Methods for performing anastomosis

Abstract

Methods of performing an anastomosis. A ring is installed at an incision or other orifice in a vessel or other organ, for use in performing an anastomosis. To install the ring, tines are advanced against an anvil to cause them to grab tissue around the orifice and curl radially. The anvil is then retracted to fold the tines so their curled ends move radially outward. A sleeve may be advanced to fold or bend the tines as their curled ends move further radially outward. The folding, curling, and further bending of the tines evert tissue near the orifice edges to expose the vessel's or organs' intima.

1 . A ring for use in preparing a first organ having an orifice for anastomosis with a second organ, said ring comprising: 
 a ring portion sized to extend around the orifice; and    malleable tines extending out from the ring portion, wherein the tines are movable relative to the ring portion from an initial configuration into a final configuration in which the tines can hold tissue of the first organ around the orifice in an everted state, the tines are configured to grab and evert the tissue as they move from the initial configuration to the final configuration, each of the tines has a free distal end and a weak portion between the ring portion and the free distal end, and said each of the tines preferentially folds at the weak portion in response to being subjected to bending force.    
   
   
       2 . The ring of  claim 1 , wherein said each of the tines has two opposed major faces and a flat cross-section.  
   
   
       3 . The ring of  claim 2 , wherein the weak portion is a section of said each of the tines through which at least one hole extends from one of the faces to another of said faces.  
   
   
       4 . The ring of  claim 2 , wherein the weak portion is a section of said each of the tines at which notches extend into said faces.  
   
   
       5 . The ring of  claim 1 , wherein the ring portion is a tubular ring portion having a top edge and a bottom edge, and said ring also includes: 
 at least one fastener element extending out from the ring portion.    
   
   
       6 . The ring of  claim 5 , wherein the fastener element is a malleable tab that extends upward from the top edge of the tubular ring portion.  
   
   
       7 . The ring of  claim 6 , wherein the tab has a weak portion at the top edge of the tubular ring portion.  
   
   
       8 . The ring of  claim 7 , wherein the weak portion of the tab is a notched section of the tab.  
   
   
       9 . The ring of  claim 7 , wherein the weak portion of the tab is a section of the tab through which at least one hole extends.  
   
   
       10 . The ring of  claim 5 , wherein the fastener element is a slotted tab having a proximal end extending out from the ring portion, and a distal end defining a slot.  
   
   
       11 . The ring of  claim 5 , wherein the fastener element is a spring element which extends radially outward from one of the top edge and the bottom edge of the ring portion.  
   
   
       12 . The ring of  claim 11 , wherein the fastener element is a tab having a body which extends radially outward from the top edge of the ring portion and a flange which extends circumferentially outward from the body.  
   
   
       13 . The ring of  claim 11 , wherein the fastener element is a generally U-shaped spring fastener comprising: 
 a body which extends out at an acute angle from the bottom edge of the ring portion; and    two tabs which extend out from the body at an obtuse angle.    
   
   
       14 . The ring of  claim 5 , wherein the fastener element is a tab element having: 
 a generally flat body which extends generally vertically from one of the top edge and the bottom edge of the ring portion; and    malleable wings which extend out from the body, wherein the wings are preformed in a compact configuration in which they extend generally parallel to each other and generally perpendicular to the body, and wherein the wings are capable of being bent away from each other relative to the body into a locking configuration.    
   
   
       15 . The ring of  claim 5 , wherein the fastener element is a.spring fastener comprising: 
 a spring portion which extends generally vertically from one of the top edge and the bottom edge of the ring portion; and    a body having a generally flat central portion and wings which extend out from the central portion, wherein said central portion extends radially inward from the spring portion at an acute angle relative to said spring portion, and the wings are oriented generally parallel to each other in planes which are at least substantially vertical.    
   
   
       16 . The ring of  claim 5 , wherein the fastener element is a spring element comprising: 
 a spring portion which extends in an at least substantially vertical plane from one of the top edge and the bottom edge of the ring portion; and    a body having a generally flat central portion and two tabs which extend out from the central portion, wherein said central portion extends radially inward from the spring portion at an acute angle relative to said spring portion, and the tabs are oriented generally parallel to each other and at least substantially perpendicular to the spring portion.    
   
   
       17 . The ring of  claim 5 , wherein the fastener element is a tab which extends out from one of the top edge and the bottom edge of the ring portion and has a free distal end portion which extends radially outside of the ring portion.  
   
   
       18 . The ring of  claim 17 , wherein the free distal end portion is oriented in a substantially horizontal plane, the tab includes: 
 a proximal end portion which extends vertically outward from said one of the top edge and the bottom edge of the ring portion; and    a curved middle portion between the proximal end portion and the free distal end portion.    
   
   
       19 . The ring of  claim 5 , wherein the fastener element is a tab comprising: 
 a proximal end which extends out from one of the top edge and the bottom edge of the ring portion;    a free distal end portion which extends radially outside of the ring portion;    a central portion between the proximal end and the free distal portion; and    two wings extending vertically from the central portion, each of the wings having a malleable end portion capable of being bent relative to the central portion into a locking configuration.    
   
   
       20 . The ring of  claim 5 , wherein the fastener element is a malleable tab having a proximal end which extends out from one of the top edge and the bottom edge of the ring portion, and a free distal end which extends vertically beyond the other of said top edge and said bottom edge of the ring portion.  
   
   
       21 . A ring for use in preparing a first organ having an orifice for anastomosis with a second organ, said ring comprising: 
 a ring portion sized to extend around the orifice; and    malleable tines extending out from the ring portion, wherein the tines are movable relative to the ring portion from an initial configuration into a final configuration in which said tines can hold tissue of the first organ around the orifice in an everted state, the tines are configured to grab and evert the tissue as they move from the initial configuration to the final configuration, each of the tines in the final configuration has a proximal portion which extends radially inward away from the ring portion, a distal portion shaped for holding said tissue in said everted state, and a central portion between the proximal portion and the distal portion, and said each of the tines in the final configuration is bent radially outward at said central portion toward the ring portion.    
   
   
       22 . The ring of  claim 21 , wherein the ring portion is a tubular ring portion having a top edge and a bottom edge.  
   
   
       23 . The ring of  claim 22 , also including: 
 at least one fastener element extending out from the ring portion.    
   
   
       24 . The ring of  claim 23 , wherein the fastener element is a spring element which extends radially outward from one of the top edge and the bottom edge of the ring portion.  
   
   
       25 . The ring of  claim 24 , wherein the fastener element is a tab having a body which extends radially outward from the top edge of the ring portion and a flange which extends circumferentially outward from body.  
   
   
       26 . The ring of  claim 24 , wherein the fastener element is a generally U-shaped spring fastener comprising: 
 a body which extends out at an acute angle from the bottom edge of the ring portion; and    two tabs which extend out from the body at an obtuse angle.    
   
   
       27 . The ring of  claim 23 , wherein the fastener element is a malleable tab element which extends generally vertically from one of the top edge and the bottom edge of the ring portion.  
   
   
       28 . The ring of  claim 23 , wherein the fastener element is a tab element having: 
 a flat body which extends generally vertically from one of the top edge and the bottom edge of the ring portion; and    two malleable wings which extend out from the body, wherein the wings are preforined in a compact configuration in which they extend generally parallel to each other and generally perpendicular to the body, and wherein the wings are capable of being bent away from each other relative to the body into a locking configuration.    
   
   
       29 . The ring of  claim 23 , wherein the fastener element is a spring fastener comprising: 
 a spring portion which extends generally vertically from one of the top edge and the bottom edge of the ring portion; and    a body having a generally flat central portion and two wings which extend out from the central portion, wherein said central portion extends radially inward from the spring portion at an acute angle relative to said spring portion, and the wings are oriented generally parallel to each other in at least substantially vertical planes.    
   
   
       30 . The ring of  claim 23 , wherein the fastener element is a spring element comprising: 
 a spring portion which extends in an at least substantially vertical plane from one of the top edge and the bottom edge of the ring portion; and    a body having a generally flat central portion and two tabs which extend out from the central portion, wherein said central portion extends radially inward from the spring portion at an acute angle relative to said spring portion, and the tabs are oriented generally parallel to each other and at least substantially perpendicular to the spring portion.    
   
   
       31 . The ring of  claim 23 , wherein the fastener element is a tab which extends out from one of the top edge and the bottom edge of the ring portion and has a free distal end portion which extends radially outside of the ring portion.  
   
   
       32 . The ring of  claim 23 , wherein the fastener element is a tab comprising: 
 a proximal end which extends out from one of the top edge and the bottom edge of the ring portion;    a free distal end portion which extends radially outside of the ring portion;    a central portion between the proximal end and the free distal portion; and    two wings extending vertically from the central portion, each of the wings having a malleable end portion capable of being bent relative to the central portion into a locking configuration.    
   
   
       33 . The ring of  claim 21 , wherein the distal portion of said each of the tines in the final configuration is shaped for piercing said tissue of the first organ.  
   
   
       34 . A method for preparing a first organ having an orifice for anastomosis with a second organ, using a ring having a ring portion sized to extend around the orifice and malleable tines that extend out from the ring portion, said method including the steps of: 
 (a) inserting an anvil into the first organ through the orifice, said anvil having a tine-forming surface;    advancing the ring toward the tine-forming surface of the anvil to cause distal ends of the tines to grab tissue of the first organ around the orifice and curl against the tine-forming surface while gripping the tissue, thereby forming a curled tine structure including curled tine ends and portions of the tissue; and    (c) after step (b), retracting the anvil so that said anvil exerts force on the curled tine structure to cause the curled tine ends of the curled tine structure to move radially outward away from each other.    
   
   
       35 . The method of  claim 34 , wherein the portions of the tissue in the curled tine structure formed in step (b) have begun to evert in response to force exerted thereon by the distal ends of the tines during step (b), and movement of the tines in steps (b) and (c) everts the tissue around the orifice sufficiently to expose an inner surface of the first organ which can be joined with tissue of the second organ.  
   
   
       36 . The method of  claim 34 , wherein step (b) includes the steps of: 
 (i) advancing the ring to cause tips of the tines to pierce the tissue of the first organ around the orifice; and    (ii) after step (i), continuing to advance the ring to cause the tips of the tines to engage the tine-forming surface of the anvil and curl radially inward while distal ends of the tines grip the tissue, thereby forming the curled tine structure.    
   
   
       37 . The method of  claim 34 , wherein step (b) includes the steps of: 
 (i) advancing the ring to cause tips of the tines to enter the orifice and engage the tine-forming surface of the anvil before grabbing the tissue, so that distal ends of the tines begin to curl radially outward against said tine-forming surface before grabbing the tissue; and    (ii) after step (i), continuing to advance the ring to cause the tips of the tines to grab the tissue of the first organ around the orifice while the distal ends of the tines continue to curl against said tine-forrning surface, thereby forming the curled tine structure.    
   
   
       38 . The method of  claim 37 , also including the step of: (d) after step (c), advancing at least one sleeve into engagement with the curled tine structure to fold said tines so their curled ends move further radially outward, wherein movement of the tines in steps (b), (c), and (d) everts the tissue around the orifice sufficiently to expose an inner surface of the first organ which can be joined with tissue of the second organ.  
   
   
       39 . The method of  claim 34 , also including the step of: 
 (d) after step (c), advancing at least one sleeve into engagement with the curled tine structure to fold said tines so their curled ends move radially outward, wherein movement of the tines in steps (b), (c), and (d) everts the tissue around the orifice sufficiently to expose an inner surface of the first organ which can be joined with tissue of the second organ.    
   
   
       40 . The method of  claim 39 , wherein each of the tines has a free distal end and a weak portion between the ring portion and the free distal end, and said each of the tines preferentially folds at the weak portion in response to the force exerted thereon by the anvil during.step (c) and in response to force exerted by the at least one sleeve during step (d).  
   
   
       41 . The method of  claim 34 , wherein each of the tines has a free distal end and a weak portion between the ring portion and the free distal end, and said each of the tines preferentially folds at the weak portion in response to the force exerted thereon by the anvil during step (c).  
   
   
       42 . A tool for installing an anastomosis ring at an orifice of a first organ to prepare the first organ for anastomosis with a second organ, wherein the anastomosis ring has a ring portion sized to extend around the orifice and malleable tines extending out from the ring portion, the tool comprising: 
 an anvil having a tine-forming surface, wherein the anvil is sized for insertion into the first organ through the orifice;    a set of independently movable sleeves around the anvil, wherein the sleeves are concentric with each other and with the anvil; and    a control assembly coupled to the anvil and the sleeves and configured to advance and retract individual ones of the anvil and the sleeves relative to other ones of the anvil and the sleeves to advance the ring toward the tine-forming surface of the anvil to cause distal ends of the tines to grab tissue of the organ around the orifice and curl against the tine-forming surface while gripping the tissue, thereby forming a curled tine structure including curled tine ends and portions of the tissue, and to retract the anvil such that the anvil exerts force on the curled tine structure to cause the curled tine ends of the curled tine structure to move radially outward away from each other.    
   
   
       43 . The tool of  claim 42 , wherein the control assembly is also configured to advance at least one of the sleeves, relative to at least one other one of the sleeves and following retraction of the anvil, into engagement with the curled tine structure to fold the tines such that their curled ends move further radially outward to evert the tissue around the orifice, thereby exposing an inner surface of the first organ which can be joined with tissue of the second organ.  
   
   
       44 . The tool of  claim 42 , wherein at least one of the sleeves has a distal end defining at least two slots, one of the slots sized to receive a tubular ring portion of a first tined anastomosis ring, and another of the slots sized to receive a tubular ring portion of a second tined anastomosis ring, wherein the tubular ring portion of the first tined anastomosis ring has smaller diameter than does the tubular ring portion of the second tined anastomosis ring.  
   
   
       45 . The tool of  claim 42 , wherein an outermost one of the sleeves has a distal end portion that defines a tine-engaging surface, the tine-engaging surface being shaped and sized to receive each of the tines and constrain advancing motion of at least a portion of said each of said tines as said tines advance into engagement with the outermost one of the sleeves.  
   
   
       46 . The tool of  claim 45 , wherein at least one of the sleeves other than the outermost one of the sleeves is configured to advance toward the tine-engaging surface of the outermost one of the sleeves, to press the curled tine structure against said tine-engaging surface following retraction of the anvil, thereby forming the ring into a final configuration.  
   
   
       47 . The tool of  claim 42 , also including a flat member releasably mounted to an outermost one of the sleeves, wherein the flat member defines a tine-engaging surface, the tine-engaging surface being shaped and sized to receive each of the tines and constrain advancing motion of at least a portion of said each of said tines as said tines advance into engagement with the outermost one of the sleeves.  
   
   
       48 . The tool of  claim 47 , wherein at least one of the sleeves other than the outermost one of the sleeves is configured to advance toward the tine-engaging surface of the outermost one of the sleeves, to press the curled tine structure against said tine-engaging surface following retraction of the anvil, thereby forming the ring into a final configuration.  
   
   
       49 . The tool of  claim 42 , wherein the ring portion is a tubular ring portion, and the set of independently movable sleeves comprises: 
 an outermost sleeve having a distal end portion which defines a tine-engaging surface;    a second sleeve concentric with and radially within the outermost sleeve, said second sleeve having a distal end defining at least one slot sized to receive the tubular ring portion of the ring;    a third sleeve concentric with and radially within the second sleeve; and    a fourth sleeve concentric with and radially within the third sleeve.    
   
   
       50 . The tool of  claim 49 , wherein the fourth sleeve has a distal surface having a concave portion shaped to engage and exert folding force on a convex portion of the curled tine structure when said concave portion of the distal surface of the fourth sleeve is advanced into engagement with the curled tine structure following retraction of the anvil.  
   
   
       51 . The tool of  claim 49 , wherein the third sleeve has a radially inner surface having a recessed portion shaped to provide clearance for the curled tine structure as said curled tine structure moves radially outward in response to force exerted thereon by the retracting anvil.  
   
   
       52 . The tool of  claim 49 , also including an innermost sleeve concentric with and radially within the fourth sleeve, wherein the anvil is concentric with and radially within the innermost sleeve.  
   
   
       53 . The tool of  claim 42 , wherein the ring portion is a tubular ring portion, and the set of independently movable sleeves comprises: 
 an outermost sleeve having a slot;    a flat member releasably mounted in the slot, said flat member having a tine-engaging surface;    a second sleeve concentric with and radially within the outermost sleeve, said second sleeve having a distal end defining at least one slot sized to receive the tubular ring portion of the ring;    a third sleeve concentric with and radially within the second sleeve; and    a fourth sleeve concentric with and radially within the third sleeve.    
   
   
       54 . The tool of  claim 53 , also including an innermost sleeve concentric with and radially within the fourth sleeve, wherein the anvil is concentric with and radially within the innennost sleeve.  
   
   
       55 . A method for installing an anastomosis ring at an orifice of a first organ using a tool, to prepare the first organ for anastomosis with a second organ, wherein the anastomosis ring has a ring portion sized to extend around the orifice and malleable tines extending out from the ring portion, the tool includes an anvil and a set of independently movable sleeves around the anvil, the anvil has a tine-forming surface, the sleeves are concentric with each other and with the anvil, the sleeves include an outermost sleeve and additional sleeves, and the outermost sleeve defines a tine-engaging surface, said method including the steps of: 
 (a) releasably mounting the ring to the tool such that tips of the tines extend away from the sleeves in a distal direction, the ring portion is releasably engaged with at least one of the sleeves, and the tine-engaging surface of the outermost sleeve exerts holding force on at least one of the tines;    (b) inserting the anvil into the first organ through the orifice;    (c) after steps (a) and (b), advancing at least some of the sleeves in the distal direction, thereby advancing the ring toward the tine-forming surface of the anvil to cause the tips of the tines to grab tissue of the first organ around the orifice, and curl against the tine-forming surface while gripping the tissue, thereby forming a curled tine structure including curled tine ends and portions of the tissue;    (d) after step (c), retracting the anvil away from at least one of the sleeves such that said anvil exerts force on the curled tine structure to cause the curled tine ends of the curled tine structure to move radially outward away from each other; and    (e) after step (d), advancing at least one of the additional sleeves relative to the outermost sleeve into engagement with the curled tine structure to fold said tines so their curled ends move further radially outward, wherein movement of the tines in steps (c), (d), and (e) everts the tissue around the orifice sufficiently to expose an inner surface of the first organ which can be joined with tissue of the second organ.    
   
   
       56 . The method of  claim 55 , wherein each of the tines has a free distal end and a weak portion between the ring portion and the free distal end, and said each of the tines preferentially folds at the weak portion in response to the force exerted thereon by the anvil during step (d).  
   
   
       57 . The method of  claim 55 , wherein each of the tines has a free distal end and a weak portion between the ring portion and the free distal end, and said each of the tines preferentially folds at the weak portion in response to the force exerted thereon by the anvil during step (d) and in response to force exerted by the sleeves during step (e).  
   
   
       58 . The method of  claim 55 , wherein step (c) includes the steps of: 
 (i) advancing the ring to cause the tips of the tines to enter the orifice and engage the tine-forming surface of the anvil before grabbing the tissue, so that distal ends of the tines begin to curl radially outward against said tine-forming surface before grabbing the tissue; and    (ii) after step (i), continuing to advance the ring to cause the tips of the tines to grab the tissue of the first organ around the orifice while the distal ends of the tines continue to curl radially outward against said tine-forming surface, thereby forming the curled tine structure.    
   
   
       59 . The method of  claim 55 , wherein step (b) includes the steps of: 
 (i) advancing the ring to cause tips of the tines to pierce the tissue of the first organ around the orifice; and    (ii) after step (i), continuing to advance the ring to cause the tips of the tines to engage the tine-forming surface of the anvil and curl radially inward while distal ends of the tines grip the tissue, thereby forming the curled tine structure.    
   
   
       60 . The method of  claim 55 , wherein the outermost sleeve includes a first portion and a flat member releasably attached to the first portion, and the tine-engaging surface is a first surface of the flat member, said method also including the step of: 
 (f) after step (e), releasing the flat member from the first portion and removing all of the tool other than the flat member from the first organ, thereby leaving said flat member installed with the ring at the orifice of the first organ.    
   
   
       61 . The method of  claim 55 , wherein the additional sleeves include a first sleeve concentric with and radially within the outermost sleeve, a second sleeve concentric with and radially within the first sleeve, a third sleeve concentric with and radially within the second sleeve, and a fourth sleeve concentric with and radially within the third sleeve, said method also including the step of: 
 (f) after step (c) but before step (d), retracting the third sleeve and the fourth sleeve relative to the anvil and the outermost sleeve, and wherein    step (e) includes the step of advancing at least the first sleeve and the second sleeve relative to the outermost sleeve against the curled tine structure to fold said tines.    
   
   
       62 . The method of  claim 55 , wherein the additional sleeves include a first sleeve concentric with and radially within the outermost sleeve, a second sleeve concentric with and radially within the first sleeve, a third sleeve concentric with and radially within the second sleeve, and a fourth sleeve concentric with and radially within the third sleeve, said method also including the step of: 
 (f) after step (c) but before step (d), retracting the third sleeve and the fourth sleeve relative to the anvil and the outermost sleeve, and wherein step (e) includes the steps of advancing the first sleeve relative to the second sleeve and the outermost sleeve to rotate the curled tine structure, then advancing the second sleeve and the third sleeve relative to the outermost sleeve against the curled tine structure to begin to fold said tines, and then further advancing the second sleeve relative to the third sleeve and the outermost sleeve against the curled tine structure to further fold said tines.    
   
   
       63 . The method of  claim 55 , wherein the additional sleeves include a first sleeve concentric with and radially within the outermost sleeve, a second sleeve concentric with and radially within the first sleeve, and a third sleeve concentric with and radially within the second sleeve, wherein the second sleeve has a radially inner surface having a recessed portion shaped to provide clearance for the curled tine structure as said curled tine structure moves radially outward in response to force exerted thereon by the retracting anvil, said method also including the step of: 
 (f) after step (c) but before step (d), retracting the third sleeve relative to the anvil, the second sleeve, and the outermost sleeve, and wherein    step (e) includes the steps of:    (g) retracting the second sleeve relative to the first sleeve and the third sleeve; (h) after step (g), advancing the third sleeve relative to the outermost sleeve against the curled tine structure to begin to fold said tines; and    (i) after step (h), advancing the second sleeve relative to the third sleeve and the outermost sleeve against the curled tine structure to further fold said tines.    
   
   
       64 . The method of  claim 63 , wherein step (e) also includes the steps of: 
 ( 1 ) after step (i), retracting the third sleeve relative to the second sleeve and the outermost sleeve; and    (k) after step  0 ), further advancing the second sleeve relative to the outermost sleeve against the curled tine structure to further fold said tines.    
   
   
       65 . A method for installing a first anastomosis ring at an orifice of a first organ, aligning the installed ring with a second anastomosis ring that has been installed at an orifice of a second organ, and fastening the aligned rings together, wherein the first anastomosis ring has a ring portion sized to extend around the orifice of the first orifice, and malleable tines and at least one fastener element that extend out from the ring portion, said method including the steps of: 
 (a) inserting an anvil having a tine-forming surface into the first organ through the orifice of said first organ;    (b) advancing the first anastomosis ring toward the tine-forming surface of the anvil to cause distal ends of the tines to grab tissue of the first organ around the orifice, and curl against the tine-forming surface while gripping the tissue, thereby forming a curled tine structure including curled tine ends and portions of the tissue;    (c) after step (b), retracting the anvil relative to the first anastomosis ring such that the anvil exerts force on the curled tine structure to cause the curled tine ends of the curled tine structure to move radially outward away from each other;    (d) after step (c), aligning the installed first anastomosis ring with the second anastomosis ring; and    (e) fastening together the aligned first and second anastomosis rings by coupling each said fastener element of the first anastomosis ring to the second anastomosis ring, thereby forming an anastomosis joining the first organ in fluid communication with the second organ.    
   
   
       66 . The method of  claim 65 , wherein each of the tines of the first anastomosis ring has a free distal end and a weak portion between the ring portion and the free distal end, and said each of the tines preferentially folds at the weak portion in response to exertion of force on the curled tine structure by the anvil during step (c).  
   
   
       67 . The method of  claim 65 , wherein the ring portion is a tubular ring portion having a top edge and a bottom edge, the fastener element is a malleable tab that extends upward from the top edge of the tubular ring portion, and step (e) includes the step of bending the malleable tab relative to the second anastomosis ring to constrain movement of the first anastomosis ring relative to said second anastomosis ring.  
   
   
       68 . The method of  claim 65 , wherein the ring portion is a tubular ring portion having a top edge and a bottom edge, the fastener element is a slotted tab having a proximal end extending out from the tubular ring portion, and a distal end defining a slot, and step (e) includes the step of inserting a feature of the second anastomosis ring through the slot.  
   
   
       69 . The method of  claim 65 , wherein the ring portion is a tubular ring portion having a top edge and a bottom edge, the fastener element is a spring element which extends radially outward from one of the top edge and the bottom edge of the ring portion, and step (e) includes the step of displacing the spring element relative to a feature of the second anastomosis ring to cause said spring element to lock against said feature.  
   
   
       70 . The method of  claim 65 , wherein the ring portion is a tubular ring portion having a top edge and a bottom edge, the fastener element is a tab element having a generally flat body which extends generally vertically from one of the top edge and the bottom edge of the ring portion, and malleable wings which extend out from the generally flat body, and step (e) includes the step of bending the malleable wings relative to the second anastomosis ring to constrain movement of the first anastomosis ring relative to said second anastomosis ring.  
   
   
       71 . The method of  claim 65 , wherein the ring portion is a tubular ring portion having a top edge and a bottom edge, the fastener element is a spring element comprising a spring portion which extends in an at least substantially vertical plane from one of the top edge and the bottom edge of the ring portion, and a body having a central portion which extends radially inward from the spring portion at an acute angle relative to said spring portion, and 
 wherein step (e) includes the step of displacing the spring portion relative to the second anastomosis ring and allowing said spring portion to spring back into a locking position in which the body constrains movement of the first anastomosis ring relative to said second anastomosis ring.    
   
   
       72 . The method of  claim 65 , wherein the first organ is a blood vessel having a sidewall and an intima, the orifice in the first organ is an incision in the sidewall, and movement of the tines in steps (b) and (c) everts the tissue around the incision sufficiently to expose the intima of the blood vessel.  
   
   
       73 . The method of  claim 65 , wherein the first organ is a blood vessel having a sidewall and an intima, and the orifice in the first organ is an incision in the sidewall, said method also including the step of: 
 (f) after step (c) but before step (d), advancing at least one sleeve into engagement with the curled tine structure to fold said tines so their curled ends move further radially outward, wherein movement of the tines in steps (b), (c), and (f) everts the tissue around the incision sufficiently to expose the intima of the blood vessel.