Endoscopic suturing device with circular needle

Abstract

The invention relates to an endoscopic suturing device with a circular needle. Provided herein is an endoscope suturing system configured to be attached to and used with an endoscope.

Description

[0001] This application is a divisional application of an application filed on June 6, 2019, with application number 201980052495.3, and invention name “Endoscopic suturing device with a circular needle”. Cross-references

[0002] This application claims the benefit of U.S. Provisional Application No. 62 / 681,783, filed June 7, 2018, which is incorporated herein by reference in its entirety. Technical Field

[0003] The present application relates to an endoscopic suturing device having a circular needle. An endoscopic suturing system configured to be attached to and used with an endoscope is provided herein. Background Art

[0004] Full-thickness gastrointestinal defects such as perforations, anastomotic+oral leaks, and fistulas are serious diseases caused by various types of pathologies. Such diseases are more likely to require intensive care, involve long-term hospitalization, and have high morbidity and mortality. Currently available advanced endoscopic closure technologies play a major role in the treatment of full-thickness gastrointestinal defects. Endoscopic clamps are the most common treatment for closing small defects. However, endoscopic clamps are less useful for larger defects due to limited jaw opening distance, low closure force, and inability to complete deep tissue capture.

[0005] Innovative endoscopic devices for placing full-thickness sutures have become an area of ​​interest for closing large defects. However, most suturing devices developed in the last two decades are bulky and expensive, leading more and more physicians to seek simple suturing devices. Endoscopic suturing is a minimally invasive technique that can be used for a variety of gastrointestinal indications, such as stoma and gastric reduction, fistula repair, bariatric treatment, stent and graft fixation, and gastrointestinal bleeding. Summary of the invention

[0006] In order to pierce correctly, the tissue must be supported relative to the needle side. However, some devices use a drive mechanism that is designed to make the needle pierce by first moving laterally, pivoting about 90 degrees, and longitudinally ending proximally from the most distal position to the receiver, which is now used as a support for piercing the tissue. In this way, when the needle moves laterally, these devices do not provide any support for the tissue, so it can be pushed away from the needle path before the tissue is completely pierced. Therefore, in order to provide such side support with such a device, a tissue grasper (e.g., a grasper, a corkscrew) is often required, which is a major disadvantage. Provided herein are devices, equipment, systems and methods (as used herein, "arcuate needle" is synonymous with "circular needle" and is an arched needle that is not completely circular but travels in a circular path or a substantially circular path), which actuates the arcuate needle by a C-shaped distal assembly that is not at right angles to the main axis of the endoscope and has an angle that is not aligned with the main axis of the endoscope. Thus, when using the device for suturing, a tissue grasper is not necessary as the device is easily manipulated to position tissue between the open ends of the "C" and once in such position enter the gap formed by the "C" of the C-shaped distal assembly without the need for a separate support.

[0007] Furthermore, with such current devices, a separate working channel must be provided to bring the grasper into the suture zone. Since the anchor exchange catheter uses one channel, the barrel must have two working channels, or have an additional working channel through the cannula. The requirement for a special two-channel barrel is another significant disadvantage, which makes the procedure more expensive. In order to maintain a small overall diameter, the grasper's working channel must have a small outer diameter. Some current devices employ a grasper that is a long shaft with a helical screw on its tip. However, such a helix often lacks sufficient torsional stiffness to work reliably due to its small diameter and long length. Furthermore, without a screw-in depth limit, the potential for perforation presents another disadvantage. Additionally, such devices employ a straight needle that travels in a circular motion when piercing the tissue. Such motion subjects the needle body to lateral tissue reaction forces, which may cause the needle to deflect and miss the receiver of the exchange catheter. To prevent this, the entire distal mechanism on such devices requires additional volume for additional stiffness. Ultimately, the distal portion of such a device is positioned so that the camera axis of the lens barrel is located in the needle operating plane, and tissue in the needle path during suturing will block the camera's view. The present invention provides a device, apparatus, system and method for actuating an arcuate needle through a C-shaped distal assembly that is not at right angles to the main axis of the endoscope and is not at an aligned angle relative to the main axis of the endoscope, which allows easy vision using the device's camera. Such a distal assembly is coupled to the distal end of the endoscope without the use of a working channel, and with a top view of the endoscope's camera during use and suturing, the needle is easily manipulated through the tissue, and simplicity and accuracy of suturing are achieved.

[0008] Other currently available devices use a circular needle that translates over the gap from the outlet to the entrance in a uniform circular motion. Although such a device can support tissue on the puncture needle, such a needle drive mechanism is too long to be used with a flexible shaft (i.e., a flexible endoscope) without hindering its flexibility and manipulability. In addition, such a device must be rigid to use its rack and pinion and crankshaft placed side by side and longitudinally at the same time, and therefore cannot be used for endoscopic surgery, in which the flexibility of the lens barrel must not be compromised. In addition, since such a device uses a box for suture replacement, the box has a needle permanently attached to the suture; such a device will not be suitable for endoscopic surgery. The device, equipment, system and method provided herein can actuate the arcuate needle by a C-shaped distal assembly coupled to the distal non-flexed end of the lens barrel, and use a simple set of lines and a shuttle coupled to the line to manipulate the arcuate needle during suturing without losing the flexibility of the lens barrel.

[0009] One aspect provided herein is an endoscopic suturing system comprising: a distal assembly comprising: a first housing comprising an arcuate needle guide, a shuttle guide and an endoscopic fastener, wherein the endoscopic fastener couples the first housing to an endoscope; an arcuate needle comprising a notch and a suture attachment, wherein the arcuate needle has a central axis, and wherein the arcuate needle is disposed within the arcuate needle guide; and a shuttle having a pawl, wherein the shuttle is conveyed within the shuttle guide; wherein the notch and the pawl engage when the shuttle translates about the central axis in a first rotational direction, and the notch and the pawl disengage when the shuttle translates opposite to the first rotational direction; a proximal assembly comprising: a second housing; an actuator connected to the second housing; and a cable connecting the actuator to the shuttle and configured to translate the shuttle in the first direction and the second direction in response to actuation of the actuator.

[0010] In some embodiments, the pawl comprises a spring, a flexure, a double spring door, a gasket, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the pawl is engagement biased. In some embodiments, the notch is ramped in a direction opposite to the first direction. In some embodiments, the endoscope fastener comprises a tie, a string, a band, a hook and loop fastener, a tape, a strap, a magnet, a cinch, a press fit, a set screw, an adhesive, or any combination thereof.

[0011] In some embodiments, the proximal outer diameter of the endoscope is about 5 mm to about 16 mm. In some embodiments, the proximal outer diameter of the endoscope is about 5 mm to about 6 mm, about 5 mm to about 7 mm, about 5 mm to about 8 mm, about 5 mm to about 9 mm, about 5 mm to about 10 mm, about 5 mm to about 11 mm, about 5 mm to about 12 mm, about 5 mm to about 13 mm, about 5 mm to about 14 mm, about 5 mm to about 15 mm, about 5 mm to about 16 mm, about 6 mm to about 7 mm, about 6 mm to about 8 mm, about 6 mm to about 9 mm, about 6 mm to about 10 mm, about 6 mm to about 11 mm, about 6mm to about 12mm, about 6mm to about 13mm, about 6mm to about 14mm, about 6mm to about 15mm, about 6mm to about 16mm, about 7mm to about 8mm, about 7mm to about 9mm, about 7mm to about 10mm, about 7mm to about 11mm, about 7mm to about 12mm, about 7mm to about 13mm, about 7mm to about 14mm, about 7mm to about 15mm, about 7mm to about 16mm, about 8mm to about 9mm, about 8mm to about 10mm, about 8mm to about 11mm, about 8mm to about 12mm, about 8mm to about 13mm, about 8mm to about 14mm, about 8mm to about 15mm, about 8mm to about 16mm, about 9mm to about 10mm, about 9mm to about 11mm, about 9mm to about 12mm, about 9mm to about 13mm, about 9mm to about 14mm, about 9mm to about 15mm, about 9mm to about 16mm, about 10mm to about 11mm, about 10mm to about 12mm, about 10mm to about 13mm, about 10mm to about 14mm, about 10mm to about 15mm, about 10 In some embodiments, the proximal outer diameter of the endoscope is about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, about 16 mm, about 12 mm to about 13 mm, about 12 mm to about 14 mm, about 12 mm to about 15 mm, about 12 mm to about 16 mm, about 13 mm to about 14 mm, about 13 mm to about 15 mm, about 13 mm to about 16 mm, about 14 mm to about 15 mm, about 14 mm to about 16 mm, or about 15 mm to about 16 mm. In some embodiments, the proximal outer diameter of the endoscope is about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. In some embodiments, the proximal outer diameter of the endoscope is at least about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, or about 15 mm.In some embodiments, the proximal outer diameter of the endoscope is at most about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm.

[0012] In some embodiments, the inner diameter of the endoscope fastener is about 5 mm to about 16 mm. In some embodiments, the inner diameter of the endoscope fastener is about 5 mm to about 6 mm, about 5 mm to about 7 mm, about 5 mm to about 8 mm, about 5 mm to about 9 mm, about 5 mm to about 10 mm, about 5 mm to about 11 mm, about 5 mm to about 12 mm, about 5 mm to about 13 mm, about 5 mm to about 14 mm, about 5 mm to about 15 mm, about 5 mm to about 16 mm, about 6 mm to about 7 mm, about 6 mm to about 8 mm, about 6 mm to about 9 mm, about 6 mm to about 10 mm, about 6 mm to about 11 mm , about 6mm to about 12mm, about 6mm to about 13mm, about 6mm to about 14mm, about 6mm to about 15mm, about 6mm to about 16mm, about 7mm to about 8mm, about 7mm to about 9mm, about 7mm to about 10mm, about 7mm to about 11mm, about 7mm to about 12mm, about 7mm to about 13mm, about 7mm to about 14mm, about 7mm to about 15mm, about 7mm to about 16mm, about 8mm to about 9mm, about 8mm to about 10mm, about 8mm to about 11mm, about 8mm to about about 12mm, about 8mm to about 13mm, about 8mm to about 14mm, about 8mm to about 15mm, about 8mm to about 16mm, about 9mm to about 10mm, about 9mm to about 11mm, about 9mm to about 12mm, about 9mm to about 13mm, about 9mm to about 14mm, about 9mm to about 15mm, about 9mm to about 16mm, about 10mm to about 11mm, about 10mm to about 12mm, about 10mm to about 13mm, about 10mm to about 14mm, about 10mm to about 15mm, about 10 In some embodiments, the inner diameter of the endoscope fastener is about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, about 16 mm, about 12 mm to about 13 mm, about 12 mm to about 14 mm, about 12 mm to about 15 mm, about 12 mm to about 16 mm, about 13 mm to about 14 mm, about 13 mm to about 15 mm, about 13 mm to about 16 mm, about 14 mm to about 15 mm, about 14 mm to about 16 mm, or about 15 mm to about 16 mm. In some embodiments, the inner diameter of the endoscope fastener is about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. In some embodiments, the inner diameter of the endoscopic fastener is at least about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, or about 15 mm.In some embodiments, the inner diameter of the endoscopic fastener is at most about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm.

[0013] In some embodiments, the system further comprises a cable jacket surrounding at least a portion of the cable. In some embodiments, the system further comprises a cable fastener that removably couples at least a portion of the cable jacket to the endoscope. In some embodiments, the cable fastener comprises a cable tie, a rope, a loop, a hook and loop fastener, a tape, a strap, a magnet, a zip tie, a press fit, a set screw, an adhesive, or any combination thereof.

[0014] In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is about 5 degrees to about 120 degrees. In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is about 5 degrees to about 10 degrees, about 5 degrees to about 20 degrees, about 5 degrees to about 30 degrees, about 5 degrees to about 40 degrees, about 5 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 5 0 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 70 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 90 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 70 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 90 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 70 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 90 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 70 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 90 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about About 100 degrees, about 50 degrees to about 120 degrees, about 60 degrees to about 70 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 90 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 70 degrees to about 80 degrees, about 70 degrees to about 90 degrees, about 70 degrees to about 100 degrees, about 70 degrees to about 120 degrees, about 80 degrees to about 90 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 90 degrees to about 100 degrees, about 90 degrees to about 120 degrees, or about 100 degrees to about 120 degrees. In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is at least about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, or about 100 degrees.In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is at most about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees.

[0015] In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within a range of about 5 degrees to about 120 degrees. In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within a range of about 5 degrees to about 10 degrees, about 5 degrees to about 20 degrees, about 5 degrees to about 30 degrees, about 5 degrees to about 40 degrees, about 5 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 1 0 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 70 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 90 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 70 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 90 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees , about 30 degrees to about 60 degrees, about 30 degrees to about 70 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 90 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 70 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 90 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about The angle of rotation can be adjusted within 100 degrees, about 50 degrees to about 120 degrees, about 60 degrees to about 70 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 90 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 70 degrees to about 80 degrees, about 70 degrees to about 90 degrees, about 70 degrees to about 100 degrees, about 70 degrees to about 120 degrees, about 80 degrees to about 90 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 90 degrees to about 100 degrees, about 90 degrees to about 120 degrees, or about 100 degrees to about 120 degrees. In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees.In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within at least about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, or about 100 degrees. In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within at most about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees.

[0016] In some embodiments, the arcuate needle comprises two or more notches. In some embodiments, at least one of the first housing, the second housing, the arcuate needle, the shuttle, or the actuator is comprised of plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. In some embodiments, the first housing further comprises a cable pulley for guiding the cable. In some embodiments, the arcuate needle comprises a suture attachment fastener. In some embodiments, the first housing further comprises a pulley, and wherein the cable is twisted around the pulley. In some embodiments, the second housing is coupled to the endoscope.

[0017] Another aspect provided herein is an endoscopic suturing system comprising: a distal assembly comprising: a first housing comprising an arcuate needle guide and an endoscopic fastener, wherein the endoscopic fastener couples the first housing to an endoscope; an arcuate needle comprising a notch and a suture attachment, wherein the arcuate needle has a central axis, and wherein the arcuate needle is disposed within the arcuate needle guide; and a proximal assembly comprising: a second housing removably attached to the endoscope; an actuator connected to the second housing; and a cable having a pawl; wherein the notch and the pawl engage when the cable translates about the central axis in a first rotational direction, and the notch and the pawl disengage when the cable translates opposite to the first rotational direction.

[0018] In some embodiments, the pawl comprises a spring, a flexure, a double spring door, a gasket, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the pawl is biased for engagement. In some embodiments, the notch is slanted in a direction opposite to the first direction. In some embodiments, the endoscope fastener comprises a press-fit fastener, a clamp, an adhesive, a tape, a strip, a set screw, a hook and loop fastener, a magnet, or any combination thereof.

[0019] In some embodiments, the proximal outer diameter of the endoscope is about 5 mm to about 16 mm. In some embodiments, the proximal outer diameter of the endoscope is about 5 mm to about 6 mm, about 5 mm to about 7 mm, about 5 mm to about 8 mm, about 5 mm to about 9 mm, about 5 mm to about 10 mm, about 5 mm to about 11 mm, about 5 mm to about 12 mm, about 5 mm to about 13 mm, about 5 mm to about 14 mm, about 5 mm to about 15 mm, about 5 mm to about 16 mm, about 6 mm to about 7 mm, about 6 mm to about 8 mm, about 6 mm to about 9 mm, about 6 mm to about 10 mm, about 6 mm to about 11 mm, about 6mm to about 12mm, about 6mm to about 13mm, about 6mm to about 14mm, about 6mm to about 15mm, about 6mm to about 16mm, about 7mm to about 8mm, about 7mm to about 9mm, about 7mm to about 10mm, about 7mm to about 11mm, about 7mm to about 12mm, about 7mm to about 13mm, about 7mm to about 14mm, about 7mm to about 15mm, about 7mm to about 16mm, about 8mm to about 9mm, about 8mm to about 10mm, about 8mm to about 11mm, about 8mm to about 12mm, about 8mm to about 13mm, about 8mm to about 14mm, about 8mm to about 15mm, about 8mm to about 16mm, about 9mm to about 10mm, about 9mm to about 11mm, about 9mm to about 12mm, about 9mm to about 13mm, about 9mm to about 14mm, about 9mm to about 15mm, about 9mm to about 16mm, about 10mm to about 11mm, about 10mm to about 12mm, about 10mm to about 13mm, about 10mm to about 14mm, about 10mm to about 15mm, about 10 In some embodiments, the proximal outer diameter of the endoscope is about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, about 16 mm, about 12 mm to about 13 mm, about 12 mm to about 14 mm, about 12 mm to about 15 mm, about 12 mm to about 16 mm, about 13 mm to about 14 mm, about 13 mm to about 15 mm, about 13 mm to about 16 mm, about 14 mm to about 15 mm, about 14 mm to about 16 mm, or about 15 mm to about 16 mm. In some embodiments, the proximal outer diameter of the endoscope is about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. In some embodiments, the proximal outer diameter of the endoscope is at least about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, or about 15 mm.In some embodiments, the proximal outer diameter of the endoscope is at most about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm.

[0020] In some embodiments, the inner diameter of the endoscope fastener is about 5 mm to about 16 mm. In some embodiments, the inner diameter of the endoscope fastener is about 5 mm to about 6 mm, about 5 mm to about 7 mm, about 5 mm to about 8 mm, about 5 mm to about 9 mm, about 5 mm to about 10 mm, about 5 mm to about 11 mm, about 5 mm to about 12 mm, about 5 mm to about 13 mm, about 5 mm to about 14 mm, about 5 mm to about 15 mm, about 5 mm to about 16 mm, about 6 mm to about 7 mm, about 6 mm to about 8 mm, about 6 mm to about 9 mm, about 6 mm to about 10 mm, about 6 mm to about 11 mm , about 6mm to about 12mm, about 6mm to about 13mm, about 6mm to about 14mm, about 6mm to about 15mm, about 6mm to about 16mm, about 7mm to about 8mm, about 7mm to about 9mm, about 7mm to about 10mm, about 7mm to about 11mm, about 7mm to about 12mm, about 7mm to about 13mm, about 7mm to about 14mm, about 7mm to about 15mm, about 7mm to about 16mm, about 8mm to about 9mm, about 8mm to about 10mm, about 8mm to about 11mm, about 8mm to about about 12mm, about 8mm to about 13mm, about 8mm to about 14mm, about 8mm to about 15mm, about 8mm to about 16mm, about 9mm to about 10mm, about 9mm to about 11mm, about 9mm to about 12mm, about 9mm to about 13mm, about 9mm to about 14mm, about 9mm to about 15mm, about 9mm to about 16mm, about 10mm to about 11mm, about 10mm to about 12mm, about 10mm to about 13mm, about 10mm to about 14mm, about 10mm to about 15mm, about 10 In some embodiments, the inner diameter of the endoscope fastener is about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, about 16 mm, about 12 mm to about 13 mm, about 12 mm to about 14 mm, about 12 mm to about 15 mm, about 12 mm to about 16 mm, about 13 mm to about 14 mm, about 13 mm to about 15 mm, about 13 mm to about 16 mm, about 14 mm to about 15 mm, about 14 mm to about 16 mm, or about 15 mm to about 16 mm. In some embodiments, the inner diameter of the endoscope fastener is about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. In some embodiments, the inner diameter of the endoscopic fastener is at least about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, or about 15 mm.In some embodiments, the inner diameter of the endoscopic fastener is at most about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm.

[0021] In some embodiments, the system further comprises a cable jacket surrounding at least a portion of the cable. In some embodiments, the system further comprises a cable fastener that removably couples at least a portion of the cable to the endoscope. In some embodiments, the cable fastener comprises a press-fit fastener, a clamp, an adhesive, a tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof.

[0022] In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is about 5 degrees to about 120 degrees. In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is about 5 degrees to about 10 degrees, about 5 degrees to about 20 degrees, about 5 degrees to about 30 degrees, about 5 degrees to about 40 degrees, about 5 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 5 0 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 70 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 90 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 70 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 90 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 70 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 90 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 70 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 90 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about About 100 degrees, about 50 degrees to about 120 degrees, about 60 degrees to about 70 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 90 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 70 degrees to about 80 degrees, about 70 degrees to about 90 degrees, about 70 degrees to about 100 degrees, about 70 degrees to about 120 degrees, about 80 degrees to about 90 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 90 degrees to about 100 degrees, about 90 degrees to about 120 degrees, or about 100 degrees to about 120 degrees. In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is at least about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, or about 100 degrees.In some embodiments, the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is at most about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees.

[0023] In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within a range of about 5 degrees to about 120 degrees. In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within a range of about 5 degrees to about 10 degrees, about 5 degrees to about 20 degrees, about 5 degrees to about 30 degrees, about 5 degrees to about 40 degrees, about 5 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 1 0 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 70 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 90 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 70 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 90 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees , about 30 degrees to about 60 degrees, about 30 degrees to about 70 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 90 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 70 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 90 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about The angle of rotation can be adjusted within 100 degrees, about 50 degrees to about 120 degrees, about 60 degrees to about 70 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 90 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 70 degrees to about 80 degrees, about 70 degrees to about 90 degrees, about 70 degrees to about 100 degrees, about 70 degrees to about 120 degrees, about 80 degrees to about 90 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 90 degrees to about 100 degrees, about 90 degrees to about 120 degrees, or about 100 degrees to about 120 degrees. In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees.In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within at least about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, or about 100 degrees. In some embodiments, the angle between the adjustable central axis within the arcuate needle guide and the adjustable proximal axis within the endoscope is adjustable within at most about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees.

[0024] In some embodiments, the arcuate needle comprises two or more notches. In some embodiments, at least one of the first housing, the second housing, the arcuate needle, or the actuator is comprised of plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. In some embodiments, the first housing further comprises a cable pulley for guiding the cable. In some embodiments, the arcuate needle comprises a suture attachment fastener. In some embodiments, the first housing further comprises a pulley, and wherein the cable is twisted around the pulley. In some embodiments, the second housing is coupled to the endoscope. BRIEF DESCRIPTION OF THE DRAWINGS

[0025] The novel features of the present disclosure are particularly set forth in the appended claims. A better understanding of the features and advantages of the present invention will be obtained by referring to the following detailed description and accompanying drawings which set forth illustrative embodiments utilizing the present principles, in which:

[0026] Figure 1 is a diagram of an exemplary endoscopic suturing system according to embodiments herein;

[0027] Figure 2 is an illustration of an exemplary first proximal assembly coupled to an endoscope according to embodiments herein;

[0028] Figure 3 is an illustration of a second exemplary proximal assembly according to embodiments herein;

[0029] Figure 4 is an illustration of a third exemplary distal assembly according to embodiments herein;

[0030] Figure 5 is an illustration of an exemplary first distal assembly on an endoscope according to embodiments herein;

[0031] Figure 6 is a detailed illustration of an exemplary first distal assembly according to embodiments herein;

[0032] Figure 7is a detailed view of an exemplary first distal assembly in a first position with a portion of a shuttle guide removed according to embodiments herein;

[0033] Figure 8 is a detailed view of an exemplary first distal assembly in a second position with a portion of a shuttle guide removed according to embodiments herein;

[0034] Fig. 9 is a detailed view of an exemplary first distal assembly in a third position with a portion of a shuttle guide removed according to embodiments herein;

[0035] Fig.10 is a detailed view of an exemplary third distal assembly in a fourth position according to embodiments herein, wherein a portion of the shuttle guide is opaque;

[0036] Fig.11 is a detailed view of an exemplary first distal assembly in a fifth position according to embodiments herein, wherein a portion of the shuttle guide is opaque;

[0037] Fig.12 is a detailed view of an exemplary first distal assembly in a sixth position according to embodiments herein, wherein a portion of the shuttle guide is opaque;

[0038] Fig.13 is a detailed view of an exemplary first distal assembly in a seventh position according to embodiments herein, wherein a portion of the shuttle guide is opaque;

[0039] Fig.14 is an illustration of an exemplary arcuate needle according to embodiments herein;

[0040] Fig.15 is an illustration of an exemplary arcuate needle having 2 notches according to embodiments of the present invention;

[0041] Fig.16 is an illustration of an exemplary arcuate needle and suture according to embodiments herein;

[0042] Fig.17 is an exemplary first illustration of in situ suture replacement by an exemplary first distal assembly according to embodiments herein;

[0043] Fig.18 is a second exemplary illustration of in situ suture replacement by an exemplary first distal assembly according to embodiments herein;

[0044] Fig.19A is an exemplary illustration of a shuttle according to embodiments herein, wherein the pawl is engaged;

[0045] Fig.19B is an exemplary illustration of a shuttle according to an embodiment of the present invention, wherein the pawl is disengaged;

[0046] Fig. 20 is a first illustration of an exemplary second proximal assembly coupled to an endoscope according to embodiments herein;

[0047] Fig.21 is a second illustration of an exemplary second proximal assembly coupled to an endoscope according to embodiments herein;

[0048] Fig. 22 is a third illustration of an exemplary second proximal assembly coupled to an endoscope according to embodiments herein;

[0049] Fig.23 is a first bottom perspective illustration of an exemplary second proximal assembly without a base plate according to embodiments herein;

[0050] Fig.24 is a second bottom perspective illustration of an exemplary second proximal assembly without a base plate according to embodiments herein;

[0051] Fig.25 is an illustration of an exemplary first housing of a second proximal assembly according to embodiments herein;

[0052] Fig.26 is a cross-sectional illustration of an exemplary second proximal assembly according to embodiments herein;

[0053] Fig.27A is a bottom cross-sectional illustration of an exemplary second proximal assembly in a first position according to embodiments herein;

[0054] Fig.27B is a bottom cross-sectional illustration of an exemplary second proximal assembly in a second position according to embodiments herein;

[0055] Fig.27C is a bottom cross-sectional illustration of an exemplary second proximal assembly in a third position according to embodiments herein;

[0056] Fig.27D is a bottom cross-sectional illustration of an exemplary second proximal assembly in a fourth position according to embodiments herein;

[0057] Fig.27E is a bottom cross-sectional illustration of an exemplary second proximal assembly in a fifth position according to embodiments herein;

[0058] Fig.27F is a bottom cross-sectional illustration of an exemplary second proximal assembly in a sixth position according to embodiments herein;

[0059] Fig.28 is a top perspective illustration of an exemplary removable first housing bottom according to embodiments herein;

[0060] Fig.29 is a bottom perspective illustration of an exemplary removable first housing according to embodiments herein;

[0061] Fig. 30A is a diagram of an exemplary first cable and pawl combination according to embodiments herein;

[0062] Fig. 30B is a diagram of an exemplary second cable and pawl combination according to embodiments herein;

[0063] Fig. 30C is a diagram of an exemplary engaged cable and pawl combination according to embodiments herein;

[0064] Fig.31A is an illustration of an exemplary third distal assembly in a first position according to embodiments herein;

[0065] Fig.31B is an illustration of an exemplary third distal assembly in a second position according to embodiments herein;

[0066] Fig.32 is another illustration of an exemplary third distal assembly in a second position according to embodiments herein;

[0067] Fig.33 is another illustration of an exemplary third distal assembly in a second position according to embodiments herein;

[0068] Fig.34 is an illustration of an exemplary first portion of a first housing of an exemplary third distal assembly in a second position according to embodiments herein;

[0069] Fig.35 is a detailed view illustration of an exemplary first portion of a first housing of an exemplary third distal assembly according to embodiments herein; and

[0070] Fig.36 is an illustration of a detailed view of an exemplary second portion of a first housing of an exemplary third distal assembly according to embodiments herein. DETAILED DESCRIPTION

[0071] Provided herein are tissue suturing systems, devices, apparatuses and methods for endoscopic suturing of in vivo tissues. In some embodiments, the systems, devices, apparatuses and methods herein are used in combination with a flexible endoscope to suturing tissues. The suturing systems, devices, apparatuses and methods described herein are configured to perform full-thickness endoscopic suturing for various gastrointestinal indications, including, for example, tissue closure, weight loss treatment, stent fixation and graft fixation. Provided herein are apparatus, devices and systems (as used herein, "arcuate needle" is synonymous with "circular needle", and is an arched needle that is not completely circular but travels in a circular path or a substantially circular path) through a C-shaped portion of a distal assembly, wherein such a C-shaped portion of the distal assembly is not at right angles to the main axis of the endoscope and has an angle that is not aligned with respect to the main axis of the endoscope (see needle axis 501 elsewhere herein). Therefore, when using the arcuate needle of the distal assembly for suturing, a tissue grabber is not necessary because the distal assembly is easily manipulated to place the tissue between the open ends of the C-shaped portion of the distal assembly and into the gap formed by the "C" of the C-shaped portion of the distal assembly, for suturing once in such a position without the need for separate support. The alignment and angle of the device, apparatus, system and method relative to the lens barrel allow easy observation using the camera of the device. Such a distal assembly is coupled to the distal end of the endoscope without using a working channel, and during use and suturing, the needle is easily manipulated to pass through the tissue with a clear view of the camera of the endoscope, and the simplicity and accuracy of suturing are obtained. Further, the device, apparatus, system and method described herein can actuate the arcuate needle by a C-shaped distal assembly coupled to the distal non-flexed end of the lens barrel, and use a simple set of wires and a shuttle coupled to the wire to manipulate the arcuate needle during suturing without losing the flexibility of the lens barrel. Endoscopic suturing system

[0072] Figure 11 is an illustration of an exemplary endoscopic suturing system 100 configured for use with an endoscope 140. As shown, the exemplary endoscopic suturing system 100 includes a distal assembly 120, a proximal assembly 110, and a cable 130. In some embodiments, the endoscopic suturing system 100 also includes a cable fastener 150 that couples at least a portion of the cable 130 to the endoscope 140. In some embodiments, the cable fastener 150 removably couples at least a portion of the cable 130 to the endoscope 140. In some embodiments, the cable fastener 150 fastens the cable 130 to the endoscope 140 by wrapping around the cable 130 and the endoscope 140. In some embodiments, the cable fastener 150 fastens the cable 130 to the endoscope 140 by clamping to the cable 130 and the endoscope 140. In some embodiments, the cable fastener 150 fastens the cable 130 to the endoscope 140 by removably adhering the cable 130 to the endoscope 140. In some embodiments, the cable fastener comprises a press-fit fastener, a clamp, an adhesive, a tape, a strip, a set screw, a hook-and-loop fastener, a magnet, or any combination thereof. In some embodiments, the endoscopic suturing system 100 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more cable fasteners 150. Proximal Components

[0073] Figure 2 and Figure 3 An illustration of an exemplary proximal assembly 110 coupled to an endoscope 140 is shown. As shown, the exemplary proximal assembly 110 includes a second housing 111 and an actuator 112. In some embodiments, the second housing 111 includes a second housing fastener 111A, an actuator support portion 111B, and a second main housing body 111C. In some embodiments, the second main housing body 111C couples the second housing fastener 111A to the actuator support portion 111B. In some embodiments, the proximal assembly 110 has a length of about 10 mm to about 50 mm. In some embodiments, the proximal assembly 110 has a length of up to about 50 mm.

[0074] In some embodiments, the second housing 111 is coupled to the endoscope 140. In some embodiments, the second housing 111 is removably coupled to the endoscope 140. In some embodiments, the second housing 111 is coupled to the endoscope 140 and the endoscope biopsy port (or instrument channel port) 140A of the endoscope 140. In some embodiments, the second housing 111 is removably coupled to the endoscope 140 at a junction between the endoscope 140 and the endoscope cable 140A. In some embodiments, the second housing 111 surrounds a portion of the endoscope 140, the endoscope cable 140A, or both. In some embodiments, the second housing 111 partially surrounds a portion of the endoscope 140, the endoscope cable 140A, or both. In some embodiments, the coupling of the second housing 111 to both the endoscope 140 and the endoscope cable 140A provides greater stability for the proximal assembly 110 on the endoscope 140.

[0075] In some embodiments, the second housing fastener 111A and the second main housing body 111C are coupled to the endoscope 140. In some embodiments, the second housing fastener 111A and the second main housing body 111C are removably coupled to the endoscope 140. In some embodiments, the second housing fastener 111A and the second main housing body 111C are coupled to the endoscope 140 and an endoscope biopsy port (or instrument channel port) 140A of the endoscope 140. In some embodiments, the second housing fastener 111A and the second main housing body 111C are removably coupled to the endoscope 140 at a junction between the endoscope 140 and the endoscope cable 140A. In some embodiments, the second housing fastener 111A and the second main housing body 111C surround a portion of the endoscope 140, the endoscope cable 140A, or both. In some embodiments, the second housing fastener 111A and the second main housing body 111C partially surround a portion of the endoscope 140, the endoscope cable 140A, or both. In some embodiments, the coupling of the second housing fastener 111A and the second main housing body 111C to the endoscope 140 and the endoscope cable 140A provides greater stability for the proximal assembly 110 on the endoscope 140. In some embodiments, the second housing fastener 111A is rigidly connected to the endoscope 140 without allowing any relative movement between the endoscope 140 and the second housing 111.

[0076] As shown, the second main housing body 111C includes a first recess and a second recess. In some embodiments, the first recess surrounds a portion of the endoscope 140. In some embodiments, the second recess surrounds a portion of the endoscope cable 140A. In some embodiments, the inner diameter of the first recess is equal to or greater than the outer diameter of the endoscope 140. In some embodiments, the inner diameter of the first recess is about 5 mm to about 50 mm. In some embodiments, the inner diameter of the second recess is equal to or greater than the outer diameter of the endoscope cable 140A. In some embodiments, the inner diameter of the second recess is about 5 mm to about 50 mm. In some embodiments, the angle between the centerline of the first recess and the centerline of the second recess is about 30 degrees. In some embodiments, the angle between the centerline of the first recess and the centerline of the second recess is approximately 5 degrees, 10 degrees, 15 degrees, 20 degrees, 25 degrees, 30 degrees, 35 degrees, 40 degrees, 45 degrees, 50 degrees, 55 degrees, 60 degrees, 65 degrees, 70 degrees, 75 degrees, 80 degrees, 85 degrees, 90 degrees, including increments therein. In some embodiments, the angle between the centerline of the first recess and the centerline of the second recess is about 5 degrees to about 90 degrees, about 10 degrees to about 90 degrees, about 10 degrees to about 80 degrees, about 20 degrees to about 70 degrees, about 5 degrees to about 60 degrees, about 10 degrees to about 60 degrees, about 20 degrees to about 60 degrees, about 10 degrees to about 50 degrees, about 5 degrees to about 45 degrees, about 10 degrees to about 50 degrees, about 15 degrees to about 65 degrees, about 25 degrees to about 65 degrees, about 30 degrees to about 60 degrees, 5 degrees to 90 degrees, 10 degrees to 90 degrees, 10 degrees to 80 degrees, 20 degrees to 70 degrees, 5 degrees to 60 degrees, 10 degrees to 60 degrees, 20 degrees to 60 degrees, 10 degrees to 50 degrees, 5 degrees to 45 degrees, 10 degrees to 50 degrees, 15 degrees to 65 degrees, 25 degrees to 65 degrees, or 30 degrees to 60 degrees. In some embodiments, at least one of the first recess or the second recess of the second main housing body 111C has a uniform thickness.

[0077] In some embodiments, the second main housing body 111C includes a fastening mechanism coupled to the second housing fastener 111A. As shown, the fastening mechanism of the second main housing body 111C includes a plurality of ridges. Alternatively, in some embodiments, the fastening mechanism of the second main housing body 111C includes a cable tie, a rope, a loop, a hook and loop fastener, a tape, a strip, a magnet, a tie, a press fit, a set screw, an adhesive, or any combination thereof.

[0078] In some embodiments, the second housing fastener 111A is coupled to a fastening mechanism of the second main housing body 111C to secure the proximal assembly 110 to the endoscope 140. As seen, the exemplary second housing fastener 111A comprises a strip extending from the second main housing body 111C. In some embodiments, the second housing fastener 111A and the second main housing body 111C are coupled by a hinge (not shown), wherein the second housing fastener 111A rotates around the second main housing body 111C via the hinge. In some embodiments, the second housing fastener 111A comprises a flexible strip that is permanently attached to the second main housing body 111C. In some embodiments, the second housing fastener 111A comprises a flexible strip that is overmolded onto the second main housing body 111C. In some embodiments, at least a portion of the second housing fastener 111A is flexible. Additionally, as shown, the end of the strip of the second housing fastener 111A includes a hook that engages and disengages with the fastening mechanism of the second main housing body 111C. Additionally, as shown, in some embodiments, the fastening mechanism of the second main housing body 111C includes a squeeze for gripping by a user during engagement and disengagement with the fastening mechanism of the second main housing body 111C. In some embodiments, the strip of the second housing fastener 111A includes a hook that engages and disengages with the fastening mechanism of the second main housing body 111C. In some embodiments, the strip of the second housing fastener 111A and the fastening mechanism of the second main housing body 111C enable the second housing 111 to be secured to endoscopes 140 of various sizes. In some embodiments, the hook and

[0079] In some embodiments, the second housing 111 includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more housing fasteners 111A. Alternatively, the second housing 111 is not coupled to the endoscope 140. In some embodiments, the proximal assembly 110 is configured to be used as a handheld assembly. In some embodiments, the proximal assembly 110 is configured to be mounted to a surface, a pole, a bracket, or any combination thereof.

[0080] In some embodiments, the wheel 113 is constrained to rotate about at least some degrees of freedom relative to the second housing 111. In some embodiments, the actuator support portion 111B includes a hole for receiving the pin 114. In some embodiments, the actuator support portion 111B surrounds at least a portion of the actuator 112. As seen, the exemplary actuator 112 includes a wheel 113 that rotates around a pin 114 within the second housing 111. In some embodiments, the actuator 112 is free to rotate around the pin 114 within the second housing 111. In some embodiments, at least one of the second housing 111, the pin 114, or the wheel 113 includes a bearing that allows the wheel 113 to rotate around the pin 114 within the second housing 111. In some embodiments, at least one of the wheel 113 or the actuator support portion 111B includes a lock, wherein the rotation of the wheel 113 around the pin 114 is temporarily locked in a single position by the lock. In some embodiments, at least one of the second housing 111, the pin 114, or the wheel 113 includes a groove, ridge, recess, spring, or any combination thereof that couples and decouples when the wheel 113 rotates about the pin 114 to allow manual advancement of the wheel 113. In some embodiments, the groove, ridge, recess, spring, or any combination thereof couples and decouples when the wheel 113 rotates about the pin 114 to provide tactile feedback indicating an increase or angle of rotation. Additionally, in some embodiments, the actuator 112 further includes a spring, groove, magnet, or any combination thereof to bias the actuator 112 to one or more positions relative to the second housing 111.

[0081] Alternatively, in some embodiments, the second housing 111 does not have the pin 114, wherein the wheel 113 rotates about a protrusion in the actuator support portion 111B. In some embodiments, the wheel 113 includes the pin 114 or an extrusion, wherein the wheel 113 and the pin 114 or extrusion rotate about corresponding holes in the actuator support portion 111B. Alternatively, in some embodiments, the wheel 113 is constrained to rotate relative to the second housing 111 via a circular channel, a spring, a cam, a pin, a screw, a bolt, or any combination thereof. In some embodiments, the pin 114 is removable for cleaning the wheel 113. As shown in FIG. Figure 3 As shown, wheel 113 is circular. In some embodiments, wheel 113 has an outer diameter. Alternatively, in some embodiments, wheel 113 has a shape including a triangle, a square, a pentagon, a hexagon, or any other polygon.

[0082] As shown, the exemplary actuator 112 includes a knob 119 that allows a user to rotate the wheel 113 about the second housing 111. In some embodiments, the knob 119 also serves as an indicator of the position of the actuator 112 relative to the second housing 111. In some embodiments, the knob 119 prevents the wheel 113 from rotating more than 360 degrees in the primary direction 131, or rotating more than 360 degrees in a second direction opposite to the primary direction 131. In some embodiments, the wheel 113 rotates in the primary direction 131 up to about 360 degrees, and in the second direction opposite to the primary direction 131 up to about 360 degrees. In some embodiments, wheel 113 rotates in primary direction 131 by at most about 20 degrees, at most about 30 degrees, at most about 40 degrees, at most about 50 degrees, at most about 60 degrees, at most about 70 degrees, at most about 80 degrees, at most about 90 degrees, at most about 110 degrees, at most about 120 degrees, at most about 130 degrees, at most about 140 degrees, at most about 150 degrees, at most about 160 degrees, at most about 170 degrees, at most about 180 degrees, at most about 190 degrees, at most about 200 degrees, at most about 210 degrees, at most about 220 degrees, at most about 230 degrees, at most about 240 degrees, at most about 250 degrees, at most about 260 degrees, at most about 270 degrees, at most about 280 degrees, at most about 290 degrees, at most about 300 degrees, at most about 310 degrees, at most about 320 degrees, at most about 330 degrees, at most about 340 degrees, at most about 350 degrees, or at most about 360 degrees. degrees, and rotated in a second direction opposite to the main direction 131 by at most about 20 degrees, at most about 30 degrees, at most about 40 degrees, at most about 50 degrees, at most about 60 degrees, at most about 70 degrees, at most about 80 degrees, at most about 90 degrees, at most about 110 degrees, at most about 120 degrees, at most about 130 degrees, at most about 140 degrees, at most about 150 degrees, at most about 160 degrees, at most about 170 degrees, at most about 180 degrees, at most about 190 degrees, at most about 200 degrees, at most about 210 degrees, at most about 220 degrees, at most about 230 degrees, at most about 240 degrees, at most about 250 degrees, at most about 260 degrees, at most about 270 degrees, at most about 280 degrees, at most about 290 degrees, at most about 300 degrees, at most about 310 degrees, at most about 320 degrees, at most about 330 degrees, at most about 340 degrees, at most about 350 degrees or at most about 360 degrees. In some embodiments, the actuator 112 further includes an indicator indicating its position relative to the second housing 111. Alternatively, in some embodiments, the actuator 112 includes or further includes a pulley, a wheel, a clamp, a knot, a post, a gear, a tooth, a chain, or any combination thereof.

[0083] As shown, the exemplary wheel 113 includes a first channel 115 that receives the first cable portion 132 and a second channel 116 that receives the second cable portion 133. In some embodiments, at least one of the first channel 115 or the second channel 116 has a circular cross-section. In some embodiments, the wheel 113 does not include the second channel 116. In such embodiments, the first channel 115 includes a single spiral channel. In some embodiments, at least one of the first channel 115 or the second channel 116 has an inner width that is equal to or greater than the width of the cable 130. In some embodiments, the radius of the first channel 115 is equal to the radius of the second channel 116. In some embodiments, the radius of the first channel 115 is greater than the radius of the second channel 116. In some embodiments, the radius of the first channel 115 is less than the radius of the second channel 116. In some embodiments, the circumference of the first channel 115 is equal to the circumference of the second channel 116. In some embodiments, the circumference of the first channel 115 is greater than the circumference of the second channel 116. In some embodiments, the circumference of the first channel 115 is less than the circumference of the second channel 116. In some embodiments, the first channel 115 and the second channel 116 are concentric. In some embodiments, the first channel 115 and the second channel 116 are not concentric. In some embodiments, the first channel 115 and the second channel 116 overlap.

[0084] In some embodiments, the actuator 112 further comprises a first fastener 118 coupling the first cable portion 132 to the wheel 113, and a second fastener (not shown) coupling the second cable portion 133 to the actuator 112. In some embodiments, the first fastener 118 retains the first cable portion 132 within the first channel 115. In some embodiments, the second fastener retains the second cable portion 133 within the second channel 116. In some embodiments, the first fastener 118 prevents the wheel 113 from rotating more than 360 degrees in the primary direction 131, or rotating more than 360 degrees in a second direction opposite to the primary direction 131. In some embodiments, the proximal assembly 110 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more fasteners. In some embodiments, the wheel 113 does not include the first fastener 118 or the second fastener. In some embodiments, the wheel 113 includes a knob, a tie, or an extrusion that couples the first cable portion 132, the second cable portion 133, or both to the wheel 113. In some embodiments, the first cable portion 132 and the second cable portion 133 are connected, and the cable 130 includes one or two components. In some embodiments, the cable 130 includes two or more components. In some embodiments, the first cable portion 132 and the second cable portion 133 are not connected, and the cable 130 includes two or more components. In some embodiments, at least one of the first cable portion 132 or the second cable portion 133 is always in tension during rotation of the wheel 113 of the actuator 112. In some embodiments, at least one of the first cable portion 132 or the second cable portion 133 has no slack during rotation of the wheel 113 of the actuator 112. In some embodiments, when the wheel 113 of the actuator 112 rotates in the primary direction 131, at least one of the first cable portion 132 or the second cable portion 133 is in tension. In some embodiments, when the wheel 113 of the actuator 112 rotates in a second direction opposite to the primary direction 131, at least one of the first cable portion 132 or the second cable portion 133 is in tension.

[0085] In some embodiments, according to Figure 3, when rotated in the main direction 131, the actuator 112 translates the first cable portion 132 away from the second housing 111 by a first distance, and translates the second cable portion 133 toward the second housing 111 by a second distance. In some embodiments, when rotated in a second direction opposite to the main direction 131, the actuator 112 translates the first cable portion 132 toward the second housing by a third distance, and translates the second cable portion 133 away from the second housing 111 by a fourth distance. In some embodiments, the first distance, the second distance, the third distance, and the fourth distance are equal. In some embodiments, at least two of the first distance, the second distance, the third distance, and the fourth distance are equal. In some embodiments, the first distance is equal to the third distance, and the second distance is equal to the fourth distance.

[0086] like Figure 3 As shown, in some embodiments, the endoscopic suturing system 100 also includes a sheath 130A surrounding at least a portion of the cable 130. In some embodiments, the cable 130 is freely translated back and forth in one direction within the sheath 130A. In some embodiments, the cable 130 and the sheath 130A include a Bowden cable. In some embodiments, the cable 130 includes a multi-strand cable, a single-strand cable, a rope, a line, a rope, a metal wire, or any combination thereof. In some embodiments, the cable 130 includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more cables. In some embodiments, at least a portion of the cable 130 is not covered by the cable sheath 130A. In some embodiments, the cable 130 is rigid. In some embodiments, the cable 130 is not elastic. In some embodiments, the cable sheath 130A includes a hollow tube that protects the cable 130 therein. In some embodiments, the cable jacket 130A is rigid. In some embodiments, the cable jacket 130A is not elastic.

[0087] As shown, the second housing 111 includes a proximal sheath fastener 117 that couples the sheath 130A to the second housing 111. As shown, the sheath fastener 117 is connected to the actuator support portion 111B of the second housing 111. Alternatively, in some embodiments, the sheath fastener 117 is connected to any portion of the second housing 111. In some embodiments, the proximal sheath fastener 117 fixes a portion of the sheath 130A relative to the second housing 111, thereby allowing the cable 130 to travel within the sheath 130A when the wheel 113 rotates. In some embodiments, the proximal sheath fastener 117 prevents the wheel 113 from rotating more than 360 degrees in the main direction 131, or rotating more than 360 degrees in a second direction opposite to the main direction. As shown, an exemplary proximal sheath fastener 117 includes a clamp. In some embodiments, the clamp includes a first plate, a second plate, and one or more screws that compress the cable 130 between the first plate and the second plate. Alternatively, in some embodiments, the proximal sheath fastener 117 comprises a screw, a zip tie, a tape, a bolt, a nut, or any combination thereof. In some embodiments, the proximal assembly 110 comprises at least one proximal sheath fastener 117 for the first cable portion 132, and at least one proximal sheath fastener 117 for the second cable portion 133. In some embodiments, the proximal assembly 110 comprises a single proximal sheath fastener 117 for both the first cable portion 132 and the second cable portion 133. In some embodiments, the proximal assembly 110 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more proximal sheath fasteners 117.

[0088] In some embodiments, the cable 130 is comprised of fabric, metal, plastic, carbon, or any combination thereof. In some embodiments, at least one of the second housing 111, the actuator 112, the wheel 113, the pin 114, the proximal sheath fastener 117, the first fastener 118, or the sheath 130A is comprised of plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. In some embodiments, the actuator does not include at least one of a crank, a gear, a rack, or a pinion. First distal assembly

[0089] Figure 4 and Figure 5An illustration of an exemplary first distal assembly 120 is shown. As shown, the exemplary first distal assembly 120 includes a first housing 121 that includes an endoscope fastener 121A. In some embodiments, the distal assembly is C-shaped, or includes a C-shaped portion, and is therefore referred to as being C-shaped. In some embodiments, the distal assembly has a C-shaped arcuate needle guide 121B, thereby providing the distal assembly with a C-shape. In some embodiments, the C-shaped portion of the distal assembly is at least an arcuate needle guide. Devices, apparatuses, and systems actuate an arcuate needle (as used herein, "arcuate needle" is synonymous with "circular needle" and is an arched needle that is not completely circular but travels in a circular path or a substantially circular path) through the C-shaped portion of the distal assembly wherein such C-shaped portion of the distal assembly is not at right angles to the endoscope main axis and has an angle that is not aligned with the endoscope main axis 502 (see needle axis 501 elsewhere herein). Thus, when suturing using the arcuate needle of the distal assembly, a tissue grabber is not necessary because the distal assembly is easily manipulated to place tissue between the open ends of the C-shaped portion of the distal assembly and into the gap formed by the "C" of the C-shaped portion of the distal assembly for suturing once in such a position without the need for separate support. In some embodiments, the end of the C-shaped portion of the distal assembly is aligned relative to the needle axis 501 at an angle of less than 180 degrees, less than about 170 degrees, less than about 160 degrees, less than about 150 degrees, less than about 145 degrees, less than about 120 degrees, less than about 100 degrees, about 20 degrees to about 170 degrees, about 30 degrees to about 150 degrees, about 40 degrees to about 120 degrees, about 45 degrees to about 110 degrees, about 50 degrees to about 120 degrees, or about 60 degrees to about 120 degrees. In some embodiments, such an angle is measured from the central axis of the pulley 2121AA or its equivalent pin, depending on the embodiment. In some embodiments, the angle is measured from the end of the C-shaped portion, which forms the smallest angle at which such an angle may be measured.

[0090] In some embodiments, the endoscope fastener 121A couples the first housing 121 to the endoscope 140. In some embodiments, the endoscope fastener 121A removably couples the first housing 121 to the endoscope 140. As shown, the endoscope fastener 121A comprises a press-fit fastener. In some embodiments, the press-fit endoscope fastener 121A is attached to the endoscope 140 by firmly pressing the press-fit endoscope fastener 121A onto the distal end of the endoscope 140. In some embodiments, the press-fit endoscope fastener 121A is attached to the endoscope 140 by firmly pressing and rotating the endoscope fastener 121A onto the distal end of the endoscope 140. In some embodiments, the press-fit endoscope fastener 121A is detached from the endoscope 140 by firmly pulling the press-fit endoscope fastener 121A away from the distal end of the endoscope 140. In some embodiments, the press-fit endoscope fastener 121A is detached from the endoscope 140 by firmly pulling and rotating the press-fit endoscope fastener 121A away from the distal end of the endoscope 140. Alternatively, in some embodiments, the endoscope fastener 121A comprises a press-fit fastener, a clamp, an adhesive, a tape, a strip, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the first distal assembly 120 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more endoscope fasteners 121A.

[0091] As shown, in some embodiments, the endoscope fastener 121A is circular. In some embodiments, the proximal outer diameter of the endoscope 140 is about 5 mm to about 16 mm. Thus, in some embodiments, the inner diameter of the endoscope fastener 121A is about 5 mm to about 16 mm. In some embodiments, the inner diameter of the endoscope fastener 121A is at least about 5 mm. In some embodiments, the inner diameter of the endoscope fastener 121A is at most about 16 mm. In some embodiments, the diameter of the press-fit endoscope fastener 121A is equal to or less than the diameter of the endoscope 140. In some embodiments, the diameter of the endoscope fastener 121A is equal to or greater than the diameter of the endoscope 140. In some embodiments, the endoscope fastener 121A is tapered and has a first inner diameter and a second inner diameter, wherein the first inner diameter is distal to the second inner diameter. In some embodiments, the first inner diameter is greater than the second inner diameter. In some embodiments, the second inner diameter is greater than the first inner diameter. In some embodiments, the diameter of the endoscope fastener 121A is measured as the maximum, minimum, or average internal width. In some embodiments, the diameter of the endoscope 140 is measured as the maximum, minimum, or average external width. Alternatively, in some embodiments, the endoscope fastener 121A has a cross-sectional shape including a triangle, a square, a hexagon, or any other polygon. In some embodiments, the inner length of the endoscope fastener 121A is about 10 mm to about 30 mm. In some embodiments, the inner length of the endoscope fastener 121A is measured as the minimum, maximum, or average length from the distal end of the endoscope fastener 121A to the proximal end of the endoscope fastener 121A. In some embodiments, the inner length of the endoscope fastener 121A is measured as the minimum, maximum, or average normal length from the distal end of the endoscope fastener 121A to the proximal end of the endoscope fastener 121A.

[0092] like Figure 4As shown, the exemplary first distal assembly 120 also includes a distal sheath fastener 128 that couples a portion of the sheath 130A to the first housing 121. As shown, the first housing 121 includes a distal sheath fastener 117 that couples the sheath 130A to the first housing 121. In some embodiments, the distal sheath fastener 117 fixes a portion of the sheath 130A relative to the first housing 121, thereby allowing the cable 130 to travel within the sheath 130A when the wheel rotates. As shown, the exemplary distal sheath fastener 128 includes a clamp. In some embodiments, the distal sheath fastener 128 includes a plate and one or more sheath fastener screws 128A, and the one or more sheath fastener screws 128A compress the cable sheath 130A between the plate and the first housing 121. Alternatively, in some embodiments, the distal sheath fastener 128 includes a screw, a tie, a tape, or any combination thereof. In some embodiments, the first housing 121 includes at least one distal sheath fastener 128 for the first cable portion 132 and at least one distal sheath fastener 128 for the second cable portion 133. In some embodiments, the first housing 121 includes distal sheath fasteners 128 for both the first cable portion 132 and the second cable portion 133. In some embodiments, a portion of the cable sheath 130A extends through the end of the distal sheath fastener 128 and into the first housing 121. In some embodiments, the distal assembly 120 includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more distal sheath fasteners 128. Alternatively, in some embodiments, the distal sheath fastener 128 includes a clamp, a tie, a loop, a hook and loop fastener, an adhesive, or any combination thereof.

[0093] In some embodiments, according to Figure 5, the angle between the needle axis 501 and the proximal axis (or main axis) 502 of the endoscope 140 is about 5 degrees to about 85 degrees. In some embodiments, the angle between the needle axis 501 and the proximal axis 502 of the endoscope 140 is adjustable within about 5 degrees to about 85 degrees. In some embodiments, the specific angle between the needle axis 501 and the proximal axis 502 of the endoscope 140 allows the camera of the endoscope 140 to observe the entrance, exit, or both the arcuate needle and the tissue being sutured. In some embodiments, the needle axis 501 is defined as an axis that is perpendicular to the plane of symmetry of the arcuate needle 122 and coincides with the center point of the radius of the arcuate needle 122. In some embodiments, the proximal axis 502 of the endoscope 140 is defined as the central axis or main axis of the distal portion of the endoscope 140. In some embodiments, the proximal axis 502 of the endoscope 140 is defined as the central axis of the endoscope fastener 121A of the first housing 121. The angle between the central axis of the arcuate needle guide 12 IB and the proximal axis 502 of the endoscope 140 is defined as the maximum, minimum, or average angle.

[0094] Figures 6 to 9 A detailed illustration of an exemplary first distal assembly 120 is shown. Figure 6 , the exemplary first housing 121 includes a first main housing portion 601, a first secondary housing portion 602, and a pin fastener 603. In some embodiments, the first secondary housing portion 602 is assembled within the first main housing portion 601. The first main housing portion 601 and the first secondary housing portion 602 are abutted by the pin fastener 603. In some embodiments, the first main housing portion 601 and the first secondary housing portion 602 are removably abutted by the pin fastener 603. In some embodiments, the first main housing portion 601 and the first secondary housing portion 602 are made of the same material. In some embodiments, the first main housing portion 601 and the first secondary housing portion 602 are made of different materials. As shown, the exemplary pin fastener 603 includes a press-fit fastener, wherein the outer diameter of the press-fit fastener is greater than the diameter of the corresponding holes in the first main housing portion 601 and the first secondary housing portion 602. Alternatively, in some embodiments, the pin fastener 603 includes a screw, a bolt, a threaded feature, a nut, a rivet, an adhesive, a pulley, a bearing, a weld, or any combination thereof. As shown, the exemplary first housing 121 includes two pin fasteners 603. Alternatively, the exemplary first housing 121 includes 1, 3, 4, 5, 6, 7, 8, 9, 10 or more pin fasteners 603.

[0095] In addition, in some embodiments, the first distal assembly 120 includes an arcuate needle 122 disposed within an arcuate needle guide 121B within the first housing 121. In some embodiments, at least one of the first main housing portion 601 or the first secondary housing portion 602 includes an arcuate needle guide 121B. In some embodiments, the arcuate needle 122 slides freely within the arcuate needle guide 121B. In some embodiments, the arcuate needle guide 121B constrains the arcuate needle 122 to rotate within one degree of freedom. In some embodiments, the arcuate needle guide 121B constrains the arcuate needle 122 to rotate within at least one rotational degree of freedom. As seen, the exemplary arcuate needle guide 121B surrounds at least a portion of the arcuate needle 122. In some embodiments, when the exemplary arcuate needle guide 121B is located within the first housing 121, it surrounds at least a portion of the arcuate needle 122. In some embodiments, the inner width of the arcuate needle guide 121B is greater than the thickness of the arcuate needle 122. In some embodiments, the cross-sectional shape of the arcuate needle guide 121B includes a circle, a square, a rectangle, or any other polygon. In some embodiments, a groove 604 is formed between a first end of the arcuate needle guide 121B and a second opposite end of the arcuate needle guide 121B within the first distal assembly 120. As seen therein, the arcuate needle guide 121B surrounds the cross-sectional circumference of the arcuate needle 122 by approximately 280 degrees. Alternatively, in some embodiments, the arcuate needle guide 121B surrounds the cross-sectional circumference of the arcuate needle 122 by approximately 100 degrees, 120 degrees, 140 degrees, 160 degrees, 180 degrees, 200 degrees, 220 degrees, 240 degrees, 260 degrees, 280 degrees, 300 degrees, 320 degrees, or more degrees, including increments therein.

[0096] In some embodiments, a groove 604 is formed between the first pin fastener 603 and the second opposing pin fastener 603 within the first distal assembly 120. In some embodiments, the groove 604 accommodates tissue for suturing by the arcuate needle 122. In some embodiments, the tissue is supported against the arcuate needle 122 throughout the suturing process. In some embodiments, the first distal assembly 120 does not include an anchor exchange catheter. In some embodiments, the first distal assembly 120 does not require a dedicated grasper to hold the tissue against the arcuate needle 122. In some embodiments, the lack of a required dedicated grasper enables the use of a standard endoscope 140 without the need for an additional dedicated working channel.

[0097] according to Figures 7 to 9, the exemplary first distal assembly 120 also includes a shuttle 123 having a pawl 124. As shown, the exemplary shuttle 123 translates within a shuttle guide 121C within the first housing 121. In some embodiments, at least one of the shuttle 123 or the shuttle guide 121C within the first housing 121 is arcuate. In some embodiments, the shuttle 123 slides within the shuttle guide 121C. In some embodiments, the shuttle 123 translates at least one rotational degree within the shuttle guide 121C. In some embodiments, the shuttle 123 translates about one rotational degree within a 270 degree arc within the shuttle guide 121C. In some embodiments, the shuttle 123 translates in an arc within the shuttle guide 121C at an angle of 90, 100, 110, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320, or more about one rotational degree. In some embodiments, at least one of the shuttle 123 or the shuttle guide 121C has a cross-sectional shape including a circle, a square, a rectangle, or any other polygon.

[0098] In some embodiments, at least one of the first main housing portion 601 or the first secondary housing portion 602 includes a shuttle guide 121C. In some embodiments, the shuttle 123 slides within the shuttle guide 121C of the distal assembly 120. As shown, the shuttle 123 is arcuate to slide within the arcuate shuttle guide 121C. In some embodiments, the first main housing portion 601 constrains the bottom surface of the shuttle 123, wherein the first secondary housing portion 602 constrains a portion of the inner surface, outer surface, and top surface of the shuttle 123. Alternatively, in some embodiments, at least one of the first main housing portion 601 or the first secondary housing portion 602 constrains one or more of the bottom surface, inner surface, outer surface, and top surface of the shuttle 123. In some embodiments, the shuttle 123 is constrained by at least one of the first main housing portion 601 or the first secondary housing portion 602 when translating within the shuttle guide 121C. As shown, the bottom surface of the shuttle 123 contacts a portion of the first main housing portion 601, while the interior and exterior of the shuttle 123 contact a portion of the first primary housing portion 602. In some embodiments, the shuttle 123 contacts at least one of the first main housing portion 601 or the first primary housing portion 602 as it translates within the shuttle guide 121C. As shown, the arcuate channel between the shuttle guide 121C and the arcuate needle guide 121B provides clearance for the pawl 124 to contact the arcuate needle 122 as the shuttle 123 translates through the shuttle guide 121C. In some embodiments, the width of the arcuate channel is greater than the width of the pawl 124 but less than the width of the arcuate needle 122.

[0099] In some embodiments, the inner surface of the shuttle 123 is defined as the surface of the shuttle 123 that is closest to the needle axis 501. In some embodiments, the outer surface of the shuttle 123 is defined as the surface of the shuttle 123 that is farthest from the needle axis 501. In some embodiments, the top surface of the shuttle 123 is defined as the surface of the shuttle 123 that is closest to the arcuate needle 122. In some embodiments, the bottom surface of the shuttle 123 is defined as the surface of the shuttle that is farthest from the arcuate needle 122.

[0100] In some embodiments, the arc length of the shuttle guide 121C is equal to the distance traveled by at least one of the first cable portion or the second cable portion during rotation of the actuator wheel minus the width of the shuttle 123. In some embodiments, during rotation of the actuator wheel, the shuttle 123 travels within the shuttle guide 121C the distance traveled by at least one of the first cable portion or the second cable portion. In some embodiments, the ratio between the length of the shuttle 123 and the arc length of the shuttle guide 121C is about 1:3 to about 1:15. In some embodiments, the ratio between the length of the shuttle 123 and the arc length of the shuttle guide 121C is at least about 1:3. In some embodiments, the ratio between the length of the shuttle 123 and the arc length of the shuttle guide 121C is at most about 1:15. In some embodiments, the ratio between the arc length of the shuttle guide 121C and the diameter of at least one of the first channel or the second channel of the wheel of the actuator is about 2:1 to about 1:5. In some embodiments, the ratio between the arc length of the shuttle guide 121C and the diameter of at least one of the first channel or the second channel of the wheel of the actuator is at least about 2: 1. In some embodiments, the ratio between the arc length of the shuttle guide 121C and the diameter of at least one of the first channel or the second channel of the wheel of the actuator is at most about 1:5.

[0101] according to Figure 8, the exemplary shuttle 123 also includes a cable attachment 127 to connect to the cable 130. As shown, the cable attachment 127 includes a chamber to accommodate and secure a portion of the cable 130. Alternatively, in some embodiments, the cable attachment 127 includes a clamp, a hole, a screw, a bolt, a nut, a clamp, a pin, or any combination thereof. In some embodiments, the cable attachment 127 includes a terminal cable attachment, wherein the cable terminates at the cable attachment 127. In some embodiments, the cable attachment 127 includes a non-terminal cable attachment, wherein the cable passes through and is coupled to the cable attachment 127. In some embodiments, the shuttle 123 includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more cable attachments 127. As seen, the exemplary shuttle 123 is rigidly connected to the cable 130 at the cable attachment 127, so that a tension on the cable 130 causes the shuttle 123 to translate in the direction of the tension.

[0102] In some embodiments, the shuttle 123 includes a pawl 124, a pad 126, or both. In some embodiments, the shuttle 123 includes a chamber 123A that accommodates the pawl 124, the pad 126, or both. In some embodiments, the inner width of the chamber 123A is greater than the outer width of the pawl 124, the outer width of the pad 126, or both. In some embodiments, the chamber 123A has a depth that ends within the shuttle 123. In some embodiments, the chamber 123A extends through the shuttle 123. In some embodiments, the chamber 123A has a cross-sectional shape that includes a square, a circle, a triangle, a hexagon, or any other polygon.

[0103] In some embodiments, the pawl 124 is biased toward engagement with the notch 122A of the arcuate needle 122. In some embodiments, the pawl 124 is biased toward the first direction 1000. In some embodiments, the pawl 124 includes a pivot 127 to rotate about the shuttle 123. In some embodiments, the pivot 127 includes a pin pressing element of the pawl 124. In some embodiments, the pivot 127 includes a pin rigidly attached to the pawl 124 that rotates about a hole in the shuttle 123. The pivot 127 includes a pin rigidly attached to the shuttle 123 that rotates about a hole in the pawl 124. Alternatively, in some embodiments, the pivot 127 includes a groove, a slot, a screw, or any combination thereof in the pawl 124, the shuttle 123, or both.

[0104] In some embodiments, the pawl 124 is biased toward being engaged by the pad 126. In some embodiments, the pad 126 is resilient. In some embodiments, the pad 126 includes a spring. In some embodiments, the pad 126 presses against the pawl 124 in a second direction opposite to the first rotational direction 1000. In some embodiments, the pad 126 presses against the pawl 124 to drive the pawl 124 upward and out of the chamber 123A to engage with the notch 122A of the arcuate needle 122. In some embodiments, the position of the pivot 127 relative to the end of the chamber 123A, combined with the position of the pad 126, biases the pawl engagement. In some embodiments, when the pawl 124 is engaged, the pad 126 presses the pawl 124 against the end of the chamber 123A of the shuttle 123. In some embodiments, when the pawl 124 is disengaged, the arcuate needle 122 presses the pawl 124 against the liner 126, so that the pawl moves upward into the chamber 123A and away from the end of the chamber 123A of the shuttle 123. In some embodiments, the upper surface of the pawl 124 is deflected toward one end of the shuttle 123. In some embodiments, the upper surface of the pawl 124 is deflected upward along a second rotational direction opposite to the first rotational direction 1000. In some embodiments, the upper surface of the pawl 124 is deflected to engage with the bevel of the arcuate needle. In some embodiments, the pawl 124 further comprises a spring, a flexure, a double spring door, a liner, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the first distal assembly 120 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more pawls 124.

[0105] In some embodiments, the gasket 126 is integrated into the pawl 124. In some embodiments, the gasket 126 is integrated into the shuttle 123. In some embodiments, the gasket 126 is integrated into the chamber 123A of the shuttle 123. In some embodiments, the shuttle 123 does not include the gasket 126. In some embodiments, the shuttle 123 does not include the gasket 126, wherein the pawl 124 includes a flexure, a spring, a double spring door, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof to bias the pawl 124 against the arcuate needle. In some embodiments, the shuttle 123 does not include the pawl 124 or the gasket 126, wherein the shuttle 123 includes a flexure, a spring, a double spring door, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof to engage and disengage with the arcuate needle.

[0106] In addition, according to Figure 7, the exemplary first housing 121 includes a cable pulley 121D that guides the cable 130 from the proximal assembly through the shuttle guide 121C to the shuttle 123 and out of the first housing 121. In some embodiments, at least one of the first main housing portion 601, the first secondary housing portion 602, or the pin fastener 603 of the first housing 121 includes a cable pulley 121D. In some embodiments, the first housing 121 includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more cable pulleys 121D. In some embodiments, the cable pulley 121D includes a bearing, a rod, a curved surface, or any combination thereof. In some embodiments, the cable pulley 121D comprises a rigid portion of the first housing 121. Alternatively, in some embodiments, the cable pulley 121D rotates within the first housing 121. Alternatively, in some embodiments, the cable pulley 121D rotates within the first main housing portion 601, the first secondary housing portion 602, or both. At least one of the first main housing portion 601 or the first secondary housing portion 602 also includes one or more cable guides that direct the cable 130 toward and away from the cable pulley 121D.

[0107] Figure 10-13 The advancement of the arcuate needle 122 as it is translated by the shuttle 123 and the pawl 124 through the arcuate needle guide 121B is shown. Fig.10 In the first position, the arcuate needle 122 is completely contained within the arcuate needle guide 121B within the first housing 121. When the cable 130 pulls the shuttle 123 within the shuttle guide 121C in a first rotational direction 1000 relative to the first housing 121, the pawl 124 engages with the notch 122A in the arcuate needle 122, as shown in FIG. Fig.11 , causing a portion of the arcuate needle 122 to leave the first housing 121. Once the shuttle 123 cannot move further in the shuttle guide 121C of the first housing 121 along the first rotational direction 1000, the cable 130 then pulls the shuttle 123 in a second rotational direction opposite to the first rotational direction 1000, causing the pawl 124 to engage with the suture end 1201 of the arcuate needle 122. The cable 130 is then pulled along the first rotational direction 1000, causing the shuttle 123 to translate along the first rotational direction 1000, while the pawl 124 pushes against the suture end 1201 of the arcuate needle 122 to translate the arcuate needle 122, as shown in FIG. Fig.12, so that most of the arcuate needle 122 leaves the first housing 121, and only a portion of the tip 1101 of the arcuate needle 122 and the suture end 1201 are within the first housing 121. After the shuttle 123 cannot move further in the shuttle guide 121C of the first housing 121 along the first rotational direction 1000, the cable 130 pulls the shuttle 123 through the shuttle guide 121C of the first housing 121 along the second rotational direction, as shown in FIG. Fig.13 , so that the pawl 124 reengages the notch 122A in the arcuate needle 122. The cable 130 then pulls the shuttle 123 in the second rotational direction within the shuttle guide 121C of the first housing 121 to translate the arcuate needle 122 in the first rotational direction and return to the first housing 121 to perform a suturing operation.

[0108] Thus, a single suturing operation includes pulling the cable 130 in a first direction 1000, pulling the cable 130 in a second direction opposite to the first direction 1000, pulling the cable 130 in the first direction 1000 a second time, pulling the cable 130 in the second direction a second time, pulling the cable 130 in the first direction 1000 a third time, and pulling the cable 130 in the second direction a third time. As shown, the first rotational direction 1000 is counterclockwise relative to the first housing 121. Alternatively, in some embodiments, the first rotational direction 1000 is clockwise relative to the first housing 121.

[0109] In some embodiments, according to Figure 3 , Figure 4 and Fig.10, pulling the cable 130 in the first rotational direction 1000 includes pulling the main cable portion 132 toward the second housing 111 of the proximal assembly 110. In some embodiments, pulling the cable 130 in the first rotational direction 1000 includes rotating the wheel 113 of the actuator 112 in a secondary direction opposite to the primary direction 131. In some embodiments, pulling the cable 130 in a second rotational direction opposite to the first rotational direction 1000 includes pulling the secondary cable portion 133 toward the second housing 111 of the proximal assembly 110. In some embodiments, pulling the cable 130 in the second rotational direction opposite to the first rotational direction 1000 includes rotating the wheel 113 of the actuator 112 in the primary direction 131. In some embodiments, translating the shuttle 123 in the first rotational direction 1000 includes pulling the main cable portion 132 toward the second housing 111 of the proximal assembly 110. In some embodiments, translating the shuttle 123 in the first rotational direction 1000 includes rotating the wheel 113 of the actuator 112 in a second direction opposite to the primary direction 131. In some embodiments, translating the shuttle 123 in the second rotational direction opposite to the first rotational direction 1000 includes pulling the secondary cable portion 133 toward the second housing 111 of the proximal assembly 110. In some embodiments, translating the shuttle 123 in the second rotational direction opposite to the first rotational direction 1000 includes rotating the wheel 113 of the actuator 112 in the primary direction 131.

[0110] In some embodiments, the shuttle 123 translates about one or more rotational degrees within the shuttle guide 121C when pulled by the cable 130 in the first direction 1000 or the second direction. In some embodiments, the shuttle 123 translates about one rotational degree within a 270 degree arc within the shuttle guide 121C when pulled by the cable 130 in the first direction 1000 or the second direction. In some embodiments, the shuttle 123 translates about one rotational degree within an arc of 90, 100, 110, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320, or more degrees (including increments therein) within the shuttle guide 121C when pulled by the cable 130 in the first direction 1000 or the second direction.

[0111] In some embodiments, at least one of the second housing 111, the arcuate needle 122, the shuttle 123, the pawl 124, the suture 125, the gasket 126, the first main housing portion 601, the first housing portion 602, or the pin fastener 603 is comprised of plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. Bow Needle and Suture

[0112] Figures 14 to 18An illustration of an exemplary arcuate needle 122 and suture 125 is shown. Fig.14 and Fig.15 In some embodiments, the arcuate needle 122 has a notch 122A, a tip 1101, and a suture end 1201. In some embodiments, the notch 122A is angled in a direction opposite to the first rotational direction. Alternatively, in some embodiments, the notch 122A is angled in the first rotational direction. In some embodiments, the notch 122A is angled at an angle of about 5 degrees, 10 degrees, 15 degrees, 20 degrees, 25 degrees, 30 degrees, 35 degrees, 40 degrees, 45 degrees, 50 degrees, 55 degrees, 60 degrees, 65 degrees, or more, including increments therein. In some embodiments, the notch 122A is angled at an angle of at least about 5 degrees. As shown, the angle between the notch 122A and the suture end 1201 of the exemplary arcuate needle 122 is about 180 degrees. Alternatively, in some embodiments, the angle between the notch 122A and the suture end 1201 of the exemplary arcuate needle 122 is about 90 degrees, 100 degrees, 120 degrees, 140 degrees, 160 degrees, 180 degrees, 200 degrees, 220 degrees, 240 degrees, 260 degrees, 2800 degrees, or more, including increments therein. In some embodiments, the angle between the notch 122A and the suture end 1201 of the exemplary arcuate needle 122 is at least about 90 degrees.

[0113] In some embodiments, the outer diameter of the arcuate needle 122 is about 7 mm to about 20 mm. In some embodiments, the outer diameter of the arcuate needle 122 is at least about 7 mm. In some embodiments, the outer diameter of the arcuate needle 122 is at most about 20 mm. In some embodiments, the thickness 1510 of the arcuate needle 122 is about 0.5 mm to about 2 mm. In some embodiments, the thickness 1510 of the arcuate needle 122 is at least about 0.5 mm. In some embodiments, the thickness 1510 of the arcuate needle 122 is at most about 2 mm. In some embodiments, the ratio between the outer diameter of the arcuate needle 122 and the thickness 1510 is about 3:1 to about 15:1. In some embodiments, the ratio between the outer diameter of the arcuate needle 122 and the thickness 1510 is at least about 3:1. In some embodiments, the ratio between the outer diameter of the arcuate needle 122 and the thickness 1510 is at most about 15:1. In some embodiments, the ratio between the outer diameter of the arcuate needle 122 and the thickness 1510 is about 3:1, 4:1, 5:1, 6:1, 7:1, 8:1, 9:1, 10:1, 11:1, 12:1, 13:1, 14:1, or 15:1. In some embodiments, the ratio between the outer diameter of the arcuate needle 122 and the thickness 1510 is at least about 3:1. In some embodiments, the outer diameter of the arcuate needle 122 is measured as the maximum distance between two points on the surface of the arcuate needle 122. In some embodiments, the outer diameter of the arcuate needle 122 is measured as the maximum outer diameter of the arcuate needle 122. In some embodiments, the width of the arcuate needle 122 is measured as the thickness 1510 of the arcuate needle 122. The thickness 1510 of the arcuate needle 122 is measured as the thickness 1510 of the arcuate needle not within the tip 1101, the suture end 1201, or the notch 122A. In some embodiments, the thickness 1510 of the arcuate needle 122 is measured as the maximum, minimum, or average thickness 1510 of the arcuate needle 122 .

[0114] In some embodiments, the tip 1101 is directed at an angle of about 5 degrees, 10 degrees, 15 degrees, 20 degrees, 25 degrees, 30 degrees, 35 degrees, 40 degrees, 45 degrees, or more, including increments therein. In some embodiments, the tip 1101 is directed at an angle of at least about 5 degrees. As shown, the exemplary suture end 1201 is flat. Alternatively, in some embodiments, the suture end 1201 is rounded, tapered, or angled.

[0115] As shown, in some embodiments, the arcuate needle 122 has two notches 122A. In some embodiments, the arcuate needle 122 has 2, 3, 4, 5, 6, 7, 8, 9, 10 or more notches 122A. In some embodiments, the arcuate needle 122 has two or more notches 122A. As shown, each notch 122A is spaced apart at an angle of about 180 degrees around the arcuate needle 122.

[0116] In some embodiments, the notches 122A are spaced at an angle of about 10 degrees to about 180 degrees around the arcuate needle 122. In some embodiments, the notches 122A are spaced at an angle of about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 10 degrees to about 140 degrees, about 10 degrees to about 160 degrees, about 10 degrees to about 180 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about about 100 degrees, about 20 degrees to about 120 degrees, about 20 degrees to about 140 degrees, about 20 degrees to about 160 degrees, about 20 degrees to about 180 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 30 degrees to about 140 degrees, about 30 degrees to about 160 degrees, about 30 degrees to about 180 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 40 degrees to about 140 degrees, about 40 degrees to about 160 degrees, about 40 degrees to about 180 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 100 degrees, about 50 degrees to about 120 degrees, about 50 degrees to about 140 degrees, about 50 degrees to about 160 degrees, about 50 degrees to about 180 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 60 degrees to about 140 degrees, about 60 degrees to about 160 degrees, about 60 degrees to about 180 degrees, about 80 degrees Angles of 0 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 80 degrees to about 140 degrees, about 80 degrees to about 160 degrees, about 80 degrees to about 180 degrees, about 100 degrees to about 120 degrees, about 100 degrees to about 140 degrees, about 100 degrees to about 160 degrees, about 100 degrees to about 180 degrees, about 120 degrees to about 140 degrees, about 120 degrees to about 160 degrees, about 120 degrees to about 180 degrees, about 140 degrees to about 160 degrees, about 140 degrees to about 180 degrees, or about 160 degrees to about 180 degrees are spaced around the arcuate needle 122. In some embodiments, the notches 122A are spaced apart at an angle of about 10, about 20, about 30, about 40, about 50, about 60, about 80, about 100, about 120, about 140, about 160, or about 180 degrees around the arcuate needle 122. In some embodiments, the notches 122A are spaced apart at an angle of at least about 10, about 20, about 30, about 40, about 50, about 60, about 80, about 100, about 120, about 140, or about 160 degrees around the arcuate needle 122.In some embodiments, the notches 122A are spaced about the arcuate needle 122 at an angle of at most about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 80 degrees, about 100 degrees, about 120 degrees, about 140 degrees, about 160 degrees, or about 180 degrees.

[0117] In some embodiments, according to Fig.15 , the ratio between the thickness 1510 of the arcuate needle 122 and the depth 1520 of the recess 122A is about 2:1 to about 15:1. In some embodiments, the ratio between the thickness 1510 of the arcuate needle 122 and the depth 1520 of the recess 122A is at least about 2:1. In some embodiments, the ratio between the thickness 1510 of the arcuate needle 122 and the depth 1520 of the recess 122A is at most about 15:1. As shown, in some embodiments, the depth 1520 of the recess 122A is measured as the maximum normal distance between the surface of the recess and the outer surface of the arcuate needle 122.

[0118] In some embodiments, according to Fig.16 , the suture end 1201 of the arcuate needle 122 includes a primary suture attachment 122D that couples the suture 125 to the arcuate needle 122. Additionally, in some embodiments, the suture 125 includes a secondary suture attachment 125A that mates with the primary suture attachment 122D. In some embodiments, the primary suture attachment 122D and the secondary suture attachment 125A are removably mated. In some embodiments, the primary suture attachment 122D and the secondary suture attachment 125A are removably mated so that the suture 125 is not disconnected from the arcuate needle 122 during suturing. In some embodiments, the primary suture attachment 122D and the secondary suture attachment 125A are removably connected and / or disconnected in situ.

[0119] As shown, the exemplary primary suture attachment 122D includes an open channel having a first channel portion and a second channel portion, wherein the first channel portion breaks through the suture end 1201 of the arcuate needle 122, and wherein the second channel portion is further from the suture end 1201 than the proximal width. As shown, the width of the second channel portion is greater than the width of the first channel portion. In some embodiments, the ratio between the width of the first channel portion and the width of the second channel portion is about 1.1:1 to about 3:1. In some embodiments, the ratio between the width of the first channel portion and the width of the second channel portion is at least about 1.1:1. In some embodiments, the proximal width partially encloses the suture. In some embodiments, the first channel portion partially encloses the secondary suture attachment 125A. In some embodiments, the first channel portion is equal to or greater than the width of the suture 125. In some embodiments, the center plane of the first channel portion and the center plane of the second channel portion are coplanar. In some embodiments, at least one of the first channel portion or the second channel portion includes a circular channel. In some embodiments, a center point of the circular surface of the first channel portion, a center point of the circular surface of the second channel portion, or both are aligned with the central arcuate axis of the arcuate needle 122 .

[0120] As shown, the secondary suture attachment 125A includes a knot or a ball. In some embodiments, the thickness of the suture 125 is less than the thickness of the suture attachment 125A. In some embodiments, the ratio between the thickness of the suture 125 and the thickness of the suture attachment 125A is about 1:1.1 to about 1:3.

[0121] Alternatively, exemplary at least one of the primary suture attachment 122D or the secondary suture attachment 125A comprises a cable tie, a rope, a loop, a hook and loop fastener, a tape, a strap, a magnet, a tie, a press fit, a set screw, an adhesive, or any combination thereof.

[0122] according to Fig.17 and Fig.18 , the primary suture attachment 122D within the exemplary arcuate needle 122 and the secondary suture attachment 125A of the secondary suture piece 125 are coupled, decoupled, or both in vitro by forceps 1701 employed in the working channel 1801 of the endoscope. Such a feature enables quick and easy replacement of the suture 125 in surgeries requiring suturing at more than one location. As shown, the secondary suture attachment 125A is located on the inner surface of the arcuate needle 122 to allow the forceps 1701 to connect or disconnect the suture 125 to the arcuate needle 122. Shuttle assembly

[0123] Fig.19A An exemplary illustration of the shuttle 123 with the pawl 124 engaged is shown. Fig.19B 1 is an exemplary illustration of a shuttle 123 with a pawl 124 disengaged. In addition, as shown, the pawl 124 rotates about a pivot 129 within the shuttle 123. In some embodiments, the pawl 124 comprises a spring, a flexure, a double spring door, a gasket, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the first distal assembly 120 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more pawls 124. In some embodiments, the shuttle slides within a shuttle guide of the distal assembly. As shown, the shuttle 123 is arcuate to slide within an arcuate shuttle guide 121C.

[0124] In some embodiments, the shuttle 123 includes a pawl 124, a pad 126, or both. In some embodiments, the pawl 124 rotates about a pivot 127 in the shuttle 123. In some embodiments, the shuttle 123 includes a chamber that accommodates the pawl 124. In some embodiments, the pawl 124 is biased to engage. In some embodiments, the pawl 124 is biased toward being engaged by the pad 126. In some embodiments, the pad 126 presses against the pawl 124 to drive the pawl 124 upward to engage with the notch 122A of the arcuate needle 122. In some embodiments, the position of the pivot 127 relative to the end of the chamber 123A, combined with the pad 126, causes the pawl to engage the bias. In some embodiments, when the pawl 124 is engaged, the pad 126 presses the pawl 124 against the end of the chamber 123A of the shuttle 123. In some embodiments, when the pawl 124 is disengaged, the arcuate needle 122 presses the pawl 124 against the pad 126 and away from the end of the chamber 123A of the shuttle 123. In some embodiments, the upper surface of the pawl 124 is inclined toward one end of the shuttle 123. In some embodiments, the upper surface of the pawl 124 is inclined to engage with the bevel of the arcuate needle.

[0125] In some embodiments, the gasket 126 is integrated into the pawl 124. In some embodiments, the gasket 126 is integrated into the shuttle 123. In some embodiments, the shuttle 123 does not include the gasket 126. In some embodiments, the shuttle 123 does not include the gasket 126, wherein the pawl 124 includes a flexure, a spring, a double spring door, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof to bias the pawl 124. In some embodiments, the shuttle 123 does not include the pawl 124 or the gasket 126, wherein the shuttle 123 includes a flexure, a spring, a double spring door, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof to engage and disengage with the arcuate needle.

[0126] In some embodiments, the exemplary shuttle 123 further comprises a cable attachment 127 to connect to the cable 130. In some embodiments, the cable attachment 127 comprises a clamp, a hole, a screw, a bolt, a nut, a clamp, a pin, or any combination thereof. In some embodiments, the cable attachment 127 comprises a terminal cable attachment, wherein the cable terminates at the cable attachment 127. In some embodiments, the cable attachment 127 comprises a non-terminal cable attachment, wherein the cable passes through and is coupled to the cable attachment 127. In some embodiments, the shuttle 123 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more cable attachments 127. In some embodiments, the shuttle 123 slides within a shuttle guide of the distal assembly. As shown, the shuttle 123 is arcuate to slide within the arcuate shuttle guide 121C. Second distal assembly

[0127] Figures 20 to 30B An illustration of an exemplary second proximal assembly 2120 and a cable 2130 having a detent 2124 is shown. In some embodiments, the second proximal assembly 2120 includes an arcuate needle 2122 having a notch 2122A and a first housing 2121 including a main housing portion 2121A and a secondary housing portion 2121B. In some embodiments, the cable 2130 includes a sheath surrounding at least a portion of the cable 2130.

[0128] like Figure 21 to Figure 25 and Fig.28As seen in the figure, the main housing portion 2121A and the secondary housing portion 2121B are connected by housing fasteners 2140. In some embodiments, the main housing portion 2121A and the secondary housing portion 2121B are connected by 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more housing fasteners 2140. As shown, the housing fastener 2140 includes a screw that passes through a through hole in the secondary housing portion 2121B and is fixed to a threaded feature 2140A in the main housing portion 2121A. Alternatively, in some embodiments, the housing fastener 2140 includes a bolt, a rivet, a nut, a weld, an adhesive, or any combination thereof in at least one of the main housing portion 2121A or the secondary housing portion 2121B. In some embodiments, the first housing 2121 does not include the main housing portion 2121A or the secondary housing portion 2121B. In some embodiments, the first housing 2121 also includes a third housing portion or more housing portions. In some embodiments, at least one of the main housing portion 2121A or the secondary housing portion 2121B includes one or more cable guides that direct the cable 2130 toward and away from the first housing 2121. In some embodiments, the main housing portion 2121A and the secondary housing portion 2121B are made of the same material. In some embodiments, the main housing portion 2121A and the secondary housing portion 2121B are made of different materials.

[0129] In some embodiments, at least one of the main housing portion 2121A or the secondary housing portion 2121B includes an endoscope fastener 2401 that couples the second proximal assembly 2120 to the endoscope 2150. In some embodiments, the endoscope fastener 2401 removably couples the first housing 121 to the endoscope 2150. As shown, the endoscope fastener 2401 includes a press-fit fastener. In some embodiments, the press-fit endoscope fastener 2401 is coupled to the endoscope 2150 by firmly pressing the press-fit endoscope fastener 2401 onto the distal end of the endoscope 2150. In some embodiments, the press-fit endoscope fastener 2401 is coupled to the endoscope 2150 by firmly pressing and rotating the press-fit endoscope fastener 2401 onto the distal end of the endoscope 2150. In some embodiments, the press fit endoscope fastener 2401 is separated from the endoscope 2150 by firmly pulling the press fit endoscope fastener 2401 away from the distal end of the endoscope 2150. In some embodiments, the press fit endoscope fastener 2401 is separated from the endoscope 2150 by firmly pulling and twisting the press fit endoscope fastener 2401 away from the distal end of the endoscope 2150.

[0130] As shown, in some embodiments, the endoscope fastener 2401 is circular. In some embodiments, the proximal outer diameter of the endoscope 2150 is about 5 mm to about 16 mm. Thus, in some embodiments, the inner diameter of the endoscope fastener 2401 is about 5 mm to about 16 mm. In some embodiments, the inner diameter of the endoscope fastener 2401 is at least about 5 mm. In some embodiments, the inner diameter of the endoscope fastener 2401 is at most about 16 mm. In some embodiments, the diameter of the press-fit endoscope fastener 2401 is equal to or less than the diameter of the endoscope 2150. In some embodiments, the diameter of the endoscope fastener 2401 is equal to or greater than the diameter of the endoscope 2150. In some embodiments, the endoscope fastener 2401 is tapered and has a first inner diameter and a second inner diameter, wherein the first inner diameter is distal to the second inner diameter. In some embodiments, the first inner diameter is greater than the second inner diameter. In some embodiments, the second inner diameter is greater than the first inner diameter. In some embodiments, the diameter of the endoscope fastener 2401 is measured as the maximum, minimum, or average internal width. In some embodiments, the diameter of the endoscope 2150 is measured as the maximum, minimum, or average external width. Alternatively, in some embodiments, the endoscope fastener 2401 has a cross-sectional shape including a triangle, a square, a hexagon, or any other polygon. Alternatively, in some embodiments, the endoscope fastener 2401 includes a press-fit fastener, a clamp, an adhesive, a tape, a strip, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the first distal assembly 120 includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more endoscope fasteners 2401.

[0131] In some embodiments, according to Fig. 20 and Fig.28 , the angle between the needle axis 2160A and the proximal axis of the endoscope 2160B is about 5 degrees to about 85 degrees. In some embodiments, the angle between the central axis of the arcuate needle guide 2121BA and the proximal axis of the endoscope 2160B is adjustable within about 5 degrees to about 85 degrees. In some embodiments, the needle axis 2160A is defined as an axis perpendicular to the plane of symmetry of the arcuate needle 122 and coincident with the center point of the radius of the arcuate needle 122. In some embodiments, the proximal axis of the endoscope 2160B is defined as the central axis of the distal portion of the endoscope 2150. In some embodiments, the proximal axis of the endoscope 2160B is defined as the central axis of the endoscope fastener 2401 of the first housing 2121. The angle between the central axis of the arcuate needle guide 2121BA and the proximal axis of the endoscope 2160B is defined as the maximum, minimum, or average angle.

[0132] As shown, in some embodiments, according to Fig.25 and Fig.26 , the main housing portion 2121A includes a pulley 2121AA, and the secondary housing portion 2121B includes a pulley hole 2121BB. Alternatively, the secondary housing portion 2121B includes a pulley 2121AA, and the main housing portion 2121A includes a pulley hole 2121BB. As shown, the main housing portion 2121A includes two pulleys 2121AA. Alternatively, in some embodiments, at least one of the main housing portion 2121A or the secondary housing portion 2121B includes more than two pulleys 2121AA. In some embodiments, the pulley 2121AA supports and guides the cable 2130 as it travels through the first housing 2121. In some embodiments, at least a portion of the pulley 2121AA is assembled within the pulley hole 2121BB. In some embodiments, at least a portion of the pulley 2121AA is press-fitted within the pulley hole 2121BB. In some embodiments, at least a portion of the pulley 2121AA fits within the pulley hole 2121BB to align the main housing portion 2121A relative to the secondary housing portion 2121B. As shown, the pulley 2121AA and the pulley hole 2121BB have a cross-sectional shape including a circle. Alternatively, in some embodiments, at least one of the pulley 2121AA or the pulley hole 2121BB has a cross-sectional shape including a triangle, a square, a pentagon, a hexagon, or any other polygon. In some embodiments, the pulley 2121AA rotates relative to at least one of the main housing portion 2121A or the secondary housing portion 2121B. In some embodiments, the pulley 2121AA is fixed relative to at least one of the main housing portion 2121A or the secondary housing portion 2121B. In some embodiments, the pulley 2121AA includes a bearing, a rod, a curved surface, or any combination thereof.

[0133] As shown, the first housing 2121 includes a distal sheath fastener that couples the sheath to the first housing 2121. In some embodiments, at least one of the main housing portion 2121A or the secondary housing portion 2121B also includes a distal sheath fastener that couples a portion of the sheath to the first housing 2121. In some embodiments, the distal sheath fastener secures a portion of the sheath relative to the first housing 2121 so as to allow the cable 130 to travel within the sheath as the wheel rotates. As shown, an exemplary distal sheath fastener includes a clamp. In some embodiments, the distal sheath fastener includes a plate and one or more sheath fastener screws that compress the cable sheath between the plate and the first housing 2121. Alternatively, in some embodiments, the distal sheath fastener includes a screw, a tie, a tape, or any combination thereof. In some embodiments, the first housing 2121 includes at least one distal sheath fastener for the first cable portion, and at least one distal sheath fastener for the second cable portion. In some embodiments, the first housing 2121 includes a single distal sheath fastener for both the first cable portion and the second cable portion. In some embodiments, a portion of the cable sheath extends through the end of the distal sheath fastener and into the first housing 2121. In some embodiments, the first housing 2121 includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more distal sheath fasteners. Alternatively, in some embodiments, the distal sheath fastener includes a clamp, a tie, a loop, a hook and loop fastener, an adhesive, or any combination thereof.

[0134] In some embodiments, the first housing 2121 has an arcuate needle guide 2121BA. In some embodiments, at least one of the main housing portion 2121A or the secondary housing portion 2121B has an arcuate needle guide 2121BA. In some embodiments, the arcuate needle 2122 slides freely within the arcuate needle guide 2121BA. In some embodiments, the arcuate needle guide 2121BA constrains the arcuate needle 2122 to rotate within one degree of freedom. In some embodiments, the arcuate needle guide 2121BA constrains the arcuate needle 2122 to rotate within at least one rotational degree of freedom. As seen, the exemplary arcuate needle guide 2121BA surrounds at least a portion of the arcuate needle 122. In some embodiments, the inner width of the arcuate needle guide 2121BA is greater than the thickness 1510 of the arcuate needle 2122. In some embodiments, at least one of the arcuate needle 2122 or the arcuate needle guide 2121BA has a cross-sectional shape including a circle, a square, a rectangle, or any other polygon.

[0135] In some embodiments, a groove 2170 is formed between a first end of the arcuate needle guide 2121BA and a second opposing end of the arcuate needle guide 2121BA in the second proximal assembly 2120. In some embodiments, a groove 2170 is formed between a first pulley hole 2121BB and a second opposing pulley hole 2121BB in the first distal assembly and the second proximal assembly 2120. In some embodiments, the groove 2170 accommodates tissue for suturing by the arcuate needle 2122. In some embodiments, the tissue is supported against the arcuate needle 2122 throughout the suturing process. In some embodiments, the second distal assembly 2120 does not include an anchor exchange catheter.

[0136] according to Fig.26 In some embodiments, the arcuate needle 2122 has a notch 2122A. In some embodiments, the arcuate needle 2122 has 2, 3, 4, 5, 6, 7, 8, 9, 10 or more notches 2122A. In some embodiments, when the cable 2130 is translated about the main housing portion 2121A, the secondary housing portion 2121B, or both in the first rotational direction 2600, the notch 2122A and the pawl 2124 engage. In some embodiments, when the cable 2130 is translated in a direction opposite to the first rotational direction 2600, the notch 2122A and the pawl 2124 disengage. In some embodiments, the notch 2122A is slanted in a direction opposite to the first rotational direction 2600. In some embodiments, the slanted notch 2122A ensures that the second pawl portion 2124B is properly seated in the notch 2122A. In some embodiments, the notch 2122A is angled at an angle of about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, or more, including increments therein. As shown, in some embodiments, the arcuate needle 2122 has two notches 2122A, wherein each notch 2122A is spaced apart at an angle of about 180 degrees around the arcuate needle 2122.

[0137] In some embodiments, the outer diameter of the arcuate needle 2122 is about 7 mm to about 20 mm. In some embodiments, the outer diameter of the arcuate needle 2122 is at least about 7 mm. In some embodiments, the outer diameter of the arcuate needle 2122 is at most about 20 mm. In some embodiments, the thickness 1510 of the arcuate needle 2122 is about 0.5 mm to about 2 mm. In some embodiments, the thickness 1510 of the arcuate needle 2122 is at least about 0.5 mm. In some embodiments, the thickness 1510 of the arcuate needle 2122 is at most about 2 mm. In some embodiments, the ratio between the outer diameter and the thickness 1510 of the arcuate needle 2122 is about 3:1 to about 15:1. In some embodiments, the ratio between the outer diameter of the arcuate needle 2122 and the thickness 1510 is about 3:1, 4:1, 5:1, 6:1, 7:1, 8:1, 9:1, 10:1, 11:1, 12:1, 13:1, 14:1, or 15:1, including increments therein. In some embodiments, the ratio between the outer diameter of the arcuate needle 2122 and the thickness 1510 is at least about 3:1. In some embodiments, the outer diameter of the arcuate needle 2122 is measured as the maximum distance between two points on the surface of the arcuate needle 2122. In some embodiments, the outer diameter of the arcuate needle 2122 is measured as the maximum outer diameter of the arcuate needle 2122. In some embodiments, the width of the arcuate needle 2122 is measured as the thickness 1510 of the arcuate needle 2122. The width of the arcuate needle 2122 is measured as the thickness 1510 of the arcuate needle not within the tip, suture end, or notch 2122A. In some embodiments, the width of the arcuate needle 2122 is measured as the maximum, minimum, or average thickness 1510 of the arcuate needle 2122.

[0138] In some embodiments, the notches 2122A are spaced at an angle of about 10 degrees to about 180 degrees around the arcuate needle 2122. In some embodiments, the notches 2122A are spaced at an angle of about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 10 degrees to about 140 degrees, about 10 degrees to about 160 degrees, about 10 degrees to about 180 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 10 degrees to about 140 degrees, about 10 degrees to about 160 degrees, about 10 degrees to about 180 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about to about 100 degrees, about 20 degrees to about 120 degrees, about 20 degrees to about 140 degrees, about 20 degrees to about 160 degrees, about 20 degrees to about 180 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 30 degrees to about 140 degrees, about 30 degrees to about 160 degrees, about 30 degrees to about 180 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 40 degrees to about 140 degrees, about 40 degrees to about 160 degrees, about 40 degrees to about 180 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 100 degrees, about 50 degrees to about 120 degrees, about 50 degrees to about 140 degrees, about 50 degrees to about 160 degrees, about 50 degrees to about 180 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 60 degrees to about 140 degrees, about 60 degrees to about 160 degrees, about 60 degrees to about 180 degrees, about 80 degrees The angles of about 100 degrees to about 120 degrees, about 80 degrees to about 140 degrees, about 80 degrees to about 160 degrees, about 80 degrees to about 180 degrees, about 100 degrees to about 120 degrees, about 100 degrees to about 140 degrees, about 100 degrees to about 160 degrees, about 100 degrees to about 180 degrees, about 120 degrees to about 140 degrees, about 120 degrees to about 160 degrees, about 120 degrees to about 180 degrees, about 140 degrees to about 160 degrees, about 140 degrees to about 180 degrees, or about 160 degrees to about 180 degrees are spaced around the arcuate needle 2122. In some embodiments, the notches 2122A are spaced apart at an angle of about 10, about 20, about 30, about 40, about 50, about 60, about 80, about 100, about 120, about 140, about 160, or about 180 degrees around the arcuate needle 2122. In some embodiments, the notches 2122A are spaced apart at an angle of at least about 10, about 20, about 30, about 40, about 50, about 60, about 80, about 100, about 120, about 140, or about 160 degrees around the arcuate needle 2122.In some embodiments, the notches 2122A are spaced about the arcuate needle 2122 at an angle of at most about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 80 degrees, about 100 degrees, about 120 degrees, about 140 degrees, about 160 degrees, or about 180 degrees.

[0139] like Figure 23 to Figure 25 As shown in FIG. 21 (without secondary housing portion 2121B), a cable 2130 having a pawl 2124 enters the first housing 2121, is wound around the first pulley 2121AA, the bow needle 2122, the second pulley 2121AA, and passes out of the first housing 2121. As shown, the cable 2130 includes a flat portion 2130A. In some embodiments, the flat portion 2130A increases the stability of the cable 2130 as the cable 2130 is wound around the pulley 2121AA. In addition, in some embodiments, the pawl 2124 is located on the flat portion of the cable 2130A. In some embodiments, the flat portion of the cable 2130A is manufactured by mechanically flattening a portion of the cable 2130A or by adhering a flat material to the cable 2130. In some embodiments, the pawl 2124 is attached to the cable 2130. In some embodiments, the pawl 2124 is coupled to the flat portion of the cable 2130A.

[0140] As per Fig.24 As shown, the pawl 2124 includes a first pawl portion 2124A and a second pawl portion 2124B, wherein the first pawl portion 2124A is attached to the cable 2130 or the flat portion of the cable 2130A, and wherein the second pawl portion 2124B is not coupled to the cable 2130 and the flat portion of the cable 2130A. In some embodiments, the pawl 2124 includes a flexure. In some embodiments, the second pawl portion 2124B bends inwardly toward the arcuate needle 2122 when at rest, and bends around the intersection between the second pawl portion 2124B and the first pawl portion 2124A. In some embodiments, when the arcuate needle 2122 contacts the second pawl portion 2124B, the second pawl portion 2124B bends outwardly away from the arcuate needle 2122 around the intersection between the second pawl portion 2124B and the first pawl portion 2124A. As shown in FIG. Fig.26 As shown, the tip of the second pawl portion 2124B contacts and presses against the notch 2122A of the arcuate needle 2122 to translate the arcuate needle 2122 along the first direction 2600. Additionally or alternatively, the tip of the second pawl portion 2124B contacts and presses against the suture end 2122B of the arcuate needle 2122 to translate the arcuate needle 2122 along the first direction 2600. Alternatively, in some embodiments, the pawl 2124 includes a spring, a double spring door, a gasket, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the pawl 2124 is biased for engagement.

[0141] Figure 27A-27F An exemplary second proximal assembly is shown in a first position, a second position, a third position, a fourth position, a fifth position, and a sixth position, respectively. Fig.27A , suturing with the second proximal assembly includes translating the cable 2130 so that the pawl 2124 travels to an end position (in a second rotational direction relative to the first rotational direction 2600) in the secondary housing portion 2121B. Fig.27A 21B), while the arcuate needle 2122 is completely enclosed in the secondary housing portion 2121B. When the pawl 2124 and arcuate needle 2122 are in this position, the pawl 2124 automatically engages with the first notch in the arcuate needle 2122, as shown. Thereafter, according to FIG. 27B to FIG. 27C , the cable 2130 is translated so that the engaged arcuate needle 2122 and the pawl 2124 travel along the first rotational direction 2600 to the end position of the pawl 2124 along the first rotational direction 2600 within the secondary housing portion 2121B. The translation of the cable 2300 and the pawl 2124 thereby moves a portion of the arcuate needle 2122 out of the secondary housing portion 2121B to perform the first suture. Fig.27D , the cable 2130 then translates in the second rotational direction within the secondary housing portion 2121B back to its end position to automatically engage the second notch within the arcuate needle 2122. FIG. 27E to FIG. 27F As seen in FIG. 26, after the cable 2130 and the pawl 2124 are translated in the first direction 2600, the arcuate needle 2122 is returned to its original position within the secondary housing portion 2121B, and further translation of the cable 2130 and the pawl 2124 in the second direction returns the pawl to its original position as shown in FIG. Fig.27A The end position of the second rotation direction in the secondary housing part 2121B. Therefore, the cable 2130 is translated along the first direction 2600, the second direction opposite to the first direction 2600, and the first direction 2600 and then the second direction to complete a single stitching, and repeating this process enables repeated stitching.

[0142] Fig.29 An arcuate needle 2122 is shown within an arcuate needle guide 2121BA of a secondary housing portion 2121B. Fig.28 As shown, the arcuate needle guide 2121BA surrounds a portion of the arcuate needle 2122. As seen therein, the arcuate needle guide 2121BA surrounds approximately 280 degrees of the cross-sectional circumference of the arcuate needle 2122. Alternatively, in some embodiments, the arcuate needle guide 2121BA surrounds approximately 100 degrees, 120 degrees, 140 degrees, 160 degrees, 180 degrees, 200 degrees, 220 degrees, 240 degrees, 260 degrees, 280 degrees, 300 degrees, 320 degrees, or more degrees of the cross-sectional circumference of the arcuate needle 2122, including increments therein.

[0143] In some embodiments, according to FIG. 30A to FIG. 30C , the cable and pawl include a single cable pawl 3000A, 3000B that includes a flat portion 2124B having a tab 2124A. As shown, the tab 2124A includes a flexure. Alternatively, in some embodiments, the tab 2124A includes an indent, a spring, or any combination thereof. In some embodiments, the tab 2124A engages and disengages with the notch of the arcuate needle in the same manner as the pawl. As shown, in some embodiments, the tab 2124A has an expanded position in which the tab 2124A is at rest and protrudes at an angle from the flat portion 2124B. In some embodiments, the tab 2124A protrudes from the flat portion 2124B at an angle of about 5 degrees, 10 degrees, 15 degrees, 20 degrees, 25 degrees, 30 degrees, 35 degrees, 40 degrees, 45 degrees, 50 degrees, 55 degrees, 60 degrees, or more, including increments therein. Fig. 30C As shown, in some embodiments, when in the expanded position, the tab 2124A engages with the notch 2122A of the arcuate needle 2122. In some embodiments, when engaged, the distal tip of the tab 2124A presses against the notch 2122A of the arcuate needle 2122. In some embodiments, the tab 2124A has a collapsed position in which the tab 2124A and the flat portion 2124B are generally coplanar. In some embodiments, in the collapsed position, the tab 2124A is pressed against the flat portion 2124B by the arcuate needle 2122. In some embodiments, when in the collapsed position, the tab 2124A disengages from the notch 2122A of the arcuate needle 2122. In some embodiments, the tab 2124A is configured to be repeatedly compressed and released to repeatedly disengage and engage with the notch of the arcuate needle. In some embodiments, according to Fig. 30A , the cable pawl 3000A is formed in a piece of material adhered to the cable 2130A. Alternatively, in some embodiments, according to Fig. 30B , the cable pawl 3000A is formed from a single continuous piece of material.

[0144] In some embodiments, at least one of the main housing portion 2121A, pulley 2121AA, secondary housing portion 2121B, cable 2130, pawl 2124, tab 2124A, or individual cable pawls 3000A, 300B is comprised of metal, plastic, wood, carbon fiber, ceramic, or any combination thereof. Inclined first shell

[0145] FIG. 31A to FIG. 36An illustration of an exemplary tilted first housing 3121 is shown, which includes a main tilted housing 3121A, a secondary tilted housing 3121B, and a third tilted housing 3121C. In some embodiments, the first housing 3121 also includes a third housing portion or more housing portions. As shown, the secondary tilted housing 3121B and the third tilted housing 3121C are rigidly attached to each other, wherein the secondary tilted housing 3121B and the third tilted housing 3121C rotate around the tilt axis 3151 relative to the main tilted housing 3121A. In some embodiments, the secondary tilted housing 3121B and the third tilted housing 3121C are a single component. In some embodiments, the tilted axis 3151 is perpendicular to the proximal endoscope axis 3152. In some embodiments, the tilted axis 3151 does not intersect the proximal endoscope axis 3152. In some embodiments, the secondary tilted housing 3121B and the third tilted housing 3121C are rigidly attached to each other by fasteners. In some embodiments, the fasteners include press-fit fasteners, screws, nuts, bolts, hook and loop fasteners, adhesives, welds, or any combination thereof.

[0146] like FIG. 31A to FIG. 31B As shown, the main tilt housing 3121A includes an endoscope fastener 3120 that couples the main tilt housing 3121A to the endoscope 3140. In some embodiments, the endoscope fastener 3120 removably couples the main tilt housing 3121A to the endoscope 3140. As shown, the endoscope fastener 3120 includes a screw, wherein the main tilt housing 3121A includes a threaded feature or threaded insert that receives the screw, such that the endoscope fastener 3120 and the threaded feature or threaded insert within the main tilt housing 3121A clamp around the distal end of the endoscope 3140 to secure the first tilt housing 3121A to the endoscope 3140. As shown, the main tilt housing 3121A includes a slot that is configured to separate the endoscope fastener 3120 from the rest of the tilt housing 3121A so that the tilt housing 3121A can be deformed when the screw is tightened. Alternatively, in some embodiments, the main tilt housing 3121A does not include a slot.

[0147] As shown, in some embodiments, the endoscope fastener 3120 is circular. In some embodiments, the proximal outer diameter of the endoscope 3140 is about 5 mm to about 16 mm. Thus, in some embodiments, the inner diameter of the endoscope fastener 3120 is about 5 mm to about 16 mm. In some embodiments, the inner diameter of the endoscope fastener 3120 is at least about 5 mm. In some embodiments, the inner diameter of the endoscope fastener 3120 is at most about 16 mm. In some embodiments, the endoscope fastener 3120 is press-fit. In some embodiments, the diameter of the press-fit endoscope fastener 3120 is equal to or less than the diameter of the endoscope 3140. In some embodiments, the diameter of the endoscope fastener 3120 is equal to or greater than the diameter of the endoscope 3140. In some embodiments, the endoscope fastener 3120 is tapered and has a first inner diameter and a second inner diameter, wherein the first inner diameter is distal to the second inner diameter. In some embodiments, the first inner diameter is greater than the second inner diameter. In some embodiments, the second inner diameter is greater than the first inner diameter. In some embodiments, the diameter of the endoscope fastener 3120 is measured as the maximum, minimum, or average internal width. In some embodiments, the diameter of the endoscope 3140 is measured as the maximum, minimum, or average external width. Alternatively, in some embodiments, the endoscope fastener 3120 has a cross-sectional shape including a triangle, a square, a hexagon, or any other polygon.

[0148] Alternatively, in some embodiments, the endoscope fastener 3120 comprises a press-fit fastener. In some embodiments, the press-fit endoscope fastener 3120 is attached to the endoscope 3140 by firmly pressing the press-fit endoscope fastener 121A onto the distal end of the endoscope 3140. In some embodiments, the press-fit endoscope fastener 3120 is attached to the endoscope 3140 by firmly pressing and rotating the press-fit endoscope fastener 3120 onto the distal end of the endoscope 3140. In some embodiments, the press-fit endoscope fastener 3120 is detached from the endoscope 3140 by firmly pulling the press-fit endoscope fastener 3120 away from the distal end of the endoscope 3140. Alternatively, in some embodiments, the endoscope fastener 3120 comprises a press-fit fastener, a clamp, an adhesive, a tape, a strip, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the first distal assembly 120 includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more endoscopic fasteners 3120 .

[0149] In addition, as shown, at least one of the secondary tilt housing 3121B or the third tilt housing 3121C secures the cable sheath of the cable 3130. In some embodiments, at least one of the secondary tilt housing 3121B or the third tilt housing 3121C includes a hole to accommodate the cable sheath of the cable 3130. In some embodiments, the cable sheath of the cable 3130 is clamped between the secondary tilt housing 3121B and the third tilt housing 3121C. Alternatively, in some embodiments, the cable sheath of the cable 3130 is coupled to at least one of the secondary tilt housing 3121B or the third tilt housing 3121C by an adhesive, a clamp, a tie, a hook and loop fastener, or any combination thereof.

[0150] according to Figure 32 to Figure 36, the exemplary main tilt housing 3121A includes a main tilt mechanism 3121AA, and the exemplary secondary tilt housing 3121B includes a secondary tilt mechanism 3121BA, wherein the main tilt mechanism 3121AA and the secondary tilt mechanism 3121BA couple the main tilt housing 3121A and the secondary tilt housing 3121B. In some embodiments, the main tilt mechanism 3121AA and the secondary tilt mechanism 3121BA rotate at least one of the secondary tilt housing 3121B or the third tilt housing 3121C relative to the main tilt housing 3121A. In some embodiments, the main tilt mechanism 3121AA and the secondary tilt mechanism 3121BA rotate at least one of the secondary tilt housing 3121B or the third tilt housing 3121C relative to the main tilt housing 3121A around the tilt axis 3151. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA rotate at least one of the secondary tilt housing 3121B or the tertiary tilt housing 3121C about 300 degrees relative to the primary tilt housing 3121A about the tilt axis 3151. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA rotate at least one of the secondary tilt housing 3121B or the tertiary tilt housing 3121C relative to the primary tilt housing 3121A so that the angle between the arcuate needle axis 3153 and the proximal endoscope axis 3152 increases from about 0 degrees (at which position the arcuate needle axis 3153 and the proximal endoscope axis 3152 are parallel) to about 300 degrees. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA rotate at least one of the secondary tilt housing 3121B or the tertiary tilt housing 3121C relative to the primary tilt housing 3121A such that the angle between the arcuate needle axis 3153 and the proximal endoscope axis 3152 increases continuously from about 0 degrees to about 300 degrees. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA rotate at least one of the secondary tilt housing 3121B or the tertiary tilt housing 3121C relative to the primary tilt housing 3121A such that the angle between the arcuate needle axis 3153 and the proximal endoscope axis 3152 increases in discrete increments from about 0 degrees to about 300 degrees. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA rotate at least one of the secondary tilt housing 3121B or the tertiary tilt housing 3121C relative to the primary tilt housing 3121A so that the angle between the arcuate needle axis 3153 and the proximal endoscope axis 3152 increases in discrete increments of approximately 1 degree, 2 degrees, 5 degrees, 10 degrees, 15 degrees, 20 degrees, 25 degrees, 30 degrees, 35 degrees, 40 degrees, 45 degrees, 50 degrees, 55 degrees, 60 degrees, or more degrees.In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA rotate at least one of the secondary tilt housing 3121B or the tertiary tilt housing 3121C relative to the primary tilt housing 3121A such that the angle between the arcuate needle axis 3153 and the proximal endoscope axis 3152 increases in discrete increments of at least about 1 degree. In some embodiments, the arcuate needle axis 3153 and the proximal endoscope axis 3152 are coincident. In some embodiments, the arcuate needle axis 3153 and the proximal endoscope axis 3152 are non-coincident.

[0151] As per Fig.35 and Fig.36 As seen, in one embodiment, the primary tilt mechanism 3121AA includes a clamp having a knurled inner surface, and the secondary tilt mechanism 3121BA includes a knob having a knurled outer surface. As shown, the secondary tilt mechanism 3121BA includes 19 knurls and recesses, such that the engagement of one knurl of the primary tilt mechanism 3121AA with one recess of the secondary tilt mechanism 3121BA defines a specific angle between the arcuate needle axis 3153 and the proximal endoscope axis 3152. As shown, the primary tilt mechanism 3121AA includes 13 knurls and recesses, such that the engagement of one knurl of the secondary tilt mechanism 3121BA with one recess of the primary tilt mechanism 3121AA defines a specific angle between the arcuate needle axis 3153 and the proximal endoscope axis 3152. Alternatively, in some embodiments, at least one of the primary tilt mechanism 3121AA or the secondary tilt mechanism 3121BA includes 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25 or more knurls and recesses. Alternatively, in some embodiments, the primary tilt mechanism 3121AA does not include the primary tilt housing 3121A. Alternatively, in some embodiments, the secondary tilt housing 3121B does not include the secondary tilt mechanism 3121BA.

[0152] In some embodiments, the clamp of the primary tilt mechanism 3121AA is tightened by tightening the screw 3201 to compress the clamp and prevent the secondary tilt housing 3121B from rotating relative to the primary tilt housing 3121A about the tilt axis 3151. The compression of the clamp is released by unscrewing the screw 3201 to release the clamp of the primary tilt mechanism 3121AA and allow the secondary tilt housing 3121B to rotate relative to the primary tilt housing 3121A about the tilt axis 3151. In some embodiments, the clamp of the primary tilt mechanism 3121AA is tightened during surgical use. Alternatively, in some embodiments, the rotation between the primary tilt housing 3121A and the secondary tilt housing 3121B is achieved by a clamp, a pin, a screw, a knob, a cable tie, a loop, a magnet, or any combination thereof.

[0153] As can be seen, the secondary tilt housing 3121B includes a gap 3601 between the secondary tilt mechanism 3121BA and the rest of the secondary tilt housing 3121B. In some embodiments, the gap 3601 accommodates a portion of the primary tilt housing 3121A when the secondary tilt housing 3121B rotates around the primary tilt housing 3121A. In some embodiments, the width of the gap 3601 is greater than the thickness of the primary tilt mechanism 3121AA. Terms and Definitions

[0154] Unless otherwise defined, all technical terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this disclosure belongs.

[0155] As used herein, the singular forms "a," "an," and "the" include plural references unless the context clearly dictates otherwise. Any reference to "or" herein is intended to include "and / or" unless stated otherwise.

[0156] As used herein, the term "about" refers to an amount that is approximately 10%, 5%, or 1%, including increments therein, of the stated amount.

[0157] As used herein, the term "about" in terms of a percentage refers to an amount that is greater or less than the stated percentage by 10%, 5%, or 1%, including increments therein.

[0158] As used herein, the phrases "at least one," "one or more," and "and / or" are open-ended expressions that are conjunctive and disjunctive in operation. For example, the expressions "at least one of A, B, and C," "at least one of A, B, or C," "one or more of A, B, and C," "one or more A, B, or C," and "A, B, and / or C" each represent A alone, B alone, C alone, A and B together, A and C together, B and C together, or A, B, and C together.

[0159] As used herein, the term "segment" refers to an arc of a circle or a portion of a circle.

Claims

1. An endoscopic suturing system, comprising: (a) a distal assembly, the distal assembly comprising: (i) a first housing comprising an arcuate needle guide and an endoscope fastener, wherein the endoscope fastener attaches the first housing to an endoscope; (ii) an arcuate needle comprising a notch and a suture attachment, wherein the arcuate needle has a central axis, and wherein the arcuate needle is disposed within the arcuate needle guide; and (b) a proximal assembly, the proximal assembly comprising: (i) a second housing; (ii) an actuator connected to the second housing; and (c) a cable having a ratchet; wherein the notch and the pawl engage when the cable translates about the central axis in a first rotational direction, and the notch and the pawl disengage when the cable translates opposite to the first rotational direction.

2. The system of claim 1, wherein the pawl comprises a spring, a flexure, a double spring door, a gasket, a piston, a rod, a pin, a tooth, or any combination thereof.

3. A system according to claim 1 or 2, wherein the pawl is engagement biased.

4. The system of claim 1, 2 or 3, wherein the notch is slanted in a direction opposite to the first rotational direction.

5. The system of any one of claims 1-4, wherein the endoscope fastener comprises a press-fit fastener, a clamp, an adhesive, a tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof.

6. The system of any one of claims 1-5, wherein the endoscope has a proximal outer diameter of about 5 mm to about 156 mm.

7. The system of any one of claims 1-6, further comprising a cable jacket surrounding at least a portion of the cable.

8. The system of claim 7, further comprising a cable fastener that removably couples at least a portion of the cable to the endoscope.

9. The system of claim 8, wherein the cable fastener comprises a press-fit fastener, a tie, a rope, a loop fastener, a hook and loop fastener, a tape, a strap, a magnet, a zip tie, a press fit, a set screw, an adhesive, or any combination thereof.

10. The system of any one of claims 1-9, wherein the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is about 5 degrees to about 85 degrees.

11. The system of claim 10, wherein the angle between the central axis of the arcuate needle guide and the proximal axis of the endoscope is adjustable within a range of about 5 degrees to about 85 degrees.

12. The system of any one of claims 1-11, wherein the arcuate needle comprises two or more notches.

13. The system of any one of claims 1-12, wherein at least one of the first housing, the second housing, the arcuate needle, and the actuator is comprised of plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof.

14. The system of any one of claims 1-13, wherein the first housing further comprises a cable pulley to guide the cable.

15. The system of any one of claims 1-14, wherein the arcuate needle further comprises a suture attachment fastener.

16. The system of any one of claims 1-15, wherein the second housing is removably coupled to the endoscope.

17. The system of any one of claims 1-16, wherein the cable includes a flat portion, and the detent is located on the flat portion of the cable.

18. The system of any one of claims 1-17, wherein the pawl extends from a cable surface and is biased in a direction away from the cable surface.

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