Endoscopic suturing device with circular needle

Abstract

To provide an endoscopic suturing system configured for attachment to, and use with, an endoscope.SOLUTION: An endoscopic suturing system comprises: a distal assembly comprising a first housing comprising an arcuate needle guide, a shuttle guide, and an endoscope fastener, an arcuate needle comprising a notch and a suture attachment, and a shuttle having a pawl; a proximal assembly comprising a second housing and an actuator; and a cable connecting the actuator to the shuttle and configured to move the shuttle in the first direction and in the second direction in response to an operation of the actuator.SELECTED DRAWING: Figure 1

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of U.S. Provisional Patent Application No. 62 / 681,783, filed June 7, 2018, which is incorporated by reference in its entirety herein. [Background technology]

[0002]

[0002] Full-thickness gastrointestinal defects, such as perforation, anastomotic leaks, and fistulas, are serious conditions resulting from various types of lesions. Such conditions are likely to require intensive care, involve long hospital stays, and are associated with high morbidity and mortality. Currently available advanced endoscopic suturing techniques play a major role in the treatment of full-thickness gastrointestinal defects. Endoscopic clips are the most common treatment for suturing small defects. However, endoscopic clips are less useful in larger defects. This is due to the limited opening distance between the clip jaws, the low suturing force, and the impossibility of achieving deep tissue capture.

[0003]

[0003] Innovative endoscopic devices for placing full thickness sutures have been in the field for the purpose of suturing large anomalies. However, many of the suturing devices developed in the past 20 years are cumbersome and expensive, and therefore many physicians continue to search for simple suturing devices. Endoscopic suturing is a minimally invasive technique that can be used for a wide variety of gastrointestinal indications, such as stoma reduction and gastric attenuation, fistula repair, bariatric care, stent and graft fixation, and gastrointestinal bleeding. Summary of the Invention [Means for solving the problem]

[0004]

[0004] To puncture accurately, the tissue must be supported against the side of the needle. However, some devices employ a drive mechanism designed to puncture the needle by first moving laterally, then pivoting about 90 degrees, and then stopping longitudinally at the most distal side of the proximal receiver, where the receiver acts as a support for the punctured tissue. Thus, these devices do not support the tissue as the needle moves laterally, and as a result, the tissue may be pushed away from the needle before it is completely punctured. Thus, tissue grabbers (e.g., graspers, corkscrews) are often required to support these devices laterally, which is a major drawback. Provided herein are devices, apparatus, systems, and methods for actuating an arcuate needle via a C-shaped distal assembly ("arctic needle" as used herein is synonymous with "circular needle" and refers to an arc-shaped needle that is not perfectly circular but travels in a circular or approximately circular path) and the C-shaped distal assembly is angled non-perpendicularly to the main axis of the endoscope and is not angularly aligned with the main axis of the endoscope. Thus, no tissue grabber is required when using the device to suture, since the device is easily manipulated to secure tissue between the ends of the opening of the "C" of the C-shaped distal assembly and in the gap formed by this "C", where suturing occurs when in these positions without the need for separate support.

[0005] Additionally, with these current devices, a separate working channel must be provided to carry the grabber to the suturing area. One channel is used for anchor exchange. Since it is used for the catheter, the scope must have two working channels, or one additional working channel with an extra tube. This need for a special dual-channel scope is another major drawback, which makes the procedure more expensive. In order to maintain a small overall diameter, the working channel for the grabber must have a small outer diameter. Some current devices employ grabbers that are long shafts with a helical thread on the tip. However, this helix often does not have enough torsional stiffness to work reliably. This is because of its small diameter and large length. Furthermore, if the threading depth is not limited, potential perforation presents another drawback. Additionally, these devices employ straight needles that move in a circular motion when piercing the tissue. Such a motion exposes the needle body to lateral tissue reaction forces that can cause the needle to deflect and miss the receiver of the exchange catheter. To prevent this, the entire distal mechanism on these devices requires additional volume to allow for added stiffness. Finally, if the distal portion of these devices were positioned to place the axis of the scope camera in the plane of needle action, tissue in the needle path would block the camera's view during suturing. Provided herein are devices, apparatus, systems, and methods that actuate arcuate needles via C-shaped distal assemblies that are angled non-perpendicular to the endoscope's main axis and are not angularly aligned with the endoscope's main axis, thereby allowing for easy viewing using the device's camera. These distal assemblies are coupled to the distal end of the endoscope without the use of a working channel, in a manner visible to the endoscope's camera, for ease of maneuvering the needle through tissue during use and suturing, as well as for simplicity and accuracy of suturing.

[0006] Other currently available devices employ circular needles that are translated through the gap from exit to entrance in a uniform circular motion. While these devices allow for support of the tissue against the piercing needle, their needle drive mechanisms are too long to be used with flexible shafts (i.e., flexible endoscopes) without compromising their flexibility and maneuverability. Furthermore, these devices must be rigid to employ both their rack-and-pinion and crankshafts that are arranged in series in the longitudinal direction, and therefore cannot be used for endoscopic procedures where the flexibility of the scope must not be compromised. Furthermore, these devices are not suitable for endoscopic procedures because they employ cassettes for suture exchange with needles permanently attached to the sutures. Provided herein are devices, apparatus, systems, and methods for actuating an arcuate needle through a C-shaped distal assembly coupled to the inflexible distal end of a scope that uses a simple set of wires and a shuttle coupled to the wires to manipulate the arcuate needle through the suturing process without compromising the flexibility of the scope.

[0007]

[0007] One aspect provided herein is an endoscopic suturing system comprising a distal assembly, a first housing having an arcuate needle guide, a shuttle guide, and an endoscope fixture, the endoscope fixture coupling the first housing to an endoscope, a first housing, an arcuate needle having a notch and a suture attachment, the arcuate needle having a central axis, the arcuate needle being disposed within the arcuate needle guide, and a shuttle having a prong, the arcuate needle being carried within the shuttle guide. , a shuttle, where the notches and pawls are engaged when the shuttle translates in a first rotational direction about a central axis and the notches and pawls are disengaged when the shuttle translates in a direction opposite the first rotational direction; a proximal assembly, the proximal assembly comprising a second housing and 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 and second directions in response to actuation of the actuator.

[0008] In some embodiments, the pawl comprises a spring, a flexure, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the pawl is biased upon engagement. In some embodiments, the notch is angled in a direction opposite the first direction. In some embodiments, the endoscope fastener comprises a clasp, 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.

[0009] In some embodiments, the endoscope has a proximal outer diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope has a proximal outer diameter of 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 6 mm to about 12 mm, about 6 mm to about 14 mm, about 6 mm to about 15 mm, about 5 mm to about 16 mm, about 6 ... 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 8 ...2mm, about 8mm 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 12mm, about 8mm 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 12mm, about 8mm to about 13mm, about 7mm to about 14mm, about 7mm to about 15mm, about 7mm to about mm to about 13 mm, about 8 mm to about 14 mm, about 8 mm to about 15 mm, about 8 mm to about 16 mm, about 9 mm to about 10 mm, about 9 mm to about 11 mm, about 9 mm to about 12 mm, about 9 mm to about 13 mm, about 9 mm to about 14 mm, about 9 mm to about 15 mm, about 9 mm to about 16 mm, about 10 mm to about 11 mm, about 10 mm to about 12 mm, about 10 mm to about 13 mm, about 10 mm to about 14 mm, about 10 mm to about 15 mm, about 10 mm to about 16 mm, The endoscope has a proximal outer diameter of about 11 mm to about 12 mm, about 11 mm to about 13 mm, about 11 mm to about 14 mm, about 11 mm to about 15 mm, about 11 mm to 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 endoscope has a proximal outer diameter of 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 endoscope has a minimum proximal outer diameter of 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 endoscope has a maximum proximal outer diameter of 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.

[0010] In some embodiments, the endoscope fixture has an inner diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope fixture has an inner diameter of 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 6 mm to about 12 mm, about 6 mm to about 13 mm, about 6 mm to about 14 mm, about 6 mm to about 15 mm, about 6 mm to about 16 mm, about 6 mm to about 16 mm, about 6 mm to about 17 mm, about 6 mm to about 18 mm, about 6 mm to about 19 mm, about 6 mm to about 20 mm, about 6 mm to about 21 mm, about 6 mm to about 22 mm, about 6 mm to about 23 mm, about 6 mm to about 24 mm, about 6 mm to about 25 mm, about 6 mm to about 26 mm, about 6 mm to about 27 mm, about 6 mm to about 28 mm, about 6 mm to about 29 mm, about 6 mm to about 30 mm, about 6 mm to about 31 mm, about 6 mm to about 32 mm, about 6 mm to about 33 mm, about 6 mm to about 34 mm, about 6 mm to about 35 mm, about 6 mm to about 36 mm, about 6 mm to about 37 mm, about 6 mm to about 3 About 11mm, 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 11 mm, about 8 mm to about 12 mm, about 8 mm to about 13 mm, about 8 mm to about 14 mm, about 8 mm to about 15 mm, about 8 mm to about 16 mm, about 9 mm to about 10 mm, about 9 mm to about 11 mm, about 9 mm to about 12 mm, about 9 mm to about 13 mm, about 9 mm to about 14 mm, about 9 mm to about 15 mm, about 9 mm to about 16 mm, about 10 mm to about 11 mm, about 10 mm to about 12 mm, about 10 mm to about 13 mm, about 10 mm to about 14 mm, about 10 mm to about 15 mm, The endoscope fixture has an inner diameter of about 10 mm to about 16 mm, about 11 mm to about 12 mm, about 11 mm to about 13 mm, about 11 mm to about 14 mm, about 11 mm to about 15 mm, about 11 mm to 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 endoscope fixture has an inner diameter of 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 endoscope fixture has a minimum inner diameter of 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 endoscope fixture has a maximum inner diameter of 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.

[0011] In some embodiments, the system further comprises a cable sheath surrounding at least a portion of the cable. In some embodiments, the system further comprises a cable fastener for releasably coupling at least a portion of the cable sheath to the endoscope. In some embodiments, the cable fastener comprises a clasp, 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.

[0012] 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 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 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 1 00 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, about 12 ... 0 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.

[0013] In some embodiments, the angle between the central axis of the arcuate needle guide, within which it is adjustable, and the proximal side of the endoscope, within which it is adjustable, is adjustable within a range of about 5 degrees to about 120 degrees. In some embodiments, the angle between the central axis of the arcuate needle guide, within which it is adjustable, and the proximal side of the endoscope, within which it is adjustable, 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 ... About 40 degrees, about 10 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 5 0 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 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 that is adjustable therein and the proximal side of the endoscope that is adjustable therein is adjustable within a range of 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 that is adjustable therein and the proximal side of the endoscope that is adjustable therein is adjustable within a range of 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, within which it is adjustable, and the proximal side of the endoscope, within which it is adjustable, is adjustable within a range of 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.

[0014] 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 constructed from plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. In some embodiments, the first housing further comprises a cable pulley to guide the cable. In some embodiments, the arcuate needle further comprises a suture attachment fixture. In some embodiments, the first housing further comprises a pulley, and the cable is threaded around the pulley. In some embodiments, the second housing is coupled to the endoscope.

[0015]

[0015] Another aspect provided herein is an endoscopic suturing system comprising a distal assembly comprising a first housing having an arcuate needle guide and an endoscope fixture, the endoscope fixture coupling the first housing to an endoscope; an arcuate needle having a notch and a suture attachment, the arcuate needle having a central axis and the arcuate needle disposed within the arcuate needle guide; a proximal assembly comprising a second housing removably attached to the endoscope and an actuator connected to the second housing; and a cable having a claw, the notch and claw engaged when the cable translates in a first rotational direction about the central axis and the notch and claw disengaged when the cable translates opposite the first rotational direction.

[0016] In some embodiments, the pawl comprises a spring, a flexure, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the pawl is biased upon engagement. In some embodiments, the notch is angled in a direction opposite the first direction. In some embodiments, the endoscope fixation device comprises a press fit fixation device, a clamp, adhesive, tape, a strap, a set screw, a hook and loop fixation device, a magnet, or any combination thereof.

[0017] In some embodiments, the endoscope has a proximal outer diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope has a proximal outer diameter of 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 6 mm to about 12 mm, about 6 mm to about 14 mm, about 6 mm to about 15 mm, about 6 mm to about 16 mm, about 6 mm to about 16 mm, about 6 mm to about 18 mm, about 6 mm to about 18 mm, about 6 mm to about 19 mm, about 6 mm to about 20 mm, about 6 mm to about 21 mm, about 6 mm to about 22 mm, about 6 mm to about 23 mm, about 6 mm to about 24 mm, about 6 mm to about 25 mm, about 6 mm to about 26 mm, about 6 mm to about 27 mm, about 6 mm to about 28 mm, about 6 mm to about 29 mm, about 6 mm to about 30 mm, about 6 mm to about 31 mm, about 6 mm to about 32 mm, about 6 mm to about 33 mm, about 6 mm to about 34 mm, about 6 mm to about 35 mm, about 6 mm to about 36 mm, about 6 mm to about 37 mm, about 6 mm to about 38 mm, about 6 mm 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 8 ...2mm, about 8mm 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 12mm, about 8mm 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 12mm, about 8mm to about 13mm, about 7mm to about 14mm, about 7mm to about 15mm, about 7mm to about mm to about 13 mm, about 8 mm to about 14 mm, about 8 mm to about 15 mm, about 8 mm to about 16 mm, about 9 mm to about 10 mm, about 9 mm to about 11 mm, about 9 mm to about 12 mm, about 9 mm to about 13 mm, about 9 mm to about 14 mm, about 9 mm to about 15 mm, about 9 mm to about 16 mm, about 10 mm to about 11 mm, about 10 mm to about 12 mm, about 10 mm to about 13 mm, about 10 mm to about 14 mm, about 10 mm to about 15 mm, about 10 mm to about 16 mm, The endoscope has a proximal outer diameter of about 11 mm to about 12 mm, about 11 mm to about 13 mm, about 11 mm to about 14 mm, about 11 mm to about 15 mm, about 11 mm to 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 endoscope has a proximal outer diameter of 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 endoscope has a proximal outer diameter of 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 endoscope has a proximal outer diameter of 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. It has an outer diameter of .

[0018] In some embodiments, the endoscope fixture has an inner diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope fixture has an inner diameter of 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 6 mm to about 15 mm, about 6 mm to about 16 mm, about 6 mm to about 17 mm, about 6 mm to about 18 mm, about 6 mm to about 19 mm, about 6 mm to about 20 mm, about 6 mm to about 21 mm, about 6 mm to about 22 mm, about 6 mm to about 23 mm, about 6 mm to about 24 mm, about 6 mm to about 25 mm, about 6 mm to about 26 mm, about 6 mm to about 27 mm, about 6 mm to about 28 mm, about 6 mm to about 29 mm, about 6 mm to about 30 mm, about 6 mm to about 31 mm, about 6 mm to about 32 mm, about 6 mm to about 33 mm, about 6 mm to about 34 mm, about 6 mm to about 35 mm, about 6 mm to about 36 mm, about 6 mm to about 37 mm, about 6 mm to about 38 mm, about 6 mm to about 39 mm, about 6 mm to about 40 mm, about 6 mm to about 41 mm, about 6 mm to about 4 m 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 12m m, 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 10mm to about 16mm, The endoscope fixture has an inner diameter of about 6 mm, about 11 mm to about 12 mm, about 11 mm to about 13 mm, about 11 mm to about 14 mm, about 11 mm to about 15 mm, about 11 mm to 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 endoscope fixture has an inner diameter of 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 endoscope fixture has a minimum inner diameter of 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 endoscope fixture has a maximum inner diameter of 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.

[0019] In some embodiments, the system further comprises a cable sheath surrounding at least a portion of the cable. In some embodiments, the system further comprises a cable fastener releasably coupling at least a portion of the cable to the endoscope. In some embodiments, the cable fastener comprises a press fit fastener, a clamp, adhesive, tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof.

[0020] 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 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 8 0 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 50 degrees to about 120 degrees 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.

[0021] In some embodiments, the angle between the central axis of the arcuate needle guide, within which it is adjustable, and the proximal side of the endoscope, within which it is adjustable, is adjustable within a range of about 5 degrees to about 120 degrees. In some embodiments, the angle between the central axis of the arcuate needle guide, within which it is adjustable, and the proximal side of the endoscope, within which it is adjustable, 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 ... About 40 degrees, about 10 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 5 0 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 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 that is adjustable therein and the proximal side of the endoscope that is adjustable therein is adjustable within a range of 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 that is adjustable therein and the proximal side of the endoscope that is adjustable therein is adjustable within a range of 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 10 ... The angle between can be adjusted within a maximum range of 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.

[0022] 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 constructed from plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. In some embodiments, the first housing further comprises a cable pulley to guide the cable. In some embodiments, the arcuate needle further comprises a suture attachment fixture. In some embodiments, the first housing further comprises a pulley, and the cable is threaded around the pulley. In some embodiments, the second housing is coupled to an endoscope.

[0023]

[0023] The novel features of the present disclosure are set forth with particularity in the appended claims. The features and advantages of the present disclosure will become better understood by reference to the following detailed description that sets forth illustrative embodiments, in which the principles of the disclosure are utilized. [Brief description of the drawings]

[0024] [Figure 1]

[0024] FIG. 1 illustrates an exemplary endoscopic suturing system, according to an embodiment of the present disclosure. [Diagram 2]

[0025] FIG. 2 illustrates an exemplary first proximal assembly coupled to an endoscope, according to embodiments herein. [Diagram 3]

[0026] FIG. 13 illustrates a second exemplary proximal assembly, according to embodiments herein. [Figure 4]

[0027] FIG. 13 illustrates a third exemplary distal assembly, according to embodiments herein. [Diagram 5]

[0028] FIG. 2 illustrates an exemplary first distal assembly on an endoscope, according to embodiments herein. [Figure 6]

[0029] FIG. 2 is a detailed view illustrating an exemplary first distal assembly, according to an embodiment herein. [Figure 7]

[0030] A detailed view illustrating an example first distal assembly in a first position with a portion of the shuttle guide removed, according to embodiments herein. [Figure 8]

[0031] A detailed view illustrating an example first distal assembly in a second position with a portion of the shuttle guide removed, according to embodiments herein. [Figure 9]

[0032] A detailed view illustrating an example first distal assembly in a third position with a portion of the shuttle guide removed, according to embodiments herein. [Figure 10]

[0033] A detailed view showing an example first distal assembly in a fourth position with a portion of the shuttle guide opaque, according to embodiments herein. [Figure 11]

[0034] A detailed view showing an example first distal assembly in a fifth position with a portion of the shuttle guide opaque, according to embodiments herein. [Figure 12]

[0035] A detailed view showing an example first distal assembly in a sixth position with a portion of the shuttle guide opaque, according to embodiments herein. [Figure 13]

[0036] A detailed view showing an example first distal assembly in a seventh position with a portion of the shuttle guide opaque, according to embodiments herein. [Figure 14]

[0037] 1 illustrates an exemplary arcuate needle, according to embodiments herein. [Figure 15]

[0038] 1 illustrates an example arcuate needle having two notches, according to embodiments herein. [Figure 16]

[0039] 1A-1C illustrate exemplary arch needles and sutures, according to embodiments herein. [Figure 17]

[0040] FIG. 13 is a first exemplary diagram illustrating in-situ suture exchange with a first exemplary distal assembly according to an embodiment herein. [Figure 18]

[0041] FIG. 11 is a second exemplary view showing an in-situ suture exchange with a first exemplary distal assembly according to an embodiment herein. [Figure 19]

[0042] FIG. 19A is an exemplary diagram showing a shuttle with the pawls engaged, according to embodiments herein.

[0043] FIG. 19B is an exemplary diagram showing a shuttle with the pawls disengaged, according to embodiments herein. [Figure 20]

[0044] FIG. 2 is a first diagram illustrating an exemplary second proximal assembly coupled to an endoscope, according to embodiments herein. [Figure 21]

[0045] FIG. 11 is a second diagram illustrating an exemplary second proximal assembly coupled to an endoscope, according to embodiments herein. [Figure 22]

[0046] FIG. 11 is a third diagram illustrating an exemplary second proximal assembly coupled to an endoscope, according to embodiments herein. [Figure 23]

[0047] FIG. 13 is a first bottom perspective view of an exemplary second distal assembly without a bottom plate according to embodiments herein. [Figure 24]

[0048] FIG. 13 is a second bottom perspective view of an exemplary second distal assembly without a bottom plate, according to embodiments herein. [Diagram 25]

[0049] 1 illustrates an exemplary first housing of a second proximal assembly according to embodiments herein. [Figure 26]

[0050] FIG. 13 is a cross-sectional view of an exemplary second proximal assembly, according to embodiments herein. [Figure 27]

[0051] FIG. 27A is a bottom cross-sectional view illustrating an example second proximal assembly in a first position according to embodiments herein.

[0052] FIG. 27B is a bottom cross-sectional view illustrating an example second proximal assembly in a second position according to embodiments herein.

[0053] FIG. 27C is a bottom cross-sectional view illustrating an example second proximal assembly in a third position according to embodiments herein.

[0054] FIG. 27D is a bottom cross-sectional view illustrating an example second proximal assembly in a fourth position, according to embodiments herein.

[0055] FIG. 27E is a bottom cross-sectional view illustrating an example second proximal assembly in a fifth position according to embodiments herein.

[0056] FIG. 27F is a bottom cross-sectional view illustrating an example second proximal assembly in a sixth position according to embodiments herein. [Figure 28]

[0057] FIG. 2 is a top perspective view of an exemplary removable first housing bottom according to embodiments herein. [Figure 29]

[0058] FIG. 2 is a bottom perspective view of an exemplary removable first housing bottom according to embodiments herein. [Diagram 30]

[0059] FIG. 30A illustrates an example first cable-claw combination, according to embodiments herein.

[0060] FIG. 30B illustrates an example second cable-claw combination, according to embodiments herein.

[0061] FIG. 30C illustrates an example engaged cable-claw combination, according to embodiments herein. [Diagram 31]

[0062] FIG. 31A illustrates an example third distal assembly in a first position, according to embodiments herein.

[0063] FIG. 31B illustrates an example third distal assembly in a second position, according to embodiments herein. [Diagram 32]

[0064] FIG. 13 is another diagram illustrating an exemplary third distal assembly in a second position, according to embodiments herein. [Diagram 33]

[0065] FIG. 13 is another diagram illustrating an exemplary third distal assembly in a second position, according to embodiments herein. [Diagram 34]

[0066] A diagram showing an example first portion of a first housing of an example third distal assembly in a second position according to embodiments herein. [Diagram 35]

[0067] FIG. 13 is a detailed view illustrating an example first portion of a first housing of an example third distal assembly according to embodiments herein. [Diagram 36]

[0068] FIG. 13 is a detailed view illustrating an example second portion of a first housing of an example third distal assembly according to embodiments herein. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0025]

[0069] Provided herein are tissue suturing systems, devices, apparatus, and methods for endoscopic suturing of tissue within the body. In some embodiments, the systems, devices, apparatus, and methods herein are used with a flexible endoscope to suture tissue. The suturing systems, devices, apparatus, and methods described herein are configured to perform full thickness endoscopic suturing for various gastrointestinal indications, including, for example, tissue suturing, bariatric treatment, stent fixation, and graft fixation. Provided herein are devices, apparatus, and systems that actuate arcuate needles through C-shaped portions of a distal assembly ("arctic needles" as used herein is synonymous with "circular needles" and refers to arc-shaped needles that are not perfectly circular but move in a circular or approximately circular path), where these C-shaped portions of the distal assembly are angled non-perpendicularly to the main axis of the endoscope and are not angularly aligned with the main axis of the endoscope (see needle axis 501 elsewhere herein). Thus, no tissue grabber is required when using the arcuate needles of the distal assembly to suture, because the distal assembly is easily manipulated to secure tissue between the ends of the openings of the C-shaped portion of the distal assembly and in the gaps formed by this "C" of the C-shaped portion of the distal assembly, where suturing occurs when in these positions without the need for separate support. The alignment and angle of the devices, apparatus, systems, and methods relative to the scope allows for easy viewing using the device's camera. These distal assemblies are coupled to the distal end of the endoscope without the use of a working channel, visible to the endoscope's camera, for ease of maneuvering the needles through tissue during use and suturing, and for simplicity and accuracy of suturing. Additionally, the devices, apparatus, and systems, and methods described herein actuate the arcuate needle via a C-shaped distal assembly coupled to the inflexible distal end of the scope, which uses a simple set of wires and a shuttle coupled to the wires to manipulate the arcuate needle through the suturing process without compromising the flexibility of the scope. Endoscopic Suturing System

[0070] 1 is a diagram of an exemplary endoscopic suturing system 100 configured for use with an endoscope 140. As shown, the exemplary endoscopic suturing system 100 comprises a distal assembly 120, a proximal assembly 110, and a cable 130. In some embodiments, the endoscopic suturing system 100 further comprises 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 releasably couples at least a portion of the cable 130 to the endoscope 140. In some embodiments, the cable fastener 150 secures the cable 130 to the endoscope 140 by wrapping around the cable 130 and the endoscope 140. In some embodiments, the cable fastener 150 secures the cable 130 to the endoscope 140 by being clamped to the cable 130 and the endoscope 140. In some embodiments, the cable fastener 150 secures the cable 130 to the endoscope 140 by releasably attaching the cable 130 to the endoscope 140. In some embodiments, the cable fasteners 150 include a press-fit fastener, a clamp, adhesive, tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the endoscopic suturing system 100 includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more cable fasteners 150. Proximal Assembly

[0071] 2 and 3 show views of an example proximal assembly 110 coupled to an endoscope 140. As shown, the example proximal assembly 110 comprises a second housing 111 and an actuator 112. In some embodiments, the second housing 111 comprises a second housing fixture 111A, an actuator support portion 111B, and a main second housing body 111C. In some embodiments, the main second housing body A second housing fixture 111C couples the second housing fixture 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.

[0026]

[0072] 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 to an endoscopic 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 140, 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 facilitates improved stability of the proximal assembly 110 on the endoscope 140.

[0027]

[0073] In some embodiments, the second housing fixture 111A and the main second housing body 111C are coupled to the endoscope 140. In some embodiments, the second housing fixture 111A and the main second housing body 111C are removably coupled to the endoscope 140. In some embodiments, the second housing fixture 111A and the main second housing body 111C are coupled to the endoscope 140 and an endoscopic biopsy port (or instrument channel port) 140A of the endoscope 140. In some embodiments, the second housing fixture 111A and the main second 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 fixture 111A and the main second housing body 111C surround a portion of the endoscope 140, the endoscope cable 140, or both. In some embodiments, second housing fixture 111A and main second housing body 111C partially surround a portion of endoscope 140, endoscope cable 140A, or both. In some embodiments, coupling of second housing fixture 111A and main second housing body 111C to both endoscope 140 and endoscope cable 140A facilitates improving stability of proximal assembly 110 on endoscope 140. In some embodiments, the fixture of second housing 111A is rigidly connected to endoscope 140 without allowing any relative motion between endoscope 140 and second housing 111.

[0028]

[0074] As shown, main second housing body 111C comprises a first concave portion and a second concave portion. In some embodiments, the first concave portion surrounds a portion of endoscope 140. In some embodiments, the second concave portion surrounds a portion of endoscopic cable 140A. In some embodiments, the first concave portion has an inner diameter equal to or greater than the outer diameter of endoscope 140. In some embodiments, the inner diameter of the first concave portion is about 5 mm to about 50 mm. In some embodiments, the second concave portion has an inner diameter equal to or greater than the outer diameter of endoscopic cable 140A. In some embodiments, the inner diameter of the second concave portion is about 5 mm to about 50 mm. In some embodiments, the angle between the centerline of the first concave portion and the centerline of the second concave portion is about 30 degrees. In some embodiments, the angle between the centerline of the first concave portion and the centerline of the second concave portion is 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, 70 degrees, 75 degrees, 80 degrees, 85 degrees, 90 degrees, including increments therein. The angle between the core wire is about 5 to about 90 degrees, about 10 to about 90 degrees, about 10 to about 80 degrees, about 20 to about 70 degrees, about 5 to about 60 degrees, about 10 to about 60 degrees, about 20 to about 60 degrees, about 10 to about 50 degrees, about 5 to about 45 degrees, about 10 to about 50 degrees, about 15 to about 65 degrees, about 25 to about 65 degrees, about 30 to about 60 degrees, 5 to 90 degrees, 10 to 90 degrees, 10 to 80 degrees, 20 to 70 degrees, 5 to 60 degrees, 10 to 60 degrees, 20 to 60 degrees, 10 to 50 degrees, 5 to 45 degrees, 10 to 50 degrees, 15 to 65 degrees, 25 to 65 degrees, or 30 to 60 degrees. In some embodiments, at least one of the first concave portion or the second concave portion of the main second housing body 111C has a uniform thickness.

[0029]

[0075] In some embodiments, the primary second housing body 111C includes a fastening mechanism that couples to the second housing fastener 111A. As shown, the fastening mechanism of the primary second housing body 111C includes a plurality of raised ridges. Alternatively, in some embodiments, the fastening mechanism of the primary second housing body 111C includes a clasp, string, band, hook and loop fastener, tape, strap, magnet, cinch, press fit, set screw, adhesive, or any combination thereof.

[0030]

[0076] In some embodiments, the second housing fixture 111A is coupled to a fastening mechanism of the main second housing body 111C, thereby securing the proximal assembly 110 to the endoscope 140. As can be seen, the exemplary second housing fixture 111A comprises a strap extending from the main second housing body 111C. In some embodiments, the second housing fixture 111A and the main second housing body 111C are coupled by a hinge (not shown), where the second housing fixture 111A rotates about the main second housing body 111C via the hinge. In some embodiments, the second housing fixture 111A comprises a flexible strap that is permanently attached to the main second housing body 111C. In some embodiments, the second housing fixture 111A comprises a flexible strap that is overmolded onto the main second housing body 111C. In some embodiments, at least a portion of the second housing fixture 111A is flexible. Further, as shown, the end of the strap of the second housing fixture 111A includes a hook that is engaged and disengaged from the fastening mechanism of the main second housing body 111C. Additionally, as shown, in some embodiments, the fastening mechanism of the main second housing body 111C includes a protruding portion for being grasped by a user during engagement and disengagement with the fastening mechanism of the main second housing body 111C. In some embodiments, the strap of the second housing fixture 111A includes a hook that is engaged and disengaged from the fastening mechanism of the main second housing body 111C. In some embodiments, the strap of the second housing fixture 111A and the fastening mechanism of the main second housing body 111C allow the second housing 111 to be secured to various sizes of endoscope 140. In some embodiments, the hook of the second housing fixture 111A and.

[0031]

[0077] In some embodiments, second housing 111 includes one, two, three, four, five, six, seven, eight, nine, ten, or more second housing fixtures 111A. Alternatively, second housing 111 is not coupled to endoscope 140. In some embodiments, proximal assembly 110 is configured to be used as a handheld assembly. In some embodiments, proximal assembly 110 is configured to be mounted on a surface, a rod, a stand, or any combination thereof.

[0032]

[0078] In some embodiments, the wheel 113 is constrained to rotate in at least one degree 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 one embodiment, the actuator support portion 111B surrounds at least a portion of the actuator 112. As can be seen, the exemplary actuator 112 comprises a wheel 113 that rotates about a pin 114 within the second housing 111. In some embodiments, the actuator 112 is free to rotate about 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 comprises a bearing that allows the wheel 113 to rotate about the pin 114 within the second housing 111. In some embodiments, at least one of the wheel 113 or the actuator support portion 111B comprises a lock, where the rotation of the wheel 113 about 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 comprises a recess, a ridge, a valley, a spring, or any combination thereof that is engaged and disengaged upon rotation of the wheel 113 about the pin 114 to allow for manual advancement of the wheel 113. In some embodiments, the recess, the ridge, the valley, the spring, or any combination thereof is engaged and disengaged upon rotation of the wheel 113 about the pin 114 to provide tactile feedback indicating an increment in the angle of rotation. Additionally, in some embodiments, the actuator 112 further comprises a spring, a recess, a magnet, or any combination thereof to bias the actuator 112 to one or more positions relative to the second housing 111.

[0033]

[0079] Alternatively, in some embodiments, the second housing 111 does not have the pin 114, where the wheel 113 rotates about a protrusion in the actuator support portion 111B. In some embodiments, the wheel 113 includes the pin 114 or protrusion, where the wheel 113 and the pin 114 or protrusion rotate about a corresponding hole 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 to clean the wheel 113. As shown in FIG. 3, the wheel 113 is circular. In some embodiments, the circular wheel 113 has an outer diameter. Alternatively, in some embodiments, the wheel 113 has a shape including a triangle, a square, a pentagon, a hexagon, or any other polygon.

[0034]

[0080] As shown, the example 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 further functions 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 the wheel 113 from rotating more than 360 degrees in a secondary direction opposite the primary direction 131. In some embodiments, the wheel 113 rotates a maximum of about 360 degrees in the primary direction 131 and a maximum of about 360 degrees in the secondary direction opposite the primary direction 131. In some embodiments, the wheel 113 rotates in the primary direction 131 at a maximum of 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 110 degrees, about 120 degrees, about 130 degrees, about 140 degrees, about 150 degrees, about 160 degrees, about 170 degrees, about 180 degrees, about 190 degrees, about 200 degrees, about 210 degrees, about 220 degrees, about 230 degrees, about 240 degrees, about 250 degrees, about 260 degrees, about 270 degrees, about 280 degrees, about 290 degrees, about 300 degrees, about 310 degrees, about 320 degrees, about 330 degrees, about 340 degrees, about 350 degrees, about 360 degrees, about 370 degrees, about 380 degrees, about 390 degrees, about 400 degrees, about 410 degrees, about 420 degrees, about 430 degrees, about 440 degrees, about 450 degrees, about 460 degrees, about 470 degrees, about 480 degrees, about 490 degrees, about 500 degrees, about 510 degrees, about 520 degrees, about 530 degrees, about 540 degrees, about 550 degrees, about 560 degrees, about 570 degrees, about 580 degrees, about 590 degrees, about 600 degrees, about 610 degrees, about 620 degrees, about 630 degrees, about 640 degrees, about 650 degrees, about 660 degrees, about 670 degrees, about 680 degrees, about 690 degrees, about 700 degrees, about 710 degrees, about 720 degrees, about 730 80 degrees, about 290 degrees, about 300 degrees, about 310 degrees, about 320 degrees, about 330 degrees, about 340 degrees, about 350 degrees, or about 360 degrees, and in a secondary direction opposite the primary direction 131, the rotation angle is at most 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 110 degrees, about 120 degrees, about 130 degrees, about 140 degrees, about 150 degrees, about 160 degrees, about 170 degrees, about 180 degrees, about 190 degrees, about 200 degrees, about 210 degrees, about 220 degrees, about 230 degrees, about 240 degrees, about 250 degrees, about 260 degrees, about 270 degrees, about 280 degrees, about 290 degrees, about 300 degrees, about 310 degrees, about 320 degrees, about 330 degrees, about 340 degrees, about 350 degrees, or about 360 degrees. degrees, about 210 degrees, about 220 degrees, about 230 degrees, about 240 degrees, about 250 degrees, about 260 degrees, about 270 degrees, about 280 degrees, about 290 degrees, about 300 degrees, about 310 degrees, about 320 degrees, about 330 degrees, about 340 degrees, about 350 degrees, or about 360 degrees. In some embodiments, the actuator 112 further comprises an indicator that indicates its position relative to the second housing 111. Alternatively, in some embodiments, the actuator 112 comprises or further comprises a pulley, wheel, clamp, knot, post, gear, cog, chain, or any combination thereof.

[0035]

[0081] As shown, the exemplary wheel 113 comprises a first channel 115 that receives a first portion of the cable 132, and a second channel 116 that receives a 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 comprise a second channel 116. In such embodiments, the first channel 115 comprises a single helical 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 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 non-concentric. In some embodiments, the first channel 115 and the second channel 116 overlap.

[0036]

[0082] 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 130 to the actuator 112. In some embodiments, the first fastener 118 maintains the first cable portion 133 within the first channel 115. In some embodiments, the second fastener maintains 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 the wheel 113 from rotating more than 360 degrees in a secondary direction opposite 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 catch, or a protruding portion 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, where the cable 130 includes one or more 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, where 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 under 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, at least one of the first cable portion 132 or the second cable portion 133 is 31, when the wheel 113 of the actuator 112 is rotated, the cable portion 132 is under tension. In some embodiments, at least one of the first cable portion 132 or the second cable portion 133 is under tension when the wheel 113 of the actuator 112 is rotated in a secondary direction opposite the primary direction 131.

[0037]

[0083] In some embodiments, according to FIG. 3, when the actuator 112 is rotated in the primary direction 131, it translates the first cable portion 132 a first distance away from the second housing 111 and translates the second cable portion 133 a second distance towards the second housing 111. In some embodiments, when the actuator 112 is rotated in a secondary direction opposite to the primary direction 132, it translates the first cable portion 132 a third distance towards the second housing and translates the second cable portion 133 a fourth distance away from the second housing 111. 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, or 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.

[0038]

[0084] As seen in FIG. 3, in some embodiments, the endoscopic suturing system 100 further comprises a sheath 130A surrounding at least a portion of the cable 130. In some embodiments, the cable 130 is free to translate back and forth in one direction within the sheath 130A. In some embodiments, the cable 130 and the sheath 130A comprise a Bowden cable. In some embodiments, the cable 130 comprises a multi-strand cable, a single-strand cable, a rope, a thread, a string, a wire, or any combination thereof. In some embodiments, the cable 130 comprises 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 comprises a hollow tube that protects the cable 130 therein. In some embodiments, the cable 130A is rigid. In some embodiments, the cable 130 is not elastic.

[0039]

[0085] 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 move within the sheath 130A as the wheel 113 rotates. In some embodiments, the proximal sheath fastener 117 prevents the wheel 113 from rotating more than 360 degrees in the primary direction 131 or the wheel 113 from rotating more than 360 degrees in a second direction opposite the primary direction 131. As shown, the exemplary proximal sheath fastener 117 includes a clamp. In some embodiments, the clamp comprises a first plate, a second plate, and one or more screws that clamp the cable 130 between the first and second plates. Alternatively, in some embodiments, the proximal sheath fastener 117 comprises a screw, a fastener, 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 at least one proximal sheath fastener 117 for both the first cable portion 132 and the second cable portion 133. In some embodiments, the proximal assembly 110 includes one, two, three, four, five, six, seven, eight, nine, ten, or more proximal sheath fasteners 117.

[0040]

[0086] In some embodiments, the cable 130 comprises 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 retainer 117, the first retainer 118, or the sheath 130A is constructed from 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

[0087] 4 and 5 show views of an exemplary first distal assembly 120. As shown, the exemplary first distal assembly 120 includes a first housing 121 that includes an endoscope fixture 121A. In some embodiments, the distal assembly is C-shaped or includes a C-shaped portion, and is therefore referred to as C-shaped. In some embodiments, the distal assembly has an arcuate needle guide 121B that is C-shaped, thus giving the distal assembly a C-shape. In some embodiments, at least the portion of the distal assembly that is C-shaped is an arcuate needle guide. The devices, apparatus, and systems actuate arcuate needles ("arctic needles" as used herein is synonymous with "circular needles" and refers to arcuate needles that are not perfectly circular but move in a circular or approximately circular path) through the C-shaped portions of the distal assembly, where these C-shaped portions of the distal assembly are angled non-perpendicularly to the main axis of the endoscope and are not angularly aligned with the main axis 502 of the endoscope (see needle axis 501 elsewhere herein). Thus, no tissue grabbers are required when using the arcuate needles of the distal assembly to suture, because the distal assembly is easily manipulated to secure tissue between the ends of the openings of the C-shaped portions of the distal assembly and in the gaps formed by this "C" of the C-shaped portions of the distal assembly, where suturing occurs when in these positions without the need for separate support. In some embodiments, the end of the C-shaped portion of the distal assembly forms an angle with respect to the needle axis 501 that is 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, the angle is measured from the central axis of the pulley 2121AA or its equivalent pin in some embodiments. In some embodiments, the angle is measured from the end of the C-shaped portion that forms the smallest angle at which it is possible to measure the angle.

[0041]

[0088] In some embodiments, endoscope fixture 121A couples first housing 121 to endoscope 140. In some embodiments, endoscope fixture 121A releasably couples first housing 121 to endoscope 140. As shown, endoscope fixture 121A comprises a press-fit fixture. In some embodiments, press-fit endoscope fixture 121A is attached to endoscope 140 by firmly pressing press-fit endoscope fixture 121A onto the distal end of endoscope 140. In some embodiments, press-fit endoscope fixture 121A is attached to endoscope 140 by firmly pressing press-fit endoscope fixture 121A onto the distal end of endoscope 140 and rotating press-fit endoscope fixture 121A. In some embodiments, press-fit endoscope fixture 121 is detached from endoscope 140 by pulling press-fit endoscope fixture 121A tightly away from the distal end of endoscope 140. In some embodiments, the press-fit endoscope fixture 121A is attached to and detached from the endoscope 140 by pulling and rotating the press-fit endoscope fixture 121A away from the distal end of the endoscope 140. Alternatively, in some embodiments, the endoscope fixture 121A may be secured to the endoscope 140 using a clamp, adhesive, tape, strips, or other suitable means. In some embodiments, the first distal fastener 120 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more endoscope fasteners 121A.

[0042]

[0089] As shown, in some embodiments, endoscope fixture 121A is circular. In some embodiments, endoscope 140 has a proximal outer diameter of about 5 mm to about 16 mm. Thus, in some embodiments, endoscope fixture 121A has an inner diameter of about 5 mm to about 16 mm. In some embodiments, endoscope fixture 121A has a minimum inner diameter of about 5 mm. In some embodiments, endoscope fixture 121A has a maximum inner diameter of about 16 mm. In some embodiments, press-fit endoscope fixture 121A has a diameter equal to or smaller than the diameter of endoscope 140. In some embodiments, endoscope fixture 121A has a diameter equal to or larger than the diameter of endoscope 140. In some embodiments, endoscope fixture 121A is tapered and has a first inner diameter and a second inner diameter, where the first inner diameter is distal to the second inner diameter. In some embodiments, the first inner diameter is larger 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 fixture 121A is measured as a maximum, minimum, or average inner width. In some embodiments, the diameter of the endoscope 140 is measured as a maximum, minimum, or average outer width. Alternatively, in some embodiments, the endoscope fixture 121A has a cross-sectional shape that includes a triangle, a square, a hexagon, or any other polygon. In some embodiments, the endoscope fixture 121A has an inner length of about 10 mm to about 30 mm. In some embodiments, the inner length of the endoscope fixture 121A is measured as a minimum, maximum, or average length from a distal end of the endoscope fixture 121A to a proximal end of the endoscope fixture 121A. In some embodiments, the inner length of the endoscope fixture 121A is measured as a minimum, maximum, or average perpendicular length from a distal end of the endoscope fixture 121A to a proximal end of the endoscope fixture 121A.

[0043]

[0090] As shown in FIG. 4, the example first distal assembly 120 further comprises a distal sheath fastener 128 that couples a portion of the sheath 130A to the first housing 121. As shown, the first housing 121 comprises 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 move within the sheath 130A as the wheel rotates. As shown, the example distal sheath fastener 128 comprises a clamp. In some embodiments, the distal sheath fastener 128 comprises a plate and one or more sheath fastener screws 128A that clamp the cable sheath 130A between the plate and the first housing 121. Alternatively, in some embodiments, the distal sheath fastener 128 comprises a screw, a fastener, a tape, or any combination thereof. In some embodiments, the first housing 112 comprises 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 1333. In some embodiments, the first housing 112 comprises a distal sheath fastener 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 into the first housing 121 past the termination point of the distal sheath fastener 128. In some embodiments, the distal assembly 120 comprises 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 comprises a clamp, a fastener, a band, a hook and loop fastener, an adhesive, or any combination thereof.

[0044]

[0091] In some embodiments, referring to FIG. 5, the needle shaft 501 and the endoscope 140 may be The angle between the needle axis 501 and the proximal 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 a range of about 5 degrees to about 85 degrees. In some embodiments, a particular angle between the needle axis 501 and the proximal axis 502 of the endoscope 140 allows the camera of the endoscope 140 to view the entrance, exit, or both of 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 123 and coincides with the center of the radius of the arcuate needle 123. 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 fixture 121A of the first housing 112. In some embodiments, the angle between the central axis 501 of the arcuate needle guide 121B and the proximal axis 502 of the endoscope 140 is defined as a maximum, minimum, or average angle.

[0045]

[0092] 6-9 show detailed views of an exemplary first distal assembly 120. According to FIG. 6, an exemplary first housing 121 includes a primary first housing portion 601, a secondary first housing portion 602, and a pin fastener 603. In some embodiments, the secondary first housing portion 602 is fitted into the primary first housing portion 601. In some embodiments, the primary first housing portion 601 and the secondary first housing portion 602 are joined by the pin fastener 603. In some embodiments, the primary first housing portion 601 and the secondary first housing portion 602 are removably joined by the pin fastener 603. In some embodiments, the primary first housing portion 601 and the secondary first housing portion 602 are made of the same material. In some embodiments, the primary first housing portion 601 and the secondary first housing portion 602 are made of different materials. As shown, the example pin fastener 603 comprises a press-fit fastener, where the press-fit fastener has an outer diameter larger than the diameter of the corresponding holes in the primary first housing portion 601 and the secondary first housing portion 602. Alternatively, in some embodiments, the pin fastener 603 comprises a screw, a bolt, a threaded formation, a nut, a rivet, an adhesive, a pulley, a bearing, a weld, or any combination thereof. As shown, the example first housing 121 comprises two pin fasteners 603. Alternatively, the example first housing 121 comprises one, two, three, four, five, six, seven, eight, nine, ten, or more pin fasteners 603.

[0046]

[0093] Additionally, in some embodiments, the first distal assembly 120 comprises an arcuate needle 122 disposed within an arcuate needle guide 121B within the first housing 121. In some embodiments, at least one of the primary first housing portion 601 or the secondary first housing portion 602 comprises 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 limits the arcuate needle 122 to rotate within one degree of freedom. In some embodiments, the arcuate needle guide 121B limits the arcuate needle 122 to rotate within at least one rotational degree of freedom. As can be seen, the illustrated arcuate needle guide 121B surrounds at least a portion of the arcuate needle 122. In some embodiments, the illustrated arcuate needle guide 121B surrounds at least a portion of the arcuate needle 122 when disposed within the first housing 121. In some embodiments, the arcuate needle guide 121B has an inner width that is greater than a thickness of the arcuate needle 122. In some embodiments, the arcuate needle guide 121B has a cross-sectional shape, including a circular, square, rectangular, or any other polygonal shape. In some embodiments, a gulf 604 is formed within the first distal assembly 120 between a first termination point of the arcuate needle guide 121B and a second, opposite termination point of the arcuate needle guide 121B. As seen herein, the arcuate needle guide 121B The arcuate needle guide 121B encircles approximately 280 degrees of the cross sectional circumference of the arcuate needle 122. Alternatively, in some embodiments, the arcuate needle guide 121B encircles 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 of the cross sectional circumference of the arcuate needle 122, including increments therein.

[0047]

[0094] In some embodiments, a gulf 604 is formed in the first distal assembly 120 between the first pin fixture 603 and the second opposing pin fixture 603. In some embodiments, the gulf 604 receives tissue to be sutured 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 grabber to hold the tissue against the arcuate needle 122. In some embodiments, the lack of a dedicated grabber required allows for the use of a standard endoscope 140 without an additional dedicated working channel.

[0048]

[0095] 7-9, the exemplary first distal assembly 120 further comprises 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 within the shuttle guide 121C at least one rotational degree. In some embodiments, the shuttle 123 translates within the shuttle guide 121C one rotational degree within a 270 degree arc. In some embodiments, the shuttle 123 translates within the shuttle guide 121C in an arc of one degree of rotation that exceeds 90 degrees, 100 degrees, 110 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 rotation. In some embodiments, at least one of the shuttle 123 or shuttle guide 121C has a cross-sectional shape, including a circle, a square, a rectangle, or any other polygon.

[0049]

[0096] In some embodiments, at least one of the primary first housing part 601 or the secondary first housing part 602 comprises the 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 for sliding within the arcuate shuttle guide 121C. In some embodiments, the primary first housing part 601 limits a bottom surface of the shuttle 123 and the secondary first housing part 602 limits a portion of the inner, outer and top surfaces of the shuttle 123. Alternatively, in some embodiments, at least one of the primary first housing part 601 or the secondary first housing part 602 limits one or more of the bottom, inner, outer and top surfaces of the shuttle 123. In some embodiments, the shuttle 123 is constrained by at least one of the primary first housing portion 601 or the secondary first housing portion 602 as it translates within the shuttle guide 121C. As shown, a bottom surface of the shuttle 123 contacts a portion of the primary first housing portion 601, while an inner portion and an outer portion of the shuttle 123 contact a portion of the secondary first housing portion 602. In some embodiments, the shuttle 123 is constrained by at least one of the primary first housing portion 601 or the secondary first housing portion 602 as it translates within the shuttle guide 121C. As shown, an arcuate channel between the shuttle guide 121C and the arcuate needle guide 121B constrains the shuttle 123 from translating within the shuttle guide 121C. 21C.

[0050]

[0097] 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 furthest 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 123 that is furthest from the arcuate needle 122.

[0051]

[0098] In some embodiments, the arc length of the shuttle guide 121C is equal to the distance traveled by at least one of the first or second cable portions during rotation of the actuation wheel minus the width of the shuttle 123. In some embodiments, the shuttle 123 moves within the shuttle guide 121C the distance traveled by at least one of the first or second cable portions during rotation of the actuation wheel. 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 or second channels of the actuator wheel 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 or second channels of the actuator wheel 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 or second channels of the actuator wheel is at most about 1:5.

[0052]

[0099] 8, the exemplary shuttle 123 further comprises a cable attachment 127 connected to the cable 130. As shown, the cable attachment 127 comprises a cavity that receives and secures a portion of the cable 130. Alternatively, in some embodiments, the cable attachment 127 comprises a clamp, hole, screw, bolt, nut, clip, pin, or any combination thereof. In some embodiments, the cable attachment 127 comprises a terminated cable attachment, where the cable terminates at the cable attachment 127. In some embodiments, the cable attachment 127 comprises a non-terminated cable attachment, where the cable passes through the cable attachment 127 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. As can be seen, the example shuttle 123 is rigidly connected to a cable 130 at a cable attachment 127 such that tension on the cable 130 causes the shuttle 123 to translate in the direction of the tension.

[0053]

[0100] In some embodiments, the shuttle 123 comprises the pawl 124, the cushion 126, or both. In some embodiments, the shuttle 123 comprises a cavity 123A that receives the pawl 124, the cushion 126, or both. In some embodiments, the cavity 123A has an inner width that is greater than the outer width of the pawl 124, the outside of the cushion 126, or both. In some embodiments, the cavity 123A terminates within the shuttle 123. In some embodiments, cavity 123A extends through shuttle 123. In some embodiments, cavity 123A has a cross-sectional shape, including a square, a circle, a triangle, a hexagon, or any other polygon.

[0054]

[0101] In some embodiments, the pawl 124 is biased in a direction to engage the notch 122A of the arcuate needle 122. In some embodiments, the pawl 124 is biased in a first direction 1000. In some embodiments, the pawl 124 comprises a pivot 127 for rotating about the shuttle 123. In some embodiments, the pivot 127 comprises a pin protruding portion element of the pawl 124. In some embodiments, the pivot 127 comprises a pin rigidly attached to the pawl 124, which rotates about a hole in the shuttle 123. In some embodiments, the pivot 127 comprises a pin rigidly attached to the shuttle 123, which rotates about a hole in the pawl 124. Alternatively, in some embodiments, the pivot 127 comprises a recessed portion, a slot, a screw, or any combination thereof in the pawl 124, the shuttle 123, or both.

[0055]

[0102] In some embodiments, the pawl 124 is biased in a direction to be engaged by the cushion 126. In some embodiments, the cushion 126 is resilient. In some embodiments, the cushion 126 comprises a spring. In some embodiments, the cushion 126 urges the pawl 124 in a second direction opposite the first rotational direction 1000. In some embodiments, the cushion 126 urges the pawl 124 to move it upwardly out of the cavity 123A to engage the notch 122A of the arch needle 122. In some embodiments, the position of the pivot 127 relative to the end point of the cavity 123A in combination with the position of the cushion 126 allows the pawl to be biased into engagement. In some embodiments, the cushion 126 urges the pawl 124 against the end point of the cavity 123A of the shuttle 123 when the pawl 124 is engaged. In some embodiments, when the pawl 124 is disengaged, the arcuate needle 122 presses the pawl 124 against the cushion 126, causing the pawl to move upward into the cavity 123A and away from the end of the cavity 123A of the shuttle 123. In some embodiments, the upper surface of the pawl 124 is angled toward one end of the shuttle 123. In some embodiments, the upper surface of the pawl 124 is angled upward in a second rotational direction opposite the first rotational direction 1000. In some embodiments, the upper surface of the pawl 124 is angled to engage the angled portion of the arcuate needle. In some embodiments, the pawl 124 further comprises a spring, a curved portion, a dual spring gate, a cushion, a piston, a rod, a pin, teeth, 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.

[0056]

[0103] In some embodiments, the cushion 126 is integrated into the pawl 124. In some embodiments, the cushion 126 is integrated into the shuttle 123. In some embodiments, the cushion 126 is integrated into the cavity 123A of the shuttle 123. In some embodiments, the shuttle 123 does not include a cushion 126. In some embodiments, the shuttle 123 does not include a cushion 126, where the pawl 124 includes a flexure, spring, dual spring gate, cushion, piston, rod, pin, teeth, or any combination thereof, for biasing the pawl 124 against the arcuate needle. In some embodiments, the shuttle 123 does not include a pawl 124 or a cushion 126, where the shuttle 123 includes a flexure, spring, dual spring gate, cushion, piston, rod, pin, teeth, or any combination thereof, for engaging and disengaging with the arcuate needle.

[0057]

[0104] Further, referring to FIG. 7, the exemplary first housing 121 is detachable from the proximal assembly. A cable pulley 121D is provided to guide the cable 130 through the shuttle guide 121C to the shuttle 123 and out of the first housing 121. In some embodiments, at least one of the primary first housing portion 601, the secondary first housing portion 602, or the pin fixture 603 of the first housing 121 is provided with the cable pulley 121D. In some embodiments, the first housing 121 is provided with 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more cable pulleys 121D. In some embodiments, the cable pulleys 121D are provided with bearings, rods, curved surfaces, or any combination thereof. In some embodiments, the cable pulleys 121D are provided with rigid portions of the first housing 121. Alternatively, in some embodiments, the cable pulleys 121D rotate within the first housing 121. Alternatively, in some embodiments, the cable pulley 121D rotates within the primary first housing part 601, the secondary first housing part 602, or both. In some embodiments, at least one of the primary first housing part 601 or the secondary first housing part 602 further comprises one or more cable guides that guide the cable 130 towards and away from the cable pulley 121D.

[0058]

[0105] 10-13 show the progression of the arcuate needle 122 as it is translated through the arcuate needle guide 121B by the shuttle 123 and pawl 124. According to FIG. 10, in a first position, the arcuate needle 122 is fully contained within the arcuate needle guide 121B in the first housing 121. As the cable 130 pulls the shuttle 123 within the shuttle guide 121C in a first rotational direction 1000 relative to the first housing 121, according to FIG. 11, the pawl 124 engages a notch 122A in the arcuate needle 122, causing a portion of the arcuate needle 123 to exit the first housing 121. When the shuttle 123 cannot move further in the shuttle guide 121C of the first housing 121 in the first rotational direction 1000, the cable 130 pulls the shuttle 123 in a second rotational direction opposite to the first rotational direction 1000, so that the pawl 124 engages the suture end 1201 of the arched needle 122. The cable 130 is then pulled in the first rotational direction 1000, so that the shuttle 123 translates in the first rotational direction 1000, whereas according to FIG. 12 the pawl 124 presses against the suture end 1201 of the arched needle 122, so that most of the arched needle 122 exits the first housing 121 and only a portion of the pointed end 1101 of the arched needle 122 and the suture end 1201 are present in the first housing 121. After the shuttle 123 can no longer move further in the first rotational direction 1000 within the shuttle guide 121C of the first housing 121, according to Fig. 13, the cable 130 pulls the shuttle 123 in a second rotational direction through the shuttle guide 121C of the first housing 121, causing the pawl 124 to re-engage with the notch 122A in the arcuate needle 122. The cable 130 then pulls the shuttle 123 in a second rotational direction within the shuttle guide 121C of the first housing 121, thereby translating the arcuate needle 122 back into the first housing 121 in the first rotational direction 100, thereby performing one suture.

[0059]

[0106] Thus, one suturing operation includes pulling the cable 130 in a first direction 1000, pulling the cable 130 in a second direction opposite the first direction 1000, pulling the cable 130 in the first direction 1000 a second time, pulling the cable 130 in the second direction 1000 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.

[0060]

[0107] In some embodiments, according to FIGS. 3, 4, and 10, pulling the cable 130 in the first rotational direction 1000 includes pulling the primary cable portion 132 towards 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 the primary direction 131. In some embodiments, pulling the cable 130 in a second rotational direction opposite the first rotational direction 1000 includes pulling the secondary cable portion 133 towards the second housing 111 of the proximal assembly 110. In some embodiments, pulling the cable 130 in the second rotational direction opposite 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 primary cable portion 132 towards 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 secondary direction opposite the primary direction 131. In some embodiments, translating the shuttle 123 in a second rotational direction opposite the first rotational direction 1000 includes pulling the secondary cable portion 133 towards the second housing 111 of the proximal assembly 110. In some embodiments, translating the shuttle 123 in the second rotational direction opposite the first rotational direction 1000 includes rotating the wheel 113 of the actuator 112 in the primary direction 131.

[0061]

[0108] In some embodiments, the shuttle 123 translates within the shuttle guide 121C one or more degrees of rotation when pulled by the cable 130 in the first direction 1000 or the second direction. In some embodiments, the shuttle 123 translates 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 within the shuttle guide 121C one arc of rotation within a range of 90, 100, 110, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320, or more degrees of rotation, including increments therein.

[0062]

[0109] In some embodiments, at least one of the first housing 111, the arcuate needle 112, the shuttle 123, the pawl 124, the shuttle 125, the cushion 126, the primary first housing portion 601, the secondary first housing portion 602, or the pin fastener 603 is constructed from plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. Arched Needle and Suture

[0110] 14-18 show diagrams of an example arched needle 122 and suture 125. According to FIGS. 14 and 15, in some embodiments, the arched needle 122 has a notch 122A, a pointed end 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 of the exemplary arcuate needle 122 and the suture end 1201 is approximately 180 degrees. Alternatively, in some embodiments, the angle between the notch 122A of the exemplary arcuate needle 122 and the suture end 1201, including increments therein, may be approximately 90 degrees, 100 degrees, 120 degrees, 140 degrees, 160 degrees, 180 degrees, 200 degrees, 220 degrees, 240 degrees, 260 degrees, 2800 degrees, or more. In some embodiments, the angle between the notch 122A of the illustrative arcuate needle 122 and the suture end 1201 is at least about 90 degrees.

[0063]

[0111] In some embodiments, the outer diameter of the arched needle 122 is about 7 mm to about 20 mm. In some embodiments, the outer diameter of the arched needle 122 is at least about 7 mm. In some embodiments, the outer diameter of the arched needle 122 is at most about 20 mm. In some embodiments, the thickness 1510 of the arched needle 122 is about 0.5 mm to about 2 mm. In some embodiments, the thickness 1510 of the arched needle 122 is at least about 0.5 mm. In some embodiments, the thickness 1510 of the arched needle 122 is at most about 2 mm. In some embodiments, the ratio between the outer diameter and the thickness 1510 of the arched needle 122 is about 3:1 to about 15:1. In some embodiments, the ratio between the outer diameter and the thickness 1510 of the arched needle 122 is at least about 3:1. In some embodiments, the ratio between the outer diameter and the thickness 1510 of the arched needle 122 is at most about 15:1. In some embodiments, the ratio between the outer diameter and the thickness 1510 of the arched needle 122 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 and the thickness 1510 of the arched needle 122 is at least about 3:1. In some embodiments, the outer diameter of the arched needle 122 is measured as the maximum distance between two points on the surface of the arched needle 122. In some embodiments, the outer diameter of the arched needle 122 is measured as the maximum outer diameter of the arched needle 122. In some embodiments, the width of the arched needle 122 is measured as the thickness 1510 of the arched needle 122. In some embodiments, the thickness 1510 of the arched needle 122 is measured as the thickness 1510 of the arched needle 122 that is not within the pointed end 1101, the suture end 1201, or the notch 122A. In some embodiments, the thickness 1510 of the arched needle 122 is measured as the maximum, minimum, or average thickness 1510 of the arched needle 122.

[0064]

[0112] In some embodiments, the pointed end 1101 is oriented 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 pointed end 1101 is oriented at an angle of at least about 5 degrees. As shown, the exemplary suture end 120 is flat. Alternatively, in some embodiments, the suture end 120 is rounded, tapered, or angled.

[0065]

[0113] As shown, in some embodiments, the arched needle 122 has two notches 122A. In some embodiments, the arched needle 122 has 2, 3, 4, 5, 6, 7, 8, 9, 10 or more notches 122A. In some embodiments, the arched needle 122 has more than two notches 122A. As shown, each notch 122A is spaced apart at an angle of about 180 degrees around the arched needle 122.

[0066]

[0114] 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, ...20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about , 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 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 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 or about 160 degrees. In some embodiments, the notches 122A are spaced about the arcuate needle 122 at an angle of at least about 10 degrees, 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. In some embodiments, the notches 122A are spaced about the arcuate needle 122 at an angle of at least about 10 degrees, 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, or about 160 degrees. In some embodiments, the notches 122A are spaced around the arcuate needle 122 at an angle of up to 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.

[0067]

[0115] 15, the ratio between the thickness 15150 of the arched needle 122 and the depth 1520 of the notch 122A is about 2:1 to about 15:1. In some embodiments, the ratio between the thickness 1510 of the arched needle 122 and the depth 1520 of the notch 122A is a minimum of about 2:1. The ratio between the thickness 15150 of the arched needle 122 and the depth 1520 of the notch 122A is a maximum of about 15:1. As shown, in some embodiments, the depth 1520 of the notch 122 is measured as the maximum vertical distance between the surface of the notch and the outer surface of the arched needle 122.

[0068]

[0116] 16, the suture end 1201 of the arcuate needle 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 releasably mated. In some embodiments, the primary suture attachment 122D and the secondary suture attachment 125A are releasably mated such that the suture 125 is not detached from the arcuate needle 122 during suturing. In some embodiments, the primary suture attachment 122D and the secondary suture attachment 125A are releasably connected and / or detached in-situ.

[0069]

[0117] As shown, the exemplary primary suture attachment 122D comprises an open channel having a first channel portion and a second channel portion, where the first channel portion passes through the suture end 1201 of the arcuate needle 122 and the second channel portion is spaced from the suture end a distance greater 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 encases the suture. In some embodiments, the first channel portion Partially encases secondary suture attachment 125A. In some embodiments, the first channel portion is equal to or greater than the width of suture 125. In some embodiments, a central plane of the first channel portion and a central plane of the second channel portion are coplanar. In some embodiments, at least one of the first channel portion or the second channel portion comprises a circular channel. In some embodiments, a central point of the circular surface of the first channel portion, a central point of the circular surface of the circular second channel portion, or both, are aligned with the arcuate central axis of arcuate needle 122.

[0070]

[0118] As shown, secondary suture attachment 125A comprises a knotted portion or a bulbous portion. In some embodiments, the thickness of suture 125 is less than the thickness of suture attachment 125A. In some embodiments, the ratio between the thickness of suture 125 and the thickness of suture attachment 125A is about 1.1:1 to about 1:3.

[0071]

[0119] Alternatively, by way of example, at least one of primary suture attachment 122D or secondary suture attachment 125A may comprise a fastener, 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.

[0072]

[0120] 17 and 18, primary suture attachment 122D in arcuate needle 122 and secondary suture attachment 125A of exemplary suture 125 are engaged, disengaged, or both in-vitro by pincer 1701 employed in working channel 1801 of an endoscope. This feature allows for quick and easy replacement of suture 125 during procedures that require suturing in more than one location. As shown, secondary suture attachment 125A is located on an inner surface of arcuate needle 122, allowing pincer 1701 to connect and disconnect suture 125 to and from arcuate needle 122. Shuttle Assembly

[0121] FIG. 19A shows an example view of the shuttle 123 where the pawl 124 is engaged. FIG. 19B shows an example view of the shuttle 123 where the pawl 124 is disengaged. Additionally, as shown, the pawl 124 rotates within the shuttle 123 about a pivot 129. In some embodiments, the pawl 124 comprises a spring, a flexure, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the first distal assembly 120 comprises one, two, three, four, five, six, seven, eight, nine, ten, or more pawls 124. In some embodiments, the shuttle slides within a shuttle guide of the distal assembly. As can be seen, the shuttle 123 is arcuate to slide within the shuttle guide.

[0073]

[0122] In some embodiments, the shuttle 123 includes the pawl 124, the cushion 126, or both. In some embodiments, the pawl 124 rotates within the shuttle 123 about a pivot 127. In some embodiments, the shuttle 123 includes a cavity that receives the pawl 124. In some embodiments, the pawl 124 is biased into engagement. In some embodiments, the pawl 124 is biased into engagement by the cushion 126. In some embodiments, the cushion 126 urges the pawl 124 to move upwardly to engage the notch 122A of the arcuate needle 122. In some embodiments, the position of the pivot 127 relative to the end of the cavity 123A in combination with the position of the cushion 126 allows the pawl to be biased into engagement. In some embodiments, the cushion 126 urges the pawl 124 against the end of the cavity 123A of the shuttle 123 when the pawl 124 is engaged. In some embodiments, when the pawl 124 is disengaged, the arcuate needle 122 is pressed against the cushion 126 by the pawl 124 . 4 is pressed away from the end of cavity 123A of shuttle 123. In some embodiments, the upper surface of pawl 124 is angled toward one end of shuttle 123. In some embodiments, the upper surface of pawl 124 is angled to engage the angled portion of the arcuate needle.

[0074]

[0123] In some embodiments, the cushion 126 is integrated into the pawl 124. In some embodiments, the cushion 126 is integrated into the shuttle 123. In some embodiments, the shuttle 123 does not include a cushion 126. In some embodiments, the shuttle 123 does not include a cushion 126, where the pawl 124 includes a flexure, spring, dual spring gate, cushion, piston, rod, pin, teeth, or any combination thereof for biasing the pawl 124. In some embodiments, the shuttle 123 does not include a pawl 124 or a cushion 126, where the shuttle 123 includes a flexure, spring, dual spring gate, cushion, piston, rod, pin, teeth, or any combination thereof for engaging and disengaging with the arcuate needle.

[0075]

[0124] In some embodiments, the illustrated shuttle 123 further comprises a cable attachment 127 that is connected to a cable. In some embodiments, the cable attachment 127 comprises a clamp, hole, screw, bolt, nut, clip, pin, or any combination thereof. In some embodiments, the cable attachment 127 comprises a terminated cable attachment, where the cable terminates at the cable attachment 127. In some embodiments, the cable attachment 127 comprises a non-terminated cable attachment, where the cable passes through the cable attachment 127 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 can be seen, the shuttle 123 is arcuate so that it slides within the shuttle guide. Second Distal Assembly

[0125] 20-30B show views of an example second proximal assembly 2110 and cable 2130 having prongs 2124. In some embodiments, second proximal assembly 2120 comprises an arched needle 2122 having a notch 2122A and a first housing 2121 comprising a primary housing portion 2121A and a secondary housing portion 2121B. In some embodiments, cable 2130 comprises a sheath surrounding at least a portion of cable 2130.

[0076]

[0126] As seen in FIGS. 21-25 and 28, the primary housing portion 2121A and the secondary housing portion 2121B are connected by housing fasteners 2140. In some embodiments, the primary housing portion 2121A and the secondary housing portion 2121B are connected by one, two, three, four, five, six, seven, eight, nine, ten, or more housing fasteners 2140. As shown, the housing fasteners 2140 comprise screws that pass through clearance holes in the secondary housing portion 2121B to secure the threaded formations 2140A within the primary housing portion 2121A. Alternatively, in some embodiments, the housing fasteners 2140 comprise bolts, rivets, nuts, welds, adhesives, or any combination thereof in at least one of the primary housing portion 2121A or the secondary housing portion 2121B. In some embodiments, the first housing 2121 does not include a primary housing portion 2121A or a secondary housing portion 2121B. In some embodiments, the first housing 2121 further includes a third housing portion or more. In some embodiments, at least one of the primary housing portion 2121A or the secondary housing portion 2121B comprises one or more cable guides that guide the cables 2130 toward and away from the first housing 2121. In some embodiments, the primary housing portion 2121A and the secondary housing portion 2121B are made of the same material. In some embodiments, the primary housing portion 2121A and the secondary housing portion 2121B are made of different materials.

[0077]

[0127] In some embodiments, at least one of the primary housing portion 2121A or the secondary housing portion 2121B comprises an endoscope fixture 2401 that couples the second proximal assembly 2120 to the endoscope 2150. In some embodiments, the endoscope fixture 2401 removably couples the first housing 121 to the endoscope 2150. As shown, the endoscope fixture 2401 comprises a press-fit fixture. In some embodiments, the press-fit endoscope fixture 2401 is coupled to the endoscope 2150 by firmly pressing the press-fit endoscope fixture 2401 onto the distal end of the endoscope 2105. In some embodiments, the press-fit endoscope fixture 2401 is coupled to the endoscope 2150 by firmly pressing the press-fit endoscope fixture 2401 onto the distal end of the endoscope 2150 and rotating. In some embodiments, the press-fit endoscope fixture 2401 is detached from the endoscope 2150 by tugging the press-fit endoscope fixture 2401 away from the distal end of the endoscope 2150. In some embodiments, the press-fit endoscope fixture 2401 is detached from the endoscope 2150 by tugging and twisting the press-fit endoscope fixture 2401 away from the distal end of the endoscope 2150.

[0078]

[0128] As shown, in some embodiments, the endoscope fixture 2401 is circular. In some embodiments, the endoscope 2150 has a proximal outer diameter of about 5 mm to about 16 mm. Thus, in some embodiments, the endoscope fixture 2401 has an inner diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope fixture 2401 has a minimum inner diameter of about 5 mm. In some embodiments, the endoscope fixture 2401 has a maximum inner diameter of about 16 mm. In some embodiments, the press-fit endoscope fixture 2401 has a diameter equal to or less than the diameter of the endoscope 2150. In some embodiments, the endoscope fixture 2401 has a diameter equal to or greater than the diameter of the endoscope 2150. In some embodiments, the endoscope fixture 2401 is tapered and has a first inner diameter and a second inner diameter, where 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 fixture 2401 is measured as a maximum, minimum, or average inner width. In some embodiments, the diameter of the endoscope 2150 is measured as a maximum, minimum, or average outer width. Alternatively, in some embodiments, the endoscope fixture 2401 has a cross-sectional shape that includes a triangle, a square, a hexagon, or any other polygon. Alternatively, in some embodiments, the endoscope fixture 2401 comprises a clamp, adhesive, tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the first distal fixture 120 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more endoscope fixtures 2401.

[0079]

[0129] 20 and 28, the angle between the needle axis 2160A and the endoscope proximal axis 2160B is about 5 degrees to about 85 degrees. In some embodiments, the angle between the central axis 2121BA of the arcuate needle guide and the proximal axis 2160B of the endoscope is adjustable within a range of 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 123 and coinciding with the center of the radius of the arcuate needle 123. In some embodiments, the proximal axis 2160B of the endoscope is defined as a central axis of the distal portion of the endoscope 2150. In some embodiments, the proximal axis 2160B of the endoscope is defined as an axis perpendicular to the plane of symmetry of the arcuate needle 123 and coinciding with the center of the radius of the arcuate needle 123. A is defined as the central axis of the endoscope fixture 2140. In some embodiments, the angle between the central axis 2160A of the arcuate needle guide and the proximal axis 2160B of the endoscope is defined as the maximum, minimum, or average angle.

[0080]

[0130] As shown, in some embodiments, according to Figs. 25 and 26, the primary housing part 2121A includes the pulley 2121AA and the secondary housing part 2121B includes the pulley hole 2121BB. Alternatively, the secondary housing part 2121B includes the pulley 2121AA and the primary housing part 2121A includes the pulley hole 2121BB. As shown, the primary housing part 2121A includes two pulleys 2121AA. Alternatively, in some embodiments, at least one of the primary housing part 2121A or the secondary housing part 2121B includes three or more pulleys 2121AA. In some embodiments, the pulley 2121AA supports and guides the cable 2130 as it moves through the first housing 2121. In some embodiments, at least a portion of the pulley 2121AA fits into the pulley hole 2121BB. In some embodiments, at least a portion of the pulley 2121AA is press-fit into the pulley hole 2121BB. In some embodiments, at least a portion of the pulley 2121AA is snapped into the pulley hole 2121BB, thereby aligning the primary housing portion 2121A with the secondary housing portion 2121B. As shown, the pulley 2121AA and the pulley hole 2121BB have a cross-sectional shape that includes a circle. Alternatively, in some embodiments, at least one of the pulley 2121AA and the pulley hole 2121BB has a cross-sectional shape that includes 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 primary housing portion 2121A and the secondary housing portion 2121B. In some embodiments, the pulley 2121AA is fixed relative to at least one of the primary housing portion 2121A or the secondary housing portion 2121B. In some embodiments, the pulley 2121AA comprises a bearing, a bar, a curved surface, or any combination thereof.

[0081]

[0131] As shown, the first housing 2121 comprises a distal sheath fastener that couples the sheath to the first housing 2121. In some embodiments, at least one of the primary housing portion 2121A or the secondary housing portion 2121B further comprises a distal sheath fastener that couples a portion of the sheath to the first housing 2121. In some embodiments, the distal sheath fastener fixes a portion of the sheath relative to the first housing 2121, thereby allowing the cable 130 to move within the sheath as the wheel rotates. As shown, an exemplary distal sheath fastener comprises a clamp. In some embodiments, the distal sheath fastener comprises a plate and one or more sheath fastener screws that clamp the cable sheath between the plate and the first housing 2121. Alternatively, in some embodiments, the distal sheath fastener comprises a screw, a fastener, a tape, or any combination thereof. In some embodiments, the first housing 2121 comprises 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 comprises 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 into the first housing 2121 past the termination point of the distal sheath fastener. In some embodiments, the first housing 2121 comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more distal sheath fasteners. Alternatively, in some embodiments, the distal sheath fastener comprises a clamp, a fastener, a band, a hook and loop fastener, an adhesive, or any combination thereof.

[0082]

[0132] In some embodiments, the first housing 2121 has an arcuate needle guide 2121BA. In some embodiments, at least one of the primary 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 limits the arcuate needle 2122 to rotate within one degree of freedom. In some embodiments, the arcuate needle guide 2121BA limits the arcuate needle 2122 to rotate within at least one degree of freedom of rotation. As can be seen, the illustrated arcuate needle guide 2121BA surrounds at least a portion of the arcuate needle 122. In some embodiments, the arcuate needle guide 2121BA has an inner width that 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 that includes a circle, a square, a rectangle, or any other polygon.

[0083]

[0133] In some embodiments, a gulf 2170 is formed in the second proximal assembly 2120 between a first termination point of the arcuate needle guide 2121BA and a second opposing termination point of the arcuate needle guide 2121BA. In some embodiments, a gulf 2170 is formed in the second proximal assembly 2120 between the first pulley hole 2121BB and the second opposing pulley hole 2121BB. In some embodiments, the gulf 2170 receives tissue to be sutured 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 proximal assembly 2120 does not include an anchor exchange catheter.

[0084]

[0134] According to FIG. 26, in some embodiments, the arched catheter 2122 has a notch 2122A. In some embodiments, the arched needle 2122 has 2, 3, 4, 5, 6, 7, 8, 9, 10, or more notches 2122A. In some embodiments, when the cable 2130 translates in a first rotational direction 2600 about the first housing portion 2121A, the second housing portion 2121B, or both, the notch 2122A and the pawl 2124 are engaged. In some embodiments, when the cable 2130 translates in a direction opposite to the first rotational direction 2600, the notch 2122A and the pawl 2124 are disengaged. In some embodiments, the notch 2130 is angled in a direction opposite to the first rotational direction 2600. In some embodiments, the sloped notch 2130 ensures proper seating of the second claw portion 2124B within the notch 2130. In some embodiments, the notch 2130 is sloped 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. As shown, in some embodiments, the arched needle 2122 has two notches 2122A, where each notch 2122A is spaced apart at an angle of about 180 degrees around the arched needle 2122.

[0085]

[0135] In some embodiments, the outer diameter of the arched needle 2122 is about 7 mm to about 20 mm. In some embodiments, the outer diameter of the arched needle 2122 is a minimum of about 7 mm. In some embodiments, the outer diameter of the arched needle 2122 is a maximum of about 20 mm. In some embodiments, the thickness 1510 of the arched needle 2122 is about 0.5 mm to about 2 mm. In some embodiments, the thickness 1510 of the arched needle 2122 is a minimum of about 0.5 mm. In some embodiments, the thickness 1510 of the arched needle 2122 is a maximum of about 2 mm. In some embodiments, the ratio between the outer diameter and the thickness 1510 of the arched needle 2122 is about 3:1 to about 15:1. In some embodiments, the ratio between the outer diameter and the thickness 1510 of the arched needle 2122, including increases therein, is about 0.5 mm to about 0.5 mm. In some embodiments, the thickness 1510 of the arched needle 212 ... ratio between the outer diameter and the thickness 1510 of the arched needle 2122 is about 0.5 mm to about 0.5 mm. In some embodiments, the thickness 1510 of the arched needle 2122 is about 0.5 mm to about 0.5 mm. In some embodiments, the thickness 1510 of the arched needle 21 , 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 and the thickness 1510 of the arched needle 2122 is at least about 3:1. In some embodiments, the outer diameter of the arched needle 2122 is measured as the maximum distance between two points on the surface of the arched needle 2122. In some embodiments, the outer diameter of the arched needle 2122 is measured as the maximum outer diameter of the arched needle 2122. In some embodiments, the width of the arched needle 2122 is measured as the thickness 1510 of the arched needle 2122. In some embodiments, the width of the arched needle 2122 is measured as the thickness 1510 of the arched needle 2122 that is not within the pointed end, suture end, or notch 2122A. In some embodiments, the width of the arched needle 2122 is measured as the maximum, minimum, or average thickness 1510 of the arched needle 2122 .

[0086]

[0136] 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 2 ...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 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 10 degrees to about 180 degrees, about About 20 degrees to about 80 degrees, about 20 degrees 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 The angles may be about 180 degrees, about 80 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. In some embodiments, the notches 2122A are spaced around the arcuate needle 2122 at angles of about 10 degrees, 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.In some embodiments, the notches 2122A are spaced at an angle of at least about 10 degrees, 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, or about 160 degrees around the arcuate needle 2122. In some embodiments, the notches 2122A are spaced 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 around the arcuate needle 2122.

[0087]

[0137] 23-25 ​​(without the second housing portion 2121B), a cable 2130 having a pawl 2124 enters the first housing 2121, wraps around a first pulley 2121AA, wraps around an arcuate needle 2122, wraps around a second pulley 2121AA, and exits through the first housing 2121. As shown, the cable 2130 includes a flat portion 2130A. In some embodiments, the flat portion 2130A improves the stability of the cable 2130 as it wraps around the pulley 2121AA. Additionally, in some embodiments, the pawl 2124 is located on a 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 applying 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.

[0088]

[0138] 24, the claw 2124 comprises a first claw portion 2124A and a second claw portion 2124B, where the first claw portion 2124A is attached to the cable 2130 or the flat portion 2130A of the cable, and the second claw portion 2124B is not coupled to the cable 2130 or the flat portion 2130A of the cable. In some embodiments, the claw 2124 comprises a curved portion. In some embodiments, the second claw portion 2124B is curved inwardly toward the arcuate needle 2122 at rest and curves around the intersection between the second claw portion 2124B and the first claw portion 2124A. In some embodiments, when the arched needle 2122 contacts the second claw portion 2124B, the second claw portion 2124B bends outwardly away from the arched needle 2122 around the intersection between the second claw portion 2124B and the first claw portion 2124A. As shown in FIG. 26, the distal end of the second claw portion 2124B contacts and presses against the notch 2122A of the arched needle 2122, thereby translating the arched needle 2122 in the first direction. Additionally or alternatively, the distal end of the second claw portion 2124B contacts and presses against the suture end 2122B of the arched needle 2122, thereby translating the arched needle 2122 in the first direction 2600. Alternatively, in some embodiments, the pawl 2124 comprises a spring, a dual spring gate, a cushion, a piston, a rod, a pin, teeth, or any combination thereof. In some embodiments, the pawl 2124 is biased by engagement.

[0089]

[0139] 27A-F show an exemplary second proximal assembly in a first position, a second position, a third position, a fourth position, a fifth position, and a sixth position, respectively. According to FIG. 27A, performing suturing using the second proximal assembly includes translating the cable 2130 to move the pawl 2124 to an end position in a second rotational direction opposite the first rotational direction 2600 within the secondary housing portion 2121B with the arcuate needle 2122 fully enclosed within the secondary housing portion 2121B (this position of the pawl 2124 is shown in FIG. 27A). When the pawl 2124 and the arcuate needle 2122 are in this position, the pawl 2124 is automatically engaged with a first notch in the arcuate needle 2122 as shown. Thereafter, according to Figures 27B-C, the cable 2130 is translated resulting in moving the engaged arcuate needle 2122 and pawl 2124 in a first rotational direction 2600 within the secondary housing part 2121B to an end position of the pawl 2124 in the first rotational direction 2600. This translation of the cable 2300 and pawl 2124 thus moves a portion of the arcuate needle 2122 away from the secondary housing part 2121B, thereby performing a first suture. According to Figure 27D, the cable 2130 is then translated in a second rotational direction back to its end position within the secondary housing part 2121B, thereby automatically engaging the second notch in the arcuate needle 2122. As seen in Figures 27E-F, translation of cable 2130 and pawl 2124 in a first direction 2600 then returns arcuate needle 2122 to its original position within secondary housing portion 2121B, and further translation of cable 2130 and pawl 2124 in a second direction returns the pawl to its terminal position in a second rotational direction within secondary housing portion 2121B according to Figure 27A. Translation of cable 2130 in first direction 2600 and then in a second direction opposite first direction 2600 and then in first direction 2600 and then in the second direction completes one suturing, allowing repeated suturing to be performed by repeating this process. .

[0090]

[0140] 29 shows an arcuate needle 2122 within an arcuate needle guide 2121BA of a secondary housing portion 2121B. As shown in FIG. 28, the arcuate needle guide 2121BA surrounds a portion of the arcuate needle 2122. As seen herein, 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 of the cross-sectional circumference of the arcuate needle 2122, including increments therein.

[0091]

[0141] In some embodiments, per Figs. 30A-C, the cable and pawl comprises a single cable pawl 3000A, 3000B comprising a flat portion 2124B with a tab 2124A. As shown, the tab 2124A comprises a curved portion. Alternatively, in some embodiments, the tab 2124A comprises a recess, a spring, or any combination thereof. In some embodiments, the tab 2124A engages and disengages from a notch in the arcuate needle in a manner similar to the pawl. As shown, in some embodiments, the tab 2124A has a deployed position where the tab 2124A is at rest and protrudes from the flat portion 2124B at an angle. In some embodiments, the tab 2124A protrudes from the flat portion 2124A 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. As shown in FIG. 30C, in some embodiments, the tab 2124A engages with the notch 2122A of the arched needle 2122 when in the deployed position. In some embodiments, when engaged, the distal tip of the tab 2124A presses against the notch 2122A of the arched needle 2122. In some embodiments, the tab 2124A has a pushed-in position, where the tab 2124A and the flat portion 2124B are generally in the same plane. In some embodiments, in the pushed-in position, the tab 2124A is clamped by the arched needle 2122 against the flat portion 2124B. In some embodiments, when in the pushed-in position, the tab 2124A is disengaged from the notch 2122A of the arcuate needle 2122. In some embodiments, the tab 2124A is configured to be repeatedly clamped and released to repeatedly disengage and engage with the notch of the arcuate needle. In some embodiments, per FIG. 30A, the cable claw 3000A is formed in a sheet of material that is attached to the cable 2130A. Alternatively, in some embodiments, per FIG. 30B, the cable claw 3000A is formed from a single continuous piece of material.

[0092]

[0142] In some embodiments, at least one of the primary housing portion 2121A, the pulley 2121AA, the secondary housing portion 2121B, the cable 2130, the claw 2124, the tab 2124A, or the single cable claw 3000A, 300B are constructed from metal, plastic, wood, carbon fiber, ceramic, or any combination thereof. Angle adjustable primary housing

[0143] 31A-36 show diagrams of an example angle-adjustable first housing 3120 comprising a primary angle-adjustable first housing 3121A, a secondary angle-adjustable housing 3121B, and a third angle-adjustable housing 3121C. In some embodiments, the angle-adjustable first housing 3120 further comprises a fourth or more tilting housing. As shown, the secondary angle-adjustable housing 3121B and the third angle-adjustable housing 3121C are rigidly attached to each other, where the secondary angle-adjustable housing 3121B and the third angle-adjustable housing 3121C rotate relative to the primary tilting housing 3121A around the angle adjustment axis 3151. In some embodiments, the secondary angle-adjustable housing 3121A and the third angle-adjustable housing 3121C are rigidly attached to each other, where the secondary angle-adjustable housing 3121B and the third angle-adjustable housing 3121C rotate relative to the primary angle-adjustable housing 3121A around the angle adjustment axis 3151. 121B and the third angle adjustable housing 3121C are a single component. In some embodiments, the angle adjustment axis 3151 is perpendicular to the proximal endoscope axis 3152. In some embodiments, the angle adjustment axis 3151 does not intersect with the proximal endoscope axis 3152. In some embodiments, the secondary angle adjustable housing 3121B and the third angle adjustable 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.

[0093]

[0144] 31A-B, the primary angle adjustable housing 3121A comprises an endoscope fixture 3120 that couples the primary angle adjustable housing 3121A to the endoscope 3140. In some embodiments, the endoscope fixture 3120 removably couples the primary angle adjustable housing 3121A to the endoscope 3140. As shown, the endoscope fixture 3120 comprises a screw and the primary angle adjustable housing 3121A comprises a threaded feature or threaded insert that receives the screw such that the endoscope fixture 3120 and the threaded feature or threaded insert in the primary angle adjustable housing 3121A are clamped around the distal end of the endoscope 3140, thereby securing the primary angle adjustable housing 3121A to the endoscope 3140. As shown, the primary angle adjustable housing 3121A includes a slot configured to disengage the endoscope fixture 3120 from the remainder of the angle adjustable housing 3121A, such that the angle adjustable housing 3121A can deform upon tightening of the screws. Alternatively, in some embodiments, the primary angle adjustable housing 3121A does not include a slot.

[0094]

[0145] As shown, in some embodiments, the endoscope fixture 3120 is circular. In some embodiments, the endoscope 3140 has an outer diameter proximal to the endoscope 3140 of about 5 mm to about 16 mm. Thus, in some embodiments, the endoscope fixture 3120 has an inner diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope fixture 3120 has an inner diameter of at least about 5 mm. In some embodiments, the endoscope fixture 3120 has an inner diameter of at most about 16 mm. In some embodiments, the endoscope fixture 3120 is a press-fit. In some embodiments, the press-fit endoscope fixture 3120 has a diameter equal to or less than the diameter of the endoscope 3140. In some embodiments, the endoscope fixture 3120 has a diameter equal to or greater than the diameter of the endoscope 3140. In some embodiments, the endoscope fixture 3120 is tapered and has a first inner diameter and a second inner diameter, where the first inner diameter is distal to the second inner diameter. In some embodiments, the first inner diameter is larger than the second inner diameter. In some embodiments, the second inner diameter is larger than the first inner diameter. In some embodiments, the diameter of the endoscope fixture 3120 is measured as a maximum, minimum, or average inner width. In some embodiments, the diameter of the endoscope 3140 is measured as a maximum, minimum, or average outer width. Alternatively, in some embodiments, the endoscope fixture 3120 has a cross-sectional shape that includes a triangle, a square, a hexagon, or any other polygon.

[0095]

[0146] Alternatively, in some embodiments, the endoscope fixture 3120 comprises a press-fit fixture. In some embodiments, the press-fit endoscope fixture 3120 is attached to the endoscope 3140 by firmly pressing the press-fit endoscope fixture 3120 onto the distal end of the endoscope 3140. In some embodiments, the press-fit endoscope fixture 3120 is attached to the endoscope 3140 by firmly pressing the press-fit endoscope fixture 3120 onto the distal end of the endoscope 3140 and rotating. In some embodiments, the press-fit endoscope fixture 3120 is detached from the endoscope 3140 by pulling the press-fit endoscope fixture 3120 away from the distal end of the endoscope 3120. Alternatively, in some embodiments, the endoscope fixture 3120 comprises a clamp, adhesive, tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the first The distal assembly 120 may include 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more endoscope fixtures 3120.

[0096]

[0147] Additionally, as shown, at least one of the secondary angle-adjustable housing 3121B or the third angle-adjustable housing 3121C secures the cable sheath of the cable 3130. In some embodiments, at least one of the secondary angle-adjustable housing 3121B or the third angle-adjustable housing 3121C includes an aperture for receiving the cable sheath of the cable 3130. In some embodiments, the cable sheath of the cable 3130 is clamped between the secondary angle-adjustable housing 3121B and the third angle-adjustable housing 3121C. In some embodiments, the cable sheath of the cable 3130 is coupled to at least one of the secondary angle-adjustable housing 3121B or the third angle-adjustable housing 3121C by adhesive, clamps, fasteners, hook-and-loop fasteners, or any combination thereof.

[0097]

[0148] 32-36, an exemplary primary angle-adjustable housing 3121A includes a tilt mechanism 3121AA, and an exemplary secondary angle-adjustable housing 3121B includes a secondary tilt mechanism 3121BA, where the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA couple the primary angle-adjustable housing 3121A and the secondary angle-adjustable housing 3121B. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA enable at least one of the secondary angle-adjustable housing 3121B or the third angle-adjustable housing 3121C to rotate relative to the primary angle-adjustable housing 3121A. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA enable at least one of the secondary angle adjustable housing 3121B or the third angle adjustable housing 3121C to rotate about the angle adjustment axis 3151 relative to the primary angle adjustable housing 3121A. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA enable at least one of the secondary angle adjustable housing 3121B or the third angle adjustable housing 3121C to rotate about 300 degrees relative to the primary angle adjustable housing 3121A. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA enable at least one of the secondary angle adjustable housing 3121B or the third angle adjustable housing 3121C to be rotated relative to the primary angle adjustable housing 3121A, such that the angle between the arcuate needle axis 3153 and the proximal endoscope axis 3152 increases from approximately 0 degrees (where the arcuate needle 3153 and the proximal endoscope axis 3152 are parallel) to approximately 300 degrees.In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA allow at least one of the secondary angle adjustable housing 3121B or the third angle adjustable housing 3121C to rotate relative to the primary angle adjustable housing 3121A such that the angle between the arcuate needle shaft 3153 and the proximal endoscope shaft 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 allow at least one of the secondary angle adjustable housing 3121B or the third angle adjustable housing 3121C to rotate relative to the primary angle adjustable housing 3121A such that the angle between the arcuate needle shaft 3153 and the proximal endoscope shaft 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 enable at least one of the secondary angle adjustable housing 3121B or the third angle adjustable housing 3121C to be rotated relative to the primary angle adjustable housing 3121A such that the angle between the arcuate needle shaft 3153 and the proximal endoscope shaft 3152 is 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. or more discrete increments from about 0 degrees to about 300 degrees. In some embodiments, the primary tilt mechanism 3121AA and the secondary tilt mechanism 3121BA enable at least one of the secondary angle adjustable housing 3121B or the third angle adjustable housing 3121C to be rotated relative to the primary angle adjustable 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.

[0098]

[0149] 35 and 36, in one embodiment, the primary tilt mechanism 3121AA comprises a clamp having a knurled interior surface and the secondary tilt mechanism 3121BA comprises a knob having a knurled exterior surface. As shown, the secondary tilt mechanism 3121BA has 19 peaks and valleys such that engagement of one peak of the primary tilt mechanism 3121AA with one valley of the secondary tilt mechanism 3121BA defines a particular angle between the arcuate needle shaft 3153 and the proximal endoscope shaft 3152. As shown, the primary tilt mechanism 3121AA has 3 peaks and valleys such that engagement of one peak of the secondary tilt mechanism 3121BA with one valley of the primary tilt mechanism 3121AA defines a particular angle between the arcuate needle shaft 3153 and the proximal endoscope shaft 3152. Alternatively, in some embodiments, at least one of the primary tilt feature 3121AA or the secondary tilt feature 3121BA comprises 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, or more peaks and valleys. Alternatively, in some embodiments, the primary tilt feature 3121AA does not comprise the primary tilt housing 3121A. Alternatively, in some embodiments, the secondary angle adjustable housing 3121B does not comprise the secondary tilt housing 3121BA.

[0099]

[0150] In some embodiments, the clamp of the primary tilt mechanism 3121A is tightened by fixing the screw 3151 to tighten the clamp and to prevent the secondary angle adjustable housing 3121B from rotating about the angle adjustable axis 3151 relative to the primary tilt housing 3121A. In some embodiments, the clamp of the primary tilt mechanism 3121AA is released by loosening the screw 3151, thereby loosening the clamp and allowing the secondary angle adjustable housing 3121B to rotate about the angle adjustable axis 3151 relative to the primary tilt housing 3121A. 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 angle adjustable housing 3121A and the secondary angle adjustable housing 3121B is achieved via a clamp, pin, screw, knob, fastener, band, magnet, or combination thereof.

[0100]

[0151] As can be seen, the secondary angularly adjustable housing 3121B includes a gap 3601 between the secondary tilt mechanism 3121BA and the remainder of the secondary angularly adjustable housing 3121B. In some embodiments, the gap 3601 receives a portion of the primary angularly adjustable housing 3121A as the secondary angularly adjustable housing 3121B rotates about the primary angularly adjustable 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

[0152] 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.

[0101]

[0153] As used herein, the singular forms "a," "an," and "the" include plural referents unless specifically stated otherwise. Any reference herein to "or" , unless expressly stated otherwise, is intended to include "and / or."

[0102]

[0154] As used herein, the term "about" means an amount that is approximately 10%, 5%, or 1% relative to the amount being referred to, including increases therein.

[0155] As used herein, the term "about" when referring to a percentage means an amount that is approximately 10%, 5%, or 1% of the referenced percentage, including increases therein.

[0103]

[0156] As used herein, the phrases "at least one," "one or more," and "and / or" are open-ended expressions that are both conjunctive and disjunctive in their operational sense. For example, the phrases "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 of A, B, or C," and "A, B, and / or C" mean A only, B only, C only, A and B, A and C, B and C, or A, B and C, respectively.

[0104]

[0157] As used herein, the term "arc" refers to an arc of a circle or a portion of a circle.

Claims

1. An endoscopic suturing system, (a) a distal assembly, (i) a first housing comprising an arcuate needle guide, a shuttle guide, and an endoscope fixture, the endoscope fixture attaching the first housing to an endoscope; (ii) an arcuate needle having a notch and a suture attachment, said arcuate needle having a central axis, said arcuate needle being disposed within said arcuate needle guide; (iii) a shuttle having a claw, the shuttle being carried within the shuttle guide; and Equipped with when the shuttle moves in a first rotational direction about the central axis, the notch and the pawl are engaged, and when the shuttle moves in a direction opposite to the first rotational direction, the notch and the pawl are disengaged. A distal assembly; and (b) a proximal assembly, (i) a second housing; (ii) an actuator connected to the second housing; and a proximal assembly comprising: (c) a cable connecting the actuator to the shuttle and configured to move the shuttle in the first direction and the second direction in response to actuation of the actuator; Equipped with Endoscopic suturing system.

2. The system of claim 1 , wherein the pawl comprises a spring, a flexure, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof.

3. The system of claim 1 or 2, wherein the pawl is biased by engagement.

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

5. 5. The system of claim 1, wherein the endoscope fastener comprises a fastener, 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.

6. 6. The system of claim 1, wherein the endoscope has a proximal outer diameter of about 5 mm to about 16 mm.

7. The system of claim 1 , further comprising a cable sheath surrounding at least a portion of the cable.

8. The system of claim 7 , further comprising a cable fastener for releasably coupling at least a portion of the cable sheath to the endoscope.

9. 9. The cable fastener of claim 8, wherein 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. system.

10. 10. The system of claim 1, wherein an angle between a central axis of the arcuate needle guide and a proximal axis of the endoscope is from 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 claim 1 , wherein the arcuate needle comprises two or more notches.

13. 13. The system of claim 1, wherein at least one of the first housing, the second housing, the arcuate needle, the shuttle, and the actuator are constructed from plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof.

14. The system of claim 1 , wherein the first housing further comprises a cable pulley for guiding the cable.

15. The system of claim 1 , wherein the arcuate needle further comprises a suture attachment fixture.

16. The system of claim 1 , wherein the second housing is removably attached to the endoscope.

17. 1. An endoscopic suturing system comprising: (a) a distal assembly, (i) a first housing including an arcuate needle guide and an endoscope fixture, the endoscope fixture attaching the first housing to an endoscope; (ii) an arcuate needle having a notch and a suture attachment, said arcuate needle having a central axis, said arcuate needle being disposed within said arcuate needle guide; a distal assembly comprising: (b) a proximal assembly, (i) a second housing; (ii) an actuator connected to the second housing; and a proximal assembly comprising: (c) a cable having a claw, the notch and the pawl are engaged when the cable moves in a first rotational direction about the central axis, and the notch and the pawl are disengaged when the cable moves opposite the first rotational direction. Cable and Equipped with Endoscopic suturing system.

18. 20. The system of claim 17, wherein the pawl comprises a spring, a flexure, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof.

19. 19. The system of claim 17 or 18, wherein the pawl is biased by engagement.

20. 20. The system of claim 17, 18, or 19, wherein the notch is angled in a direction opposite the first direction.

21. 21. The system of any one of claims 17 to 20, wherein the endoscope fastener comprises a press fit fastener, a clamp, adhesive, tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof.

22. 22. The system of any one of claims 17 to 21, wherein the endoscope has a proximal outer diameter of about 5 mm to about 156 mm.

23. 23. The system of any one of claims 17 to 22, further comprising a cable sheath surrounding at least a portion of the cable.

24. 24. The system of claim 23, further comprising a cable fastener that releasably couples at least a portion of the cable to the endoscope.

25. 25. The system of claim 24, wherein the cable fastener comprises a press-fit fastener, a clip, 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.

26. 26. The system of any one of claims 17 to 25, wherein an angle between a central axis of the arcuate needle guide and a proximal axis of the endoscope is from about 5 degrees to about 85 degrees.

27. 27. The system of claim 26, 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.

28. 28. The system of any one of claims 17 to 27, wherein the arcuate needle comprises two or more notches.

29. 29. The system of any one of claims 17-28, wherein at least one of the first housing, the second housing, the arcuate needle, and the actuator are constructed from plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof.

30. 30. The system of claim 17, wherein the first housing further comprises a cable pulley for guiding the cable.

31. 31. The system of any one of claims 17 to 30, wherein the arcuate needle further comprises a suture attachment fixture.

32. 32. The system of any one of claims 17 to 31, wherein the second housing is removably coupled to the endoscope.

Images