Abstract:
A torsional ligation clip applier and method of use for endoscopic or laparoscopic vessel occlusion procedures is provided. The ligation clip includes a hub portion and ligation arms for occluding a vessel. Ligation arms are independently rotatable about a common axis that is parallel to the longitudinal axis of the ligation arms. The ligation arms are biased in a first position by a biasing mechanism. The ligation arms of the clip are rotatable through at least one of a plurality of positions wherein it has a larger diameter than an access device. An applier receives at least one ligating clip in a first position and delivers the ligating clip to a vessel in a second position. Occlusion of the vessel occurs when one of the ligation arms is rotated into a third position.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS  
       [0001]     This application claims priority from, and the benefits of, U.S. provisional application No. 60/376,424 filed on Apr. 29, 2002, the entire contents of which are incorporated herein by reference. 
     
    
     BACKGROUND  
       [0002]     1. Technical Field  
         [0003]     The present disclosure relates to ligating clips, and to devices and methods for applying the same in surgical procedures. More specifically, the present disclosure relates to torsionally biased surgical ligating clips suitable for clamping blood vessels and ducts during laparoscopic or endoscopic surgery.  
         [0004]     2. Background of Related Art  
         [0005]     During surgical procedures, procedures frequently require the temporary or permanent occlusion of vessels to prevent the leakage of fluids (e.g. blood) through incisions made at the surgical site. A broad range of surgical ligating devices and techniques exist for occluding vessels. These include applying surgical ligating clips that are available in a variety of shapes and sizes including spring biased wires and plates. Typically, these devices are stored in a first position wherein the jaws of the clip are biased closed. The applying device opens the jaws of the ligating clip a predetermined distance against the bias of the ligating clip to position the ligating clip about a vessel. The applying device then releases the jaws to allow the bias of the ligating clip to return the jaws of the ligating clip to the closed position and occlude the vessel.  
         [0006]     Ligating clips configured for use with applying devices are frequently limited in their application by the distance the jaws can open without permanently deforming the clip. The use of such clips is further limited by the accessibility to the surgical site. For example, only those clips sized to be inserted through an appropriately sized cannula can be used during laparoscopic or endoscopic procedures. In addition, clips having extended jaws can lose the amount of applied bias over time as the tissue shrinks and/or necroses.  
         [0007]     Ligating clips for clamping blood vessels and ducts during open and endoscopic (herein understood to include laparoscopic) surgical procedures are well known in the art. The particular dimensions of a ligating clip to be used in an open surgical procedure are not constrained by the size of the access opening to the surgical site. However, during endoscopic surgical procedures access to the surgical site is typically achieved through an access device, such as a cannula, having a limited internal dimension (e.g. a diameter of 15, 10, or 5 mm). Accordingly, ligating clips used during endoscopic surgical procedures must be dimensioned and configured to be admitted to the surgical site through the access device. Because of the dimensional constraints on ligating clips used for endoscopic surgery, currently available ligating clips suffer from several drawbacks. These drawbacks include a smaller or reduced clamp opening, i.e., the distance between opposed clamping members of the ligating clip in the open position, and a difficulty in applying the ligating clips about tissue.  
         [0008]     A continuing need exists for a simplified ligating clip having suitable flexibility for application over a range of vessel sizes without excessively deforming and that can maintain pressure on a vessel even when the vessel increases or decreases in size over time.  
         [0009]     A continuing need also exists for a ligating clip that can be of a size that facilitates delivery through a cannula of limited internal dimensions, yet can maintain pressure on a vessel even when the vessel increases or decreases in diameter over time.  
         [0010]     Accordingly, a need exists for a ligating clip that is suitable for use during endoscopic surgical procedures that has an enlarged clamp opening that can be positioned quickly and easily about tissue. In addition, there is a need for a ligating clip system including an applier and method for applying the ligating clip.  
         [0011]     There is also a need for a clip applier that can apply the aforementioned ligating clips and that can be employed through cannulae having internal diameters of 15, 10, or 5 mm.  
       SUMMARY  
       [0012]     This invention is directed to a ligating clip for occluding a vessel including first and second clamping members. Each of the clamping members includes a hub portion with a substantially centrally located throughhole where the hub portions defining a common pivot axis for the hub portions and clamping members, an elongated ligation arm disposed substantially parallel to the common pivot axis, and a hub extension extending between and connecting the hub portion to the ligation arm, the first and second clamping members being pivotably connected by a biasing member such that the clamping members are rotatable about the common pivot axis, and the ligation arms are biased by the biasing member. Each ligation arm can include an elongate vessel clamping surface where the clamping surfaces are biased by the biasing member to engage each other to clamp a vessel therebetween. The biasing member can bias the ligation arms such that in the absence of a vessel therebetween, the clamping surface of one ligation arm contacts at least a portion of the other ligation arm&#39;s clamping surface. One of the first and second clamping members can be rotatable relative to the other clamping member through an arc of from about 0° to about 360°, or, less preferably, through an arc of from greater than about 0° to about 360°. Each ligation arm can include a ligation arm abutment surface that is oppositely disposed to each ligation arm&#39;s clamping surface and the abutment surfaces of the ligation arms being abuttable with each other. The biasing member can bias the ligation arms such that the ligation arms are rotatable from and amongst a plurality of positions. The biasing member may be a torsion spring. Each ligation arm can be disposed substantially orthogonal to the hub extension to which the ligation arm is connected. One clamping member can have an extension abutment surface that is adapted to abut the hub extension of the opposed clamping member. The throughhole of one hub portion can be defined by the inside surface of a cylindrical wall that defines the common pivot axis, and the outside surface of the cylindrical wall partly defines a portion of a channel for receiving the biasing member therein.  
         [0013]     This invention is also directed to a ligating clip system for occluding a vessel including at least one ligating clip having first and second clamping members. Each of the clamping member includes a hub portion with a substantially central throughhole where the hub portions define a common pivot axis, a ligation arm disposed substantially parallel to the common pivot axis, and a hub extension connecting the hub portion to the ligation arm, where the first and second clamping members are pivotably connected such that each is rotatable about the common pivot axis in relation to the other and the ligation arms are biased by a biasing member, and an applier including an elongate tube having a diameter, the elongate tube having a proximal end and a distal end defining a channel therebetween, the channel configured and adapted to receive and restrain the at least one ligating clip, the channel further including an elongate pusher member disposed along a longitudinal axis of the tube, the pusher member being for advancing the ligating clip a predetermined distance distally along the longitudinal axis. The clamping members of the ligation clip can be biased for rotation amongst a plurality of positions. Each ligation arm can include a clamping surface and an opposed abutment surface. The biasing member may be a torsion spring. The system can include an actuation mechanism where the actuation mechanism includes a trigger assembly. The channel can receive and restrain the at least one ligating clip in a first position where the abutment surfaces are in contact with one another. The distal end of the tube can be adapted and configured to contact the clamping assemblies. The biasing member and the distal end of the tube can cooperate to rotate the clamping members of the ligating clip from the first position to a second position as it advances distally from the distal end of the channel wherein the first ligation arm is spaced apart from the second ligation arm. The first and second ligation arms can be substantially parallel to one another in a substantially planar arrangement. The ligation arms can span a distance that is greater than the diameter of the distal end of the elongate tube. The biasing member and the distal end of the tube can cooperate to rotate the clamping members of the ligating clip from the second position to a third position as the ligating clip advances from the channel to the predetermined distance wherein the clamping surfaces are biased by the biasing member to engage one another in a manner sufficient to occlude a vessel therebetween were it placed between the clamping members. The elongate tube can have opposed first and second inserts disposed along at least a portion of the elongate tube where the inserts restrain the ligating clip in the first position inside the elongate tube. The elongate tube can include opposed elongate restraining walls running through at least the distal end of the tube where the opposed restraining walls forming a clip restraining channel, and one of the restraining walls forming a ledge that extends distally from and beyond the distal end of the tube.  
         [0014]     This invention is further directed to a method for occluding a vessel including the steps of making an incision in a patient, inserting an access device into the incision, inserting a clip applier into the access device where the applier has a distal end and at least one ligating clip, and the at least one ligating clip has a pair of distally extending ligation arms biased to clampingly engage each other and the clip being in a first position of a plurality of positions, actuating an actuation mechanism located on or in the applier to cause the ligation arms of the ligating clip to rotate to a second position of the plurality of positions where the ligating arms in the second clip position being of a span greater than a diameter of the clip applier, positioning the ligating clip around the vessel, and actuating the actuation mechanism located on the applier to cause the ligating clip to biasedly rotate to a third position of the plurality of positions thereby clampingly engaging and occluding the vessel. The ligating clip in the second position can have a larger outside diameter than the access device. The applier can include a number of ligating clips. The access device can be a cannula. The actuation mechanism can be a trigger assembly. The applier can include opposed first and second inserts disposed along at least a portion of the inside of the elongate tube where at least one of the inserts extending beyond the distal end of the applier and restraining the ligating clip in the second position.  
         [0015]     This invention is directed to a clip applier including an elongate tubular member having proximal and distal ends, opposed elongate restraining walls running through at least the distal end of the tubular member where the opposed restraining walls forming a clip restraining channel, and an elongated pusher for pushing a clip through and beyond the distal end of the tubular member. One of the opposed restraining walls can form a ledge that extends distally from and beyond the distal end of the tubular member and the elongated pusher is adapted to push the clip onto the ledge.  
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0016]     Preferred embodiments of the presently disclosed ligating clip are described herein with reference to the drawings, wherein:  
         [0017]     FIG. I is a perspective view of an embodiment of a ligating clip in a first position in accordance with the present disclosure;  
         [0018]      FIG. 2  is a perspective view of the ligating clip of  FIG. 1  in a second position;  
         [0019]      FIG. 3  is a perspective view of the ligating clip of  FIG. 1  in a third position;  
         [0020]      FIG. 4A  is a proximal end view of a first clamping member of the ligating clip of  FIG. 1 ;  
         [0021]      FIG. 4B  is a distal end view of a second clamping member of the ligating clip of  FIG. 1 ;  
         [0022]      FIG. 4C  is a proximal end view of the second clamping member of the ligating clip of  FIG. 1 ;  
         [0023]      FIG. 5A  is a perspective view of the first clamping member of the ligating clip of  FIG. 1 ;  
         [0024]      FIG. 5B  is a perspective view of the second clamping member of the ligating clip of  FIG. 1 ;  
         [0025]      FIG. 5C  is a proximal end view of the ligating clip of  FIG. 1  in the first position;  
         [0026]      FIG. 6A  is a side view of the first clamping member of the ligating clip of  FIG. 1 ;  
         [0027]      FIG. 6B  is a side view of the second clamping member of the ligating clip of  FIG. 1 ;  
         [0028]      FIG. 7  is a perspective view, with parts broken away, of an embodiment of an applier having a ligating clip in the first position in accordance with the present disclosure;  
         [0029]      FIG. 8  is a perspective view, with parts broken away, of the applier and ligating clip of  FIG. 4  in the second position;  
         [0030]      FIG. 9  is a perspective view, with parts broken away, of the applier and ligating clip of  FIG. 4  in the third position;  
         [0031]      FIG. 10  is a perspective view, with parts broken away, of the applier and ligating clip in the second position surrounding a vessel; and  
         [0032]      FIG. 11  is a perspective view, with parts broken away, of the applier and ligating clip in the third position with the vessel captured, or occluded, by the clip. 
     
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS  
       [0033]     Preferred embodiments of the presently disclosed ligating clip will now be described in detail with reference to the drawings, in which like reference numerals designate identical or corresponding elements in each of the several views. As used herein, the term “distal” refers to that portion of the tool, or component thereof which is further from the user while the term “proximal” refers to that portion of the tool or component thereof which is closer to the user.  
         [0034]     Referring to  FIGS. 1-3 , the surgical, or ligating, clip, shown generally as  10 , includes first and second clamping members  12 ,  14 . Clamping members  12 ,  14  include hub portions  16 ,  18 , respectively, hub extensions  20 ,  22 , respectively, and ligation arms  24 ,  26 , respectively. Hub portions  16 ,  18  are stacked one on top of the other and are pivotal one in relation to the other about a common central pivot axis-W ( FIG. 2 ). Each hub portion  16 ,  18  has a substantially central throughhole  30 . When hub portions  16 ,  18  are stacked on top of one another, throughholes  30  are aligned with each other and define common central pivot axis-W. Hub extensions  20 ,  22  project generally radially and outwardly from hub portions  16 ,  18  and join ligation arms  24 ,  26  substantially perpendicularly to hub extensions  20 ,  22  and substantially parallel to, but offset from each other when hub extensions  20 ,  22  are seen in end views (see  FIG. 5C ).  
         [0035]     Hub portions  16 ,  18  include channel portions  27   a ,  27   b , respectively, for engaging one end of a biasing member  28 . In combination, such as when hub portions  16 ,  18  are aligned and stacked one on top of the other or behind the other, as shown in  FIG. 5C , channel portions  27   a ,  27   b  form the terminal end portions of a channel  27  that is configured and dimensioned to receive biasing member  28 , preferably a torsion spring (not shown). Each channel portion  27   a ,  27   b  may include a shoulder or a recess formed within each hub portion  16 ,  18  to receive or restrain the terminal ends of biasing member  28 . Biasing member  28  is positioned for rotating clamping members  12 ,  14  in relation to each other about pivot axis-W. Preferably, one of clamping members  12 ,  14  is independently rotatable in relation to the other over an arc of from about 0°, less preferably from greater than about 0°, to about 360° (less than 360°, because of the width of one ligation arm). Alternately, other channel portions are envisioned, for example, a groove for receiving at least a portion of the terminal end of biasing member  28 , or a hole for receiving the terminal end of biasing member  28 .  
         [0036]     Each ligation arm  24 ,  26  has an abutment surface  24   a ,  26   a  and a clamping surface  24   b ,  26   b , respectively. Preferably, the thickness of each ligation arm  24 ,  26  decreases from its abutment surface side  24   a ,  26   a  to the clamping surface side  24   b ,  26   b . Alternately, ligation arms  24 ,  26  may have other configurations, e.g., circular, oval, oblong, triangular, rectilinear, etc. In the first, or fully open, starting position of ligating clip  10 , i.e., when clamping members  12 ,  14  have been rotated against the bias of biasing member  28  into contact with each other, abutment surfaces  24   a ,  26   a  abut against one another along ligation arms  24 ,  26 , as shown in  FIG. 1 .  
         [0037]     Ligating clip  10  is shown in a second, or “ready,” position in  FIG. 2 . With clamping member  12  held steady or restrained and clamping member  14  unrestrained, as in  FIG. 1 , biasing member  28  moves clamping member  14  in a clockwise arc of 180° towards clamping member  12  causing rotation of clamping member  14  about central pivot axis-W. By way of example, which is not shown, if clamping member  14  is restrained and clamping member  12  is unrestrained, biasing member  28  will move clamping member  12  counterclockwise toward clamping member  14 . Referring again to  FIG. 2 , applied force from biasing member  28  causes clamping member  14  to rotate about central pivot axis-W. In a preferred embodiment, in the intermediate, ready position, ligation arms  24 ,  26  are shown about 180° apart and substantially parallel to one another.  FIG. 2  shows ligation arm  26 -in transit to the approximate 360° position, restrained at the 180° position. It is contemplated that a ligation arm can be restrained at any rotational position, 180° being preferred because it provides the widest spread of the ligation arms to facilitate placing a vessel therebetween.  
         [0038]      FIG. 3  shows ligating clip  10  in the third, or fully closed, ligating, or clamped position, where clamping surfaces  24   b ,  26   b  abut against each other. Clamping surfaces  24   b ,  26   b  may be provided with an irregular surface, e.g. roughened, patterned, knurled, undulated, protrusions, etc., to enhance gripping and/or clamping of tissue. Biasing member  28  maintains clamping surfaces  24   b ,  26   b  in the abutting relationship shown in  FIG. 3 .  
         [0039]     By rotating clamping members  12 ,  14  about pivot axis-W and against the bias of biasing member  28  until abutment surfaces  24   a ,  26   a  are in contact with one another, ligating clip  10  will be back in the first, or fully open, position (see  FIG. 1 ). If clamping members  12 ,  14  are released simultaneously (i.e. neither clamping member  12 ,  14  is restrained), biasing member  28  imparts rotational force to each clamping member  12 ,  14  that will cause clamping members  12 ,  14  to initially rotate away from each other about pivot axis-W. Since neither member is being restrained, clamping members  12 ,  14  will both rotate through the second, or ready, position (see  FIG. 2 ) where they are about 180° apart and substantially parallel to one another. Biasing member  28  continues to apply biasing forces that cause the continued rotation of clamping members  12 ,  14  about pivot axis-W until clamping surfaces  24   b ,  26   b  are in contact with one another, thereby defining the third, or clamped, position of ligating clip  10  (see  FIG. 3 ).  
         [0040]     Ligating clip  10  is preferably formed from surgical grade plastics, although the biasing member may be formed from a surgical grade metal. Alternately, the ligating clip may be formed from any material suitable for surgical use including metals, plastics, ceramics, etc. Ligating clips can be comprised of biodegradable or biological material.  
         [0041]     Detailed views of the components of ligating clip  10  are illustrated in  FIGS. 4A-4C . First, with reference to  FIG. 4A , a proximal end view of ligating clip  10  is shown, detailing the structure of first clamping member  14 . As previously discussed, clamping member  14  includes hub portion  16  having a cylindrical wall  32  defining throughhole  30  that is centrally disposed in hub portion  16  and whose central axis is aligned with central pivot axis-W. Hub portion  16  includes a peripheral wall  33  that surrounds cylindrical wall  32 . The two walls together generally defining an annular channel  27  (dashed lines in  FIG. 1 ) having a tangential terminal end portions including channel portion  27 a (dashed lines in  FIG. 1 ) in hub portion  16  of first clamping member  14  and channel portion  27   b  (dashed lines in  FIG. 1 ) in hub portion  18  of second clamping member  12 . Abutment surface  26   a  and clamping surface  26   b  are on opposing sides of first clamping member  14 , while ligation arm  26  is connected to hub extension  20  in an orthogonal arrangement.  
         [0042]      FIG. 4B  shows a distal end view and  FIG. 4C  shows a proximal end view of second clamping member  12 . Second clamping member  12  includes hub portion  18  that has a circular configuration, thereby defining large throughhole  30  that receives cylindrical wall  32  of first clamping member  14 . A channel portion  27   b  is in communication with throughhole  30  and extends, preferably as a tangential groove or slot, internal to hub extension  22 . Abutment surface  24   a  and clamping surface  24   b  are on opposing sides of second clamping member  12 , while ligation arm  24  is connected to hub extension  22  in an orthogonal arrangement.  FIG. 4B  shows an angled or diagonal abutment wall  25  adjoining ligation arm  24  and hub extension  22  for abutting hub extension  20  of clamping member  14 .  
         [0043]      FIGS. 5A and 5B  show perspective views of first clamping member  14  and second clamping member  12 . In  FIG. 5A , first clamping member  14  includes hub portion  16 . Disposed in hub portion  16  is cylindrical wall  32  that extends beyond the plane of hub portion  16 . Cylindrical wall  32  is disposed in the center of hub portion  16 , defines throughhole  30 , and is adapted for sliding engagement or coupling with hub portion  18  of second clamping member  12 . Clamping member  12 , as shown in  FIG. 5B , includes hub portion  18  that defines throughhole  30  and that is configured and dimensioned for peripherally encompassing cylindrical wall  32  of clamping member  14 . Hub extensions  20 ,  22  are connected to hub portions  16 ,  18  respectively and extend preferably generally radially outward from hub portions  16 ,  18 , and substantially parallel to the plane defined by the distal surfaces of respective hub portions  16 ,  18 . Ligation arms  24 ,  26  extend perpendicularly and distally from the distal walls of hub extensions  20 ,  22 . Abutment surfaces  24   a ,  26   a  are adapted for contact with each other along at least a portion of, preferably their entire length.  
         [0044]      FIG. 5C  shows a proximal end view of the assembled clamping members  12 ,  14 , in the first, or closed, position. The proximal and distal faces of hub portions  16 ,  18  are preferably parallel to the proximal and distal faces of hub extensions  20 ,  22 . Ligation arms  24 ,  26  communicate orthogonally with hub extensions  20 ,  22  and are disposed generally parallel to pivot axis-W. Peripheral wall  33  of hub portion  16  surrounds cylindrical wall  32  to form a portion channel  27  in hub portion  16 . Peripheral wall  35  of hub portion  18  has the same diameter and thickness as peripheral wall  33  of hub portion  16 , and together the hubs form channel  27  for biasing member  28  (not shown). Clamping surfaces  24   b ,  26   b  are disposed on the outer edges of ligation arms  24 ,  26  (see also  FIGS. 6A and 6B ).  
         [0045]      FIGS. 7-9  show a ligating clip system, i.e. a clip applier and clip, where ligating clip  10  is being applied to a surgical site using an applier  50  having a longitudinal axis-X and preferably a cylindrical body  52  having a pair of spaced inserts  54   a ,  54   b . Inserts  54   a ,  54   b  can be generally semi-spherical but, as shown, preferably are arcuate segments of a circle (i.e. formed by a secant). The internal wall of cylindrical body  52  and the secants of inserts  54   a ,  54   b  define a channel  56  having flat walls  58  and spherical walls  60 . Insert  54 a projects, preferably permanently, outwardly from the distal end  52   a  of cylindrical body  52 . Alternately, other channel configurations, or stops, that provide a stop against rotation of hub extensions  20 ,  22  and thereby prevent relative rotation of arms  24 ,  26  while ligating clip  10  is positioned within channel  56  are envisioned.  
         [0046]     A pusher member  100 , shown schematically (in dashed lines) in  FIG. 7 , is movably positioned within cylindrical body  52 . At least one, and preferably multiple, ligating clips  10  (one shown) are positioned in longitudinal alignment within channel  56  of cylindrical body  52  preferably in the first, or fully open, position ( FIG. 1 ) with ligation arms  24 ,  26  positioned distally of hub portions  16 ,  18 . The distal end of the pusher member  100  is positioned to engage a proximal end portion of ligating clip  10 , e.g., the proximal face of hub extension  22  of the proximal-most ligating clip  10 . Other engagement, clip ejection, and/or pusher systems know in the art can be employed herein for pushing a proximal clip to eject and apply a distal-most clip.  
         [0047]     The proximal end of cylindrical body  52  can be attached directly to, near, or to a remote housing (not shown). An actuation mechanism can be included in the housing and can be operatively coupled to pusher member  100 . The actuation mechanism is adapted and configured to distally advance pusher member  100  a predetermined distance for each actuation operation and consequently to distally advance ligating clip  10  the predetermined distance.  
         [0048]     Preferably, one complete operation of the actuation mechanism will result in the distal advancement of ligating clip  10  such that hub extension  20  engages or goes beyond the distal end of insert  54   a  and will result in the occlusion of vessel  90 . In order to ensure that only one ligating clip  10  is expelled during one operation of the actuation mechanism, preferably a latch and pawl mechanism (not shown) is provided in the housing. In operation, as the actuation mechanism is operated, pusher member  100  is moved distally through cylindrical body  52  thereby engaging and commencing the advancement of ligating clip  10 . Once the actuation mechanism is engaged for operation, the latch and pawl mechanism is configured to prohibit the actuation mechanism from backstroking until the actuation mechanism has been completely cycled and ligating clip  10  has been fully advanced, thereby expelling it from cylindrical body  52 . Upon complete operation of the actuation mechanism, the pawl clears the gear teeth (not shown) and the pawl rotates away from the teeth due to a spring biasing (not shown), thereby allowing the actuation mechanism to return to its ready condition.  
         [0049]     Upon complete operation of the actuation mechanism, pusher member  100  travels a predetermined distance through cylindrical body  52 , causing ligating clip  10  to be advanced a predetermined amount. Preferably, the distance is sufficient for ligating clip  10  to engage and occlude vessel  90 , and to distally advance at least one additional ligating clip  10  such that at least a portion of ligation arms  24 ,  26  are exposed at distal end  52   a  of cylindrical body  52 . Moreover, when the actuation mechanism is only partially operated, the spring-loaded pawl (not shown) operates to hold the actuation mechanism stationary and will continue to function to hold the actuation mechanism stationary until the actuation mechanism has been completely operated. In this way, the advancement of ligating clips  10  is controlled so that only a single ligating clip  10  is expelled at a time.  
         [0050]     In use, when pusher member  100  is advanced, the distal-most clip  10  is pushed from the distal end  52   a  of cylindrical body  52 . As illustrated in  FIG. 7 , clamping members  12 ,  14  of ligating clip  10  extend from cylindrical body  52  but the diameter or width of ligating clip  10  in the first, or fully open, position is less than that of cylindrical body  52 . Ligating clip  10  is maintained in the first, or fully open, position ( FIG. 1 ) by the flat sides of inserts  54   a ,  54   b  until it is pushed from and beyond the distal end  52   a  of cylindrical body  52 . Referring to  FIG. 8 , when hub extension  20  passes distally beyond tube body  52  and engages the distal end of insert  54   b , the bias of torsion spring  28  ( FIG. 2 ) rotates clamping member  14  approximately 180° in relation to clamping member  12  until hub extension  20  abuts the flat side of distally protruding insert  54   a  by which and whereat ligating clip  10  is maintained in the second, or “ready” position. Alternately, but less preferably, insert  54   a  may be positioned or configured to allow clamping member to rotate through greater or lesser arcs of rotation, e.g., 90°, 120°, 270°, etc., to provide any desirable orientation of clamping members  12 ,  14  in the second, or ready, position. Because the central pivot axis-W of hub portions  16 ,  18  is offset from the central longitudinal axis-X of cylindrical body  52 , in the ready position, the clamp opening, i.e., the distance between clamping surfaces  24   b  and  26   b , is uniquely greater than the diameter of cylindrical body  52 . Thus, clamping members  12 ,  14  can be more easily positioned about tissue  90  to be clamped. (See  FIG. 10 .)  
         [0051]     Referring to  FIG. 9 , when pusher member  100  and, thus, ligating clip  10 , is advanced further to the point at which hub extension  20  of hub portion  16  passes distally beyond the distal end of insert  54   a , the bias of torsion spring  28  effects rotation of clamp members  12 ,  14  to the third, closed or clamped, position ( FIGS. 9 and 11 ) in which clamping surfaces  24   b ,  26   b  are in abutting relationship ( FIG. 9 ) and tissue  90  is clamped therebetween ( FIG. 11 ). After ligating clip  10  has been clamped about tissue  90 , the pusher member (not shown) can be left in place as it has been pushing on the most proximal of a plurality of aligned ligating clips  10  within cylindrical body  52 , and, in that case, advanced further to dispense additional ligating clips  10  as and when desired.  
         [0052]     It will be understood that various modifications may be made to the embodiments disclosed herein. For example, the configuration of the channel  56  need not be that of a truncated cylinder. Other configurations, which maintain ligating clip  10  in an open, or first, position during delivery of ligating clip  10  through channel  56  of applier  50 , are envisioned. Although ligating clip  10  is shown as being constructed of multiple components, it is envisioned that ligating clip  10  could be constructed from a single piece of spring wire or the like. Although no actuating mechanism has been disclosed to effect advancement of pusher member  100 , any handle actuator assembly known in the surgical arts for effecting advancement of a pusher member  100  including pistol type actuators having trigger assemblies or in-line handle actuators may be incorporated into applier  50  to effect advancement of pusher member  100 . Therefore, the above description should not be construed as limiting, but merely as exemplifications of preferred embodiments. Those skilled in the art will envision other modifications within the scope and spirit of the claims appended hereto.