axe identically numbered. In lieu of a knob 56 which enables the manual rotation of the cable 55, the instrument 70 is provided with automatic means represented by a stepping motor 72 and a controller 74 for rotation of the caLle 55 in precisely controlled amounts.
The controller 74 and motor 72 are connected to receive power from an electrical Bower source 76. A foot pedal trigger switch 75 is used by the operator to energize the stepping motor 72 for a precise time interval during which time the flexible cable 55 is axially rotated by an amount which moves the elastic rings a precise distance along the tubular member 25 such that the most distal elastic ring 50 is forced off tire end of the tubular member 25 and the remaining ring 50 is forced off the end of the tubular member 25 and the remaining rings 50 are retained thereon. In effect, the precise time interval of motor operation moves tl~e elastic rings a distance which corresponds to the distance between adjacent coils of the helical groove 40.
It is to be appreciated therefore that the endoscopic instrument 70 provides tire operator with means for precisely controlling when an elastic ring 50 is dislodged from the instrument and for insuring that only one elastic ring is dislodge when ligating a target lesion. It is therefore possible for the operator to dislodged additional elastic rings in sequence and at times controlled by the operator so that multiple lesions can be ligated during a single insertion of the instrument.
A further embodiment of the invention represented by the endoscopic instrument 80 is disclosed in FIGS. 11-15. T'he endoscopic instrument 80 differs from the instruments 10 and 70 in the nature and operation of the tubular assembly which is affixed to the insertion end of the endoscope, but is otherwise identical thereto. As drown in FIG. 11, a rigid WO 95/3d2d4 PCTJ0895/01305 tube B1 is fixed in coaxial-relation to the insertion end of the endoscope, preferably by a sleeve adapter 82. A tubular textile member 83 of an inelastic material, such as tkm commercial product Kevlar or other inelastic flexible material, is mounted onto the rigid tube 81 such that the member 83 is folded over the distal end of the tube 81 with a first portion 83a thereof being sleeved over the tube 81 and a second portion 83b thereof diseased internally of the tube 81 and substantially coaxial thereto.
As shown in FIG. 11, a plurality of elastic liyating rings 50a are placed in stretched condition in encircling relation about tire portion 83a of the tubular member 83. The textile material of portion 83a is provided with an external surface having a plurality of annular ridge.~> 84 in the encircling relation thereto and preferably arranged in pairs which define a plurality of uniformly spaced annular recesses or grooves 85, each of which is adapted to receive an elastic ring 50a therein. The elastic rings 50a are therefore maintained in uniform side-by-side spacing on the tubular portion 83a.
The end of the second portion 83b of tire textile tubular member 83 is fitted with a rigid annular ring clamping assembly 86 to wlriclr the textile fabric of the tubular member 83 is attached. Tlre clamping assembly 86 comprises an outer retaining ring 86a and an inner clamping ring 86b which is of a smaller external diameter than the internal diameter of the outer ring 86a and is insertable therein from the distal end of the tube 81 to clamp tire portion 83b of the textile tubular member 83 tlrerebetween. Freferably, the inner wall of the outer ring 86a is formed with an annular coaxial groove 87 and the outer wall of the inner ring 86b is farmed with arr annular ridge 88 of conforming configuration and location such as to serve in retaining the textile member 83 therebetween. The outer ring 86a is also provided with at least three centering protuberances 90 which are in uniform 2iJ~:i7l WO 95/34244 PCTlCTS95l01305 angular spacing and serve to maintain the ring 86a in coaxial relation to the tube 81 and in a tight friction fit therein.
As best seen in FIG. 11, the adapl:er 82 is sleeved over an annular bevel surface 89 an the attaching end of tire tube 81 and is provided with an internal annular flange 91 which latches in an annular groove 92 formed about the external surface of the rigid tube 81. At its other end, the adapter is designed for a press fit connection with tire insertion end of the endascope as provided for the adapter 27 in the embodiment of FIG. 1 or could be provided with threads, if desired.
A flexible cable 55a, similar to the cable 55 shown in the embodiment of FIG. 1, and similarly threaded through the working channel of the endoscope is attached to an internal flange 93 on the inner wall of the clamping ring 86b. As best seen in FIGS. 11 and 12, one end of the cable SSa is placed in an axial blind bore formed inwardly from one end of a sleeve member 94 which is swayed in engagement therewith.
The sleeve member 94 which is externally threaded at its other end, is inserted through an opening in the flange 93 and secured by a nut 95 on its threaded end. It is thus to be seen that by a pull on the cable 55a to the right as drown in FIG. 11, the portion 83b of textile tubular member 83 which is interior of the rigid tube 81 is increased and the Portion 83a which is exterior of tlxe tube 81 is decreased.
The relative movement of tkre flexible tube 83 with respect to the rigid tube 81 is illustrated by arrows in FIG
13 which show the textile tubular member 83 sliding over tire distal end of the tube 81. As this movement increases, the most distal of the elastic ligating rings SOa passes over the distal end of the tube 81 and is discharged therefrom. When the assembly of tubes 81, 83 are placed in surrounding relation to a target lesion, arid lesion tissue is drawn into the tube 83 by suction in a manner as previously described, it is to be appreciated that ligation of a lesion as shown in W() 95134244 ~ ~ ~ ~, d~ ~ i PCTlI1S95101305 FTG. 9 can be readily achieved.
It is important that only a single 'ligatiug ring 50a be discharged from the instrument SO for treating each lesion and the nravement of tire cable 50a must be determined accordingly. AFter treating one lesion, the instrument can be reoriented in surrounding relation to another lesion and the procedure repeated. Accordingly, multiple lesions can be ligated during a single insertion of the instrument. For most applications, tare instrument should be provided with at i0 least six elastic rings 50a.
In FIG. 15, the cable 55a is shown attached to a reel 96 whereby an indexed rotati.an thereof is designed to move the cable 55a a predetermined distance to cause the discharge of only a single ligating ring 50a. Obviously, the movement i'~ could be controlled manually or other techniques employed for controlling a precise axial movement of the cable 55a.
A variation in the arrangement of ridges 84 on the external surface of the textile tubular member 83 is shown in FIG. 14. Ln this modified form of the member 83, only a 20 single ridge 84 is used for aligning the elastic rings 50a in uniform spacing on the member 83. The rings 50a are installed whereby each is in abutting engagement with the side of a ridge 84 which faces toward the distal end of the tubular assembly so as to prevent their being moved or 25 disturbed as the instrument is inserted into a body organ.
It is to ire noted that in the embodiment of tire invention disclosed in FIGS. 11-15, the force required to pull tire sleeve member 83 over tire distal end of the tube 81 increases proportionately with the number of elastic rings, such that a 30 strong and sturdy construction must be used for tire parts mounted an the insertion end of the endosco!>e and the camponerrl parla for imparting sliding movement between the sleeve 83 and the tube 81 and for a precise amount of sliding to ensure that only one ring is dislodged at a time. Tlxe 35 force to dislodge the first ring, which must be strong enough to pull the sleeve and all the elastic rings towards the distal end of the tube, is considerably greater than the force required to dislodge the last remaining elastic ring from the tube.
A third embodiment of the invention represented by the endoscopic instrument 100 disclosed in FIGS. 16-19 requires a pulling force to dislodge an elastic ring which is comparable to that required for dislodging the last ring of the sleeve version disLlosed in FIGS. 11-15. As best seen in FIG. 16, a transparent rigid tube 101 is fitted to the insertion,end of the endoscope 1(10 by an adapter section 102 which provides a friction fit with the insertion end of the endoscope. The endoscope 100 is provided with a plurality of flexible and substantially in elastic cords 103, each of which is folded over the distal end of the tube 101 and includes a first portion which is laid over the exterior surface of the tube and a second portion wliicli is disposed internally of the tube. The ends of the cords 103 inside the tube are fastened to one end of a flexible line 105 as by tying thereto or the use of an adapter connector 106. From its connection with cords 103, the flexible line 105 is threaded through the working channel 19 of the endoscope and exits near the rearward end of the endoscope such that the exiting end portion of the line 105 may be fitted with a handle.
As best seen in FIG. 17, the cords 103 are disposed iii preferably uniform angular spacing about the longitudinal axis 107 of the tube 101. A plurality of elastic ligating rings 50 are. each placed in stretched condition in sleeved relationship aUout llie tube 101 and in overlying relation to the plurality of cord) 103 to thereby hold the cords against the Lube 101.
It is to be noted in FIGS. 16, 18 and ZO that the rings 50 are spaced from one another in the longitudinal direction of the tubular member at successingly greater distances from the distal end 108. Each cord 103 is also provided with a W095I3.a244 PCfIUS9SI013(K y series of longitudinally spaced knots 109 against each of which an elastic ring 5U is placed on the forward side of the knot. A means For imparting sliding motion between said cords and the tubular member is provided by the flexible line element 105 by which becau.~~>e of its connection to the ends of the words 103 wiLliin the tubular member 101, a pulling force may be exerted at its outer end to cause sliding movement between the cords and the tubular member so as to dislodge each of the elastic rings in desirably controlled sequence.
When the pull is applied, a knot 109 acts as a shoulder which precludes relative movement between tire elastic ring and the cord until the ring is dislodged at the distal end of the tubular mernber.
As is best shown in F'IG. lfi, each cord 103 incluQes a segment of cord between each pair of adjacent elastic rings which his in slack condition and of a length which is equal to the distance between said pair plus the distance from the distal end of the tube 101 to the ring of the pair which is nearest the distal end 108. it will therefore be seen that when the cords are pulled a distance vahich moves the forward ring of the pair to the distal end of the tube and oLF tlue tube, the slack length of cord suffices to preclude any movement of the remaining elastic rings. It is therefore to be noted that tire required pulling force to dislodge a ring 29 is that which is necessary to move a single ring and the required force does not increase as additional rings are dislodged.
AFter the cords 103 and elastic rings 50 have been loaded on the rigid tube 101 and positioned thereon as shown in F7:G.
16 and 18, it may be a desirable option to place a flexible sleeve of plastic ar a textile material to fit loosely over tlae cords 103 and the tube 101. Such a sleeve, when attacired at one end to the flexible section I2 of the endoscope and extending over the cords 103 and elastic rings 50 to approximately tire distal end of the tube 101, would serve to W095l34244 ~ PC'fIUS95l01305 protect against "snagging" of the slack segments or loop of cords between the rings when the endoscope is in use or prepared for use.
It is to be understood that the foregoing descriptions of a preferred embodiment of tile invention has been presented for purposes of illustration and explanation and are not intended to limit flue invention to the precise forms disclosed. For example, a motor control could be provided for controlling the movement of the cable 55a in precise steps. Also, the number of elastic ligating rings 50 or 5Da could be greater or less than those illustrated herein. In some instances the rings 50a can be aligned on the textile tubular member 83 without ridges 89. It is to be appreciated therefore, tlnat various rnaterial and structural changes may be made by those skilled in the art without departing from the spirit of the invention.

Claims (19)

CLAIMS:

1. A flexible endoscopic instrument for ligating a multiplicity of lesions within a hollow body organ, such as the alimentary tract, said instrument comprising:
(a) a flexible fiber optic endoscope having a forward insertion end and a rearward end, said endoscope including means for illumination and viewing though said endoscope, means for providing a suction force at said insertion end, and a working channel;
(b) a tubular member having a forward distal end, a rearward end and a longitudinal axis, said rearward end having means for providing attachment to the insertion end of the endoscope;
(c) a plurality of string-like cords of flexible substantially inelastic material, each said cord being folded over the distal end of the tubular member with a first portion of each said cord overlaying a part of the exterior of said tubular member and a second portion thereof being disposed internally of said tubular member, said cords being oriented in angular spacing about the longitudinal axis of said tubular member;
(d) a plurality of elastic ligating rings removably mounted in stretched condition on said tubular member in coaxial relation thereto and in overlying relation to said cords, said rings being spaced from one another in the longitudinal direction of the tubular member at successively greater different distances from the distal end of the tubular member; and (e) means for imparting relative sliding motion between said cords and said tubular member to dislodge each of the elastic rings in controlled sequence during a single insertion of the endoscope into the body organ whereby each of the elastic rings can be dislodged from the endoscope and placed in ligating relation to a lesion when lesion tissue is drawn info the tubular member by said suction means with each ring being applied to a different one of multiple lesions present in the body organ, said means comprising a flexible line element threaded through the working channel of the endoscope and connecting at one end to said cords disposed within said tubular member and exiting the endoscope at the rearward end thereof whereby a pulling force may be exerted on the other end of the line element to cause sliding movement of the cords over said tubular member, each said cord being arranged in slack condition between each pair of adjacent elastic rings.

2. A flexible endoscopic instrument as set forth in claim 1 wherein the elastic rings are placed on said tubular member such that the length of each cord between each pair of adjacent elastic rings is at least equal to the distance between the distal end of the tubular member and the furthest ring of said pair from said distal end.

3. An endoscopic ligating instrument as set forth in claim 2 wherein each said cord on the portion thereof which overlies said rigid tubular member includes a series of radially extending shoulders at spaced intervals and against each of which a different one of said elastic rings is placed in abutting engagement and facing the distal end of said rigid tubular member and wherein each of said shoulders of a cord is in substantially co-planar relationship with a shoulder of each of the other cords.

4. An endoscopic ligating instrument as set forth in claim 2 wherein each said cord on the portion thereof which overlies said rigid tubular member includes a series of knots at spaced intervals and against each of which a different one of said elastic rings is placed in abutting engagement and facing the distal end of said rigid tubular member and wherein each of said knots of a cord is in substantially co-planar relationship with a knot of each of the other of said cords.

5. A flexible endoscopic instrument for ligating a multiplicity of lesions within a hollow body organ, such as the alimentary tract, said instrument comprising:
(a) a flexible fiber optic endoscope having a forward insertion end and a rearward end, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion end, and a working channel;
(b) a tubular member having a forward distal end, a rearward end and a longitudinal axis, said rearward end having means for providing attachment to the insertion end of the endoscope;
(c) a plurality of string-like cords of flexible substantially inelastic material, each said cord being folded over the distal end of the tubular member with a first portion of each said cord overlaying a part of the exterior of said tubular member and a second portion thereof being disposed internally of said tubular member, said cords being oriented in angular spacing about the longitudinal axis of said tubular member;
(d) a plurality of elastic ligating rings removably mounted in stretched condition on said tubular member in coaxial relation thereto and in overlying relation to said cords, said rings being spaced from one another in the longitudinal direction of the tubular member and between at least one pair of adjacent elastic rings each of said cords having a slack segment of cord of a length which is at least equal to the distance between the distal end of the tubular member and the ring of said pair which is furthest from said distal end; and (e} means for imparting relative sliding motion between said cords and said tubular member to dislodge each of the elastic rings in controlled sequence during a single insertion of the endoscope into the body organ whereby each of the elastic rings can be dislodged from the endoscope and placed in ligating relation to a lesion when lesion tissue is drawn into the tubular member by said suction means with each ring being applied to a different one of multiple lesions present in the body organ, said means comprising a flexible line element threaded through the working channel of the endoscope and connecting at one end to said cords disposed within said tubular member and exiling the endoscope at the rearward end thereof whereby a pulling force may be exerted on the other end of the line element to cause sliding movement of the cords over said tubular member, each said cord being arranged in slack condition between each pair of adjacent elastic rings.

6. An endoscopic ligating instrument as set forth in claim 5 wherein said cord on the portion thereof which overlies said rigid tubular member includes a series of shoulders at spaced intervals and against each of which a different one of said elastic rings is placed in abutting engagement and facing the distal end of said rigid tubular member and wherein each of said shoulders of a cord is in substantially co-planar relationship with a shoulder of each of the other cords.

7. An endoscopic ligating instrument as set forth in claim 5 wherein each said cord on the portion thereof which overlies said rigid tubular member includes a series of knots at spaced intervals and against each of which a different one of said elastic rings is placed in abutting engagement and facing the distal end of said rigid tubular member and wherein each of said knots of a cord is in substantially co-planar relationship with a knot of each of the other of said cords.

8. A flexible endoscopic instrument for multiple ligation, said instrument comprising:
(a) a flexible endoscope having a forward insertion portion, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion portion, and a working channel;
(b) a hollow support member having a forward distal end and a rearward portion, said rearward portion being connectable to the insertion portion of the endoscope;
(c) at least two string-like cords of flexible substantially inelastic material, each of said cords having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and (d) a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in overlying contacting relation to each of said cords, said rings being spaced from one another along said support member at successively greater different distances from said distal end of said support member;
wherein a pulling force may be exerted on each of said cords to cause movement of each of said cords relative to said support member to dislodge one or more of said rings in controlled sequence from said support member, each of said cords being arranged in slack condition between each pair of adjacent elastic rings.

9. The apparatus of claim 8, further comprising a flexible line element extending into the working channel of the endoscope and connecting to each of said cords for transmitting pulling force to each said cord.

10. Use of a ligation apparatus for ligating tissue, said ligation apparatus including:
a hollow support member having a forward distal end and a rearward portion;
at least two string-like cords of flexible substantially inelastic material, each of said cords having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in overlying contacting relation to each of said cords, each of said cords being arranged in slack condition between each pair of adjacent elastic rings, wherein:
said rearward portion of said support member is capable of connection to a forward insertion end of an endoscope;
said forward end of said support member is capable of insertion into a body organ and placement adjacent tissue to be ligated;
said ligation apparatus is capable of drawing tissue within said support member; and said ligation apparatus is capable of dislodging one of said rings from said support member to ligate tissue drawn within said support member upon exertion of a pulling force on each of said cords.

11. The use of claim 10, wherein said ligation apparatus is capable of sequentially dislodging a plurality of said rings from said support member to ligate a plurality of tissues successively drawn within said support member, upon successive exertions of a pulling force on each of said cords.

12. A flexible endoscopic instrument for multiple ligation, said instrument comprising:
(a) a flexible endoscope having a forward insertion portion, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion portion, and a working channel;
(b) a hollow support member having a forward distal end and a rearward portion, said rearward portion being connectable to the insertion portion of the endoscope;
(c) at least two string-like cords of flexible substantially inelastic material, each of said cords having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and (d) a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in contacting relation to each of said cords, said rings being spaced from one another along said support member at successively greater different distances from said distal end of said support member;
wherein a pulling force may be exerted on each of said cords to cause movement of each of said cords relative to said support member to dislodge one or more of said rings in controlled sequence from said support member, each of said cords being arranged in slack condition between each pair of adjacent elastic rings.

13. The apparatus of claim 12, further comprising a flexible line element extending into the working channel of the endoscope and connecting to each of said cords for transmitting pulling force to each of said cords.

14. A flexible endoscopic instrument for multiple ligation, said instrument comprising:
(a) a flexible endoscope having a forward insertion portion, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion portion, and a working channel;
(b) a hollow support member having a forward distal end and a rearward portion, said rearward portion being connectable to the insertion portion of the endoscope;
(c) at least one string-like cord of flexible substantially inelastic material, each said cord having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and (d) a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in overlying contacting relation to each said cord, said rings being spaced from one another along said support member at successively greater different distances from said distal end of said support member;

wherein a pulling force may be exerted on each said cord to cause movement of each said cord relative to said support member to dislodge one or more of said rings in controlled sequence from said support member, each said cord being arranged in slack condition between each pair of adjacent elastic rings.

15. The apparatus of claim 14, further comprising a flexible line element extending into the working channel of the endoscope and connecting to each said cord for transmitting pulling force to each said cord.

16. Use of a ligation apparatus for ligating tissue, said ligation apparatus including:
a hollow support member having a forward distal end and a rearward portion;
at least one string-like cord of flexible substantially inelastic material, each said cord having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in overlying contacting relation to each said cord, each said cord being arranged in slack condition between each pair of adjacent elastic rings, wherein:
said rearward portion of said support member is capable of connection to a forward insertion end of an endoscope;

said forward end of said support member is capable of insertion into a body organ and placement adjacent tissue to be ligated;
said ligation apparatus is capable of drawing tissue adjacent to said forward end, within said support member: and said ligation apparatus is capable of dislodging one of said rings from said support member to ligate tissue drawn within said support member upon exertion of a pulling force on each said cord.

17. The use of claim 16, wherein said ligation apparatus is capable of sequentially dislodging a plurality of said rings from said support member to ligate a plurality of tissues successively drawn within said support member, upon successive exertions of a pulling force on each said cord.

18. A flexible endoscopic instrument for multiple ligation, said instrument comprising:
(a) a flexible endoscope having a forward insertion portion, said endoscope including means for illumination and viewing through said endoscope, means for providing a suction force at said insertion portion, and a working channel;
(b) a hollow support member having a forward distal end and a rearward portion, said rearward portion being connectable to the insertion portion of the endoscope;
(c) at least one string-like cord of flexible substantially inelastic material, each said cord having a first portion overlaying a part of the exterior of said support member and a second portion disposed internally of said support member; and (d) a plurality of elastic ligating rings removably mounted in stretched condition on said support member and each of said rings being in contacting relation to each said cord, said rings being spaced from one another along said support member at successively greater different distances from said distal end of said support member;
wherein a pulling force may be exerted on each said cord to cause movement of each said cord relative to said support member to dislodge one or more of said rings in controlled sequence from said support member, each said cord being arranged in slack condition between each pair of adjacent elastic rings.

19. The apparatus of claim 18, further comprising a flexible line element extending into the working channel of the endoscope and connecting to each said cord for transmitting pulling force to each said cord.