Patent Publication Number: US-10307166-B2

Title: Manual surgical ligation clip applier

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a Divisional of pending application Ser. No. 13/618,858, filed Sep. 14, 2012, which claims priority to earlier filed U.S. Provisional Application No. 61/535,190, filed on Sep. 15, 2011. This application claims priority to the above mentioned applications and the disclosures of which are hereby incorporated by reference, in their entirety. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates to medical devices and, in particular, a device for applying surgical clips for ligation of vessels or tissue. 
     BACKGROUND 
     Many surgical procedures require vessels or other fluid ducts or tissue conduits and structures to be ligated during the surgical process, such as, for example, veins or arteries in the human body. For example, many surgical procedures require cutting blood vessels, and these blood vessels may require ligation to reduce bleeding. In some instances, a surgeon may wish to ligate the vessel temporarily to reduce blood flow to the surgical site during the surgical procedure. In other instances a surgeon may wish to permanently ligate a vessel. Ligation of vessels or other tissues can be performed by closing the vessel with a ligating clip, or by suturing the vessel with surgical thread. The use of surgical thread for ligation requires complex manipulations of the needle and suture material to form the knots required to secure the vessel. Such complex manipulations are time-consuming and difficult to perform, particularly in endoscopic surgical procedures, which are characterized by limited space and visibility. By contrast, ligating clips are relatively easy and quick to apply. Accordingly, the use of ligating clips in endoscopic as well as open surgical procedures has grown dramatically. 
     Various types of hemostatic and aneurysm clips are used in surgery for ligating blood vessels or other tissues to stop the flow of blood. Such clips have also been used for interrupting or occluding ducts and vessels in particular surgeries such as sterilization procedures. Typically, a clip is applied to the vessel or other tissue by using a dedicated mechanical instrument commonly referred to as a surgical clip applier, ligating clip applier, or hemostatic clip applier. Generally, the clip is left in place after application to the tissue until hemostasis or occlusion occurs. 
     Ligating clips can be classified according to their geometric configuration (e.g., symmetric clips or asymmetric clips), and according to the material from which they are manufactured (e.g., metal clips or polymeric clips). Symmetric clips are generally “U” or “V” shaped and thus are substantially symmetrical about a central, longitudinal axis extending between the legs of the clip. Symmetric clips are usually constructed from metals such as stainless steel, titanium, tantalum, or alloys thereof. But, with the advent of high technology diagnostic techniques using computer tomography (CATSCAN) and magnetic resonance imaging (MRI), metallic clips have been found to interfere with the imaging techniques. To overcome such interference limitations, biocompatible polymers have been increasingly used for surgical clips. 
     Some well known polymeric clips are disclosed in U.S. Pat. Nos. 4,834,096 and 5,062,846. These plastic clips generally comprise a pair of curved legs joined at their proximal ends with an integral hinge or heel, and a closure or locking mechanism at their distal ends. Another example of a bio-compatible clip is shown in U.S. Pat. No. 4,671,281, which includes a mechanism to be actuated on a proximal end of the clip for causing the distally extending legs of the clip to converge. However this clip is: (i) rudimentary in construction, (ii) does not provide adequate clip closing or clamping strength, (iii) lacks any complex geometry which would adequately retain the clip in a closed position, and further (iv) is too unstable when closed to be safely applied over vessels. Examples of metal hemostatic clips are shown in U.S. Pat. Nos. 3,326,216 and 5,908,430. 
     In all of the known ligating clips however, there remains a need to improve the effectiveness of clamping about a vessel, while minimizing the damage to the vessel and surrounding tissue. For endoscopic surgical procedures, it is important to use tools and instruments that have the smallest, narrowest profile possible, such as the shafts of a tubular endoscope. Prior art polymeric and metal clips do not lend themselves to deployment through small diameter instrumentation, such as, for example, a ˜5 mm endoscope. Known prior art clips can be very wide profile, especially when in the open position prior to closure and ligation, and thus require larger, wider endoscopic instruments and appliers for use in surgery. It is desirable therefore to provide for a surgical ligation clip that has the narrowest profile possible. It may also be desirable to allow for a clip to be opened again after initial closure, which is especially a problem with known surgical clips, such as metal hemostatic clips. Furthermore, prior art polymeric clips involve locking the distal ends of their legs together in order to clamp down on the vessel or structure being ligated. Such closure of a clip having locking parts at its distal end generally causes or requires dissection, removal, or clearance of additional surrounding tissue, in order to allow the clip&#39;s locking features to come together, and/or due to actuation of an applier tool surrounding or applied against the distal clip ends, requiring additional time during a surgical procedure and damage to tissue. In other cases, the user may choose not to prepare a path for the locking features and rely on the locking features penetrating through the tissue. In these cases, the locking feature may have difficulty penetrating the tissue or may have difficulty locking after it has penetrated the tissue. This technique may also result in unintended penetration of tissue or vessels. 
     Therefore it is desirable to provide a clip and a method and/or device for applying the clip which minimizes such dissection of tissue during application. It is further desirable to provide a clip which provides a proper, well-calibrated, reliable clamping force, such that the clip, when closed, is stable around the vessel ligated. 
     Accordingly, there is a need to provide an improved surgical ligating clip and a method and/or device for applying the clip, where the clip serves to reliably secure the tissue or vessel engaged by the clip, while robustly remaining attached to the vessel with a minimum level of damage to tissue. 
     SUMMARY OF THE INVENTION 
     The invention provides, in one or more embodiments, a surgical ligation clip and a device and/or a method of applying the clip to a vessel or tissue. The device may contain a plurality of claims and may apply a first clip to a vessel or tissue and advance a second clip contained in the applier to an applying position. 
     In another aspect of the invention, a method of applying a surgical ligation clip includes positioning the clip in an open position proximate an inner anatomical body vessel, the clip having first and second legs each extending along a longitudinal axis of the clip and having proximal and distal end portions with respect to said longitudinal axis, a clip hinge means joining the first and second legs at a point on their respective proximal end portions, the first and second legs each having inner clamping surface means between the clip hinge and the distal end portions of said first and second legs, the clamping surface means being apposed when the clip is in a fully closed position, and a locking means for biasing the legs closed extending proximal to the clip hinge means. An external force is applied substantially along the longitudinal axis to a proximal end portion of one of the legs which forms a portion of the locking means, to move a body formed as a first part of said locking means from a first position to a second position to provide an abutment force between a curved planar segment abutment portion of said body and a curved surface formed on a second part of said locking means disposed on the first leg to bias the clip in a closed position. The method may further include moving the clip through an instrument prior to positioning the clip proximate the vessel, and may also further include that a portion of the instrument opens the clip from a closed position to an open position. 
     In some embodiments, a ligation clip applier is provided. The applier includes: a pair of jaws; a distal clevis tube to which the jaws are pivotally mounted; a proximal clevis tube located behind the distal clevis tube, wherein the distal clevis tube and the proximal clevis tubes move axially with respect to each other; a clip lock actuator fixed to one of the proximal and distal clevis tubes; and a distal pushrod extending through the distal and proximal clevis tubes and forming a camming connection with the jaws configured to close and move the jaws toward a proximal direction toward the clip lock actuator when the distal pushrod is moved in the proximal direction. 
     A method of applying a clip on a vessel is provided. The method may include: retaining a clip in a pair of jaws by inclined surfaces on a distal portion on each leg of the clip with a corresponding inclined surfaces on the jaws; moving a distal pushrod in a proximal direction; sliding projections along a slot in at least one jaw to rotate the at least one jaw to a closed position; and moving the legs of the clip by closing the jaws. 
     In some embodiments, a ligation clip applier is provided. The applier may include: means for pinching; a distal clevis tube to which the means for pinching are pivotally mounted; a proximal clevis tube located behind the distal clevis tube, wherein the distal clevis tube and the proximal clevis tubes move axially with respect to each other; means for locking a clip fixed to one of the proximal and distal clevis tubes; and means for moving the means for pinching extending through the distal and proximal clevis tubes and forming a camming connection with the means for pinching configured to close and move the means for pinching toward a proximal direction toward the means for locking a clip when the means for moving the means for pinching is moved in the proximal direction. 
     The applier is a manually loaded instrument used to deploy proximal locking polymeric ligation clips. The manual applier will load/apply a single clip at a time. The applier is an endoscopic instrument suitable for use in laparoscopic surgery applications. 
     The polymeric clips will be positioned in clip cartridges. The clips will then be loaded into the applier manually by pressing the distal end of the applier down on the end of the clip. The will be guided by features on the cartridge and will grab the clip in the clip catch mechanism internal to the applier. When the applier is pulled away from the cartridge the clip will release from the cartridge and stay internal to the applier. A clip indicator internal to the applier will indicate that a clip is present at the proximal end of the applier shaft. This will allow the user to know a clip is present prior to and during insertion/manipulation of the applier. 
     The jaws will be able to actuate without disturbing the loaded clip. This allows the jaws to be used in the dissection and grasping of tissue around the vessel being ligated if necessary. 
     In a first embodiment of the invention; the jaws of the applier will clamp over the vessel to flatten the section to be ligated. The clip is opened internally in the applier by a set of wedges during clip load. The clip is then positioned over the vessel and subsequently closed with actuation of the wedges and catch mechanism. Once closed, a punch mechanism will engage the locking feature to maintain the clamping pressure of the clip. The jaws then will open allowing the ligated vessel and clip to clear the applier jaws. 
     In a seconded embodiment of the invention; the clip is positioned over the vessel with actuation of the wedge and catch mechanism and is subsequently closed when a punch mechanism is engaged with the locking feature on the clip. The features of the clip lock cause the legs of the clip to close and once fully locked the clip maintains the clamping pressure on the vessel. 
     Each of the distal end actuations are accomplished through the use of a proximal handle. The handle is made of a housing and rotation knob, which allow for a 360° continuous rotation of the distal end, separate triggers for jaw actuation and clip functions, and a multi stage transmission that allows the distal end to be actuated in the proper sequence for effective clip delivery. 
     There has thus been outlined, rather broadly, certain embodiments of the invention in order that the detailed description thereof herein may be better understood, and in order that the present contribution to the art may be better appreciated. There are additional embodiments and features of the invention that will be described below. 
     In this respect, before explaining at least one embodiment of the invention in detail, it is to be understood that the invention is not limited in its application to the details of construction and to the arrangements of the components set forth in the following description or illustrated in the drawings. The invention is capable of embodiments in addition to those described and of being practiced and carried out in various ways. Also, it is to be understood that the phraseology and terminology employed herein, as well as the abstract, are for the purpose of description and should not be regarded as limiting. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  shows a view of a first embodiment of a surgical ligation clip of the present invention. 
         FIGS. 2 a , 2 b , and 2 c    show side, top, and bottom views respectively, of the clip shown in  FIG. 1 . 
         FIGS. 3 and 4  show perspective views of the clip shown in  FIG. 1  from a first side. 
         FIG. 5  shows a perspective view of the clip shown in  FIG. 1  from the side opposite to that shown in  FIGS. 3 and 4 . 
         FIG. 6  is another side view of the clip shown in  FIG. 1 . 
         FIG. 6 a    is a close-up detail view of the portion of the clip shown in  FIG. 6  in region “ 6   a ” therein. 
         FIG. 6 b    is a sectional view of the clip shown in  FIG. 6  taken along section B-B in the direction shown in  FIG. 6 . 
         FIG. 7  is another side view of the clip shown in  FIG. 1  from the opposite side to that shown in  FIG. 6 . 
         FIG. 7 a    is a close-up detail view of the portion of the clip shown in  FIG. 7  in region “ 7 A” therein. 
         FIG. 7 b    is a sectional view of the clip shown in  FIG. 7  taken along section C-C in the direction shown in  FIG. 7 . 
         FIGS. 8 a , 8 b , and 8 c   , are side, top, and bottom views, respectively, of the clip shown in  FIG. 1  in an open position. 
         FIG. 9  is a perspective view from the bottom of the clip shown in  FIG. 8 a    in the open position. 
         FIG. 10  is a perspective side view from the top of the clip shown in  FIG. 8 a    in the open position. 
         FIGS. 11 a , 11 b , and 11 c    show side, top, and bottom views respectively, of the clip shown in  FIG. 1 , with the proximal locking components in locked position. 
         FIG. 12  is a perspective view from the top of the clip shown in  FIG. 11   a.    
         FIG. 13  is a side view of the clip shown in  FIG. 11   a.    
         FIG. 13 a    is a close-up detail view of the portion of the clip shown in  FIG. 13  in region “ 13   a ” therein. 
         FIG. 14  is a side view of the clip shown in  FIG. 11 a    from the side opposite to that shown in  FIG. 13 . 
         FIG. 14 a    is a close-up detail view of the portion of the clip shown in  FIG. 14  in region “ 14   a ” therein. 
         FIG. 15  is a view of the clip shown in  FIG. 1 . 
         FIG. 15 a    is a close-up detail view of the portion of the clip shown in  FIG. 15  in region “ 15   a ” therein. 
         FIG. 16  shows a side view of an applier. 
         FIG. 17  shows an applier clamped on vessel. 
         FIG. 18  shows an isometric view of clip latched on vessel. 
         FIG. 19  shows a clip latched on vessel. 
         FIG. 20  shows an exploded view of applier parts. 
         FIG. 21  shows a wedge. 
         FIG. 22  shows a catch. 
         FIG. 23  shows a punch. 
         FIG. 24  shows a clip indicator. 
         FIG. 25  shows an inner tube. 
         FIG. 26  shows a jaw/inner tube camming. 
         FIG. 27  shows a jaw/inner tube cam points. 
         FIGS. 28 a , 28 b  and 28 c    shows jaws. 
         FIG. 29  shows an outer tube. 
         FIG. 30  shows an applier shaft distal end. 
         FIG. 31  shows an applier shaft proximal end. 
         FIG. 32  shows loaded clips in cartridge. 
         FIG. 33  shows a cross section view of loaded clip. 
         FIG. 34  shows clip legs held by detents in cartridge. 
         FIGS. 35 and 36  shows a clip cartridge. 
         FIG. 37  shows an approach to cartridge for clip load. 
         FIG. 38  shows a clip load. 
         FIG. 39  shows an approach to clip cartridge (cartridge and clip not shown). 
         FIG. 40  shows a clip load (cartridge not shown). 
         FIG. 41  shows a clip loaded. 
         FIG. 42  shows jaws closed. 
         FIG. 43  shows a clip advance into jaw over vessel. 
         FIG. 44  shows a clip advanced over vessel wedges begin to advance. 
         FIG. 45  shows wedges advance to close clip. 
         FIG. 46  shows a punch latches clip on vessel. 
         FIG. 47  shows a punch moves up to buttress. 
         FIG. 48  shows a buttress rotating as the punch moves forward. 
         FIG. 49  shows a clip just before latch. 
         FIG. 50  shows a clip locked. 
         FIG. 51  shows wedges retract. 
         FIG. 52  shows wedges fully retracted. 
         FIG. 53  shows a punch retracting. 
         FIG. 54  shows a clip free/jaws open. 
         FIG. 55  shows a punch fully retracted. 
         FIG. 56  shows an internal end view of an applier shaft. 
         FIG. 57  shows an end view of applier with jaws open and clip loaded. 
         FIG. 58  shows a isometric view of distal end of applier. 
         FIG. 59  shows a isometric view of distal end of applier shaft with clip loaded. 
         FIG. 60  shows a clip viewport. 
         FIG. 61  shows a second embodiment of the applier. 
         FIG. 62  shows a second embodiment—catch tube with wedges and catches. 
         FIG. 63  shows a second embodiment—catches and wedges. 
         FIG. 64  shows an applier handle. 
         FIG. 65  shows a handle configuration (outer shell hidden). 
         FIG. 66  shows trigger components. 
         FIG. 67  shows a handle configuration (upper trigger hidden). 
         FIG. 68  shows internal handle components. 
         FIG. 69  shows multistage transmission components. 
         FIG. 70  shows an assembled multistage transmission. 
         FIG. 71  shows a transmission outer shell and with the Leur port removed. 
         FIG. 72  shows a transmission with the jaw actuator links removed. 
         FIG. 73  shows a transmission with the catch pusher latches and dowels removed. 
         FIG. 74  shows a transmission with the punch latch interlock and dowel removed. 
         FIG. 75  shows a transmission with the center spindle and dowel removed. 
         FIG. 76  shows a transmission with the punch return spring removed (distal shaft connection points shown). 
         FIG. 77  shows a cross-section of the transmission where the jaws are open (clip loaded), 
         FIG. 78  shows a cross-section of the transmission where the jaws are closed (clip loaded). 
         FIG. 79  shows a cross-section of the transmission where the clip is advanced. 
         FIG. 80  shows a cross-section of the transmission where the clip is closed. 
         FIG. 81  shows a cross-section of the transmission where the clip is latched. 
         FIG. 82  shows a cross-section of the transmission where the wedges return. 
         FIG. 83  shows a cross-section of the transmission where the connection pins are no longer in the pocket. 
         FIG. 84  shows a cross-section of the transmission where the punch is unlatched. 
         FIG. 85  shows a cross-section of the transmission where the clip is free from the device. 
         FIG. 86  shows a cross-section of the transmission where the punch spring has returned. 
         FIG. 87  shows an isometric view of a transmission in an embodiment that does not have a punch latch interlock. 
         FIG. 88  shows an exploded isometric view of another embodiment showing multistage transmission components; 
         FIG. 89  shows a cross-section of the transmission where the jaws are open (clip loaded). 
         FIG. 90  shows a cross-section of the transmission where the jaws are closed (clip loaded). 
         FIG. 91  shows a cross-section of the transmission where the clip is advanced (wedges and catch move together). 
         FIG. 92  shows a cross-section of the transmission where the clip is latched. 
         FIGS. 93-97  show side views of an applier in some FIGS. internal components are exposed and illustrated. 
         FIG. 98  is a side view of another clip used in accordance with an embodiment of the invention. 
         FIG. 99  is a top view of a clip illustrated in  FIG. 98 . 
         FIG. 100  is a isometric view of the clip illustrated in  FIG. 98 . 
         FIG. 101  is an isometric view of a clip applied onto tissue or a blood vessel. 
         FIG. 102  is a side view of a clip locked onto a tissue or blood vessel. 
         FIG. 103  is a isometric view of a distal end of applier. 
         FIG. 104  is a isometric view of a shaft assembly. 
         FIG. 105  is a isometric view of a handle assembly. 
         FIG. 106  is an isometric view of a clip cartridge. 
         FIG. 107  is an isometric view of a jaw. 
         FIG. 108  is an isometric view of a pivot rivet. 
         FIG. 109  is an isometric view of a distal locking clevis tube. 
         FIG. 110  is an isometric view of a proximal locking clevis tube. 
         FIG. 111  is an isometric view of an actuation shaft. 
         FIG. 112  is an isometric view of a spring. 
         FIG. 113  is an isometric view of a clip lock actuator. 
         FIG. 114  is an isometric view of a distal pushrod. 
         FIG. 115  is a partial isometric view of applier jaws. 
         FIG. 116  is a partial isometric view of a distal portion of an applier. 
         FIG. 117  is an isometric, cross-sectional, partial view of a portion of an applier. 
         FIGS. 118-120  are partial cutaway views of the distal portion of an applier. 
         FIG. 121  is a partial distal view of a midsection of an applier. 
         FIG. 122  is a partial cutaway view of the jaws of applier. 
         FIG. 123  is a side view of another clip that may be used in accordance with invention. 
         FIG. 124  is a side view of the clip shown  FIG. 123  and a closed position. 
         FIG. 125  is a isometric view of the clip illustrated in  FIG. 123 . 
     
    
    
     DETAILED DESCRIPTION 
     The invention will now be described with reference to the drawing figures, in which like parts are referred to with like reference numerals throughout. Clips that may be used in accordance with some embodiments of the invention are described in U.S. provisional patent application No. 61/312,156, filed on Mar. 9, 2010, and U.S. non-provisional application Ser. No. 13/042,864, filed on Mar. 8, 2011 by Philip Schmidt, et al. the disclosures of which are both incorporated by reference in their entirety. 
       FIG. 1  shows a view of a first embodiment of a surgical ligation clip  100  in accordance with present invention. The clip  100  defines a longitudinal axis “L” along its longest dimension and includes a first leg  101  and a second leg  102  each extending along the longitudinal axis L and having proximal  111 ,  112  and distal  121 ,  122  end portions with respect to said longitudinal axis. As used herein, the term “proximal” shall refer to the portion of the clip referenced herein which is away from the tips of the clip which open, and “distal” shall refer to the portion of the clip at the tips which open, in accordance with the convention that the clip is inserted distal tip first through an instrument towards an anatomical body to be ligated, such that distal generally refers to the direction away from the user or applier of the surgical clip and proximal refers to the direction opposite to distal. 
     In clip  100 , a clip hinge  130  joins the first and second legs  101 ,  102  at a point on their respective proximal end portions  111 ,  112 , the first and second legs each having respective inner clamping surfaces  131 ,  132  between the clip hinge  130  and the distal ends  123 ,  124  of said first and second legs, the clamping surfaces being apposed when the clip is in a fully closed position. As used herein, the term “apposed” when used with regard to the inner clamping surfaces  131 ,  132  shall mean close to, or nearly in contact with each other, allowing for some small spacing therebetween or a concave radius of curvature for the clamping surfaces, such to allow for a clipped vessel to reside between such apposed surfaces, as is more fully illustrated herein and with respect to the drawing figures. The clip hinge  130  can include a bar or cylindrically shaped body or tube which defines a lateral pivot axis “P” (shown in  FIGS. 2 b  and 2 c   ) about which the legs  101  and  102  pivot as the clip moves from open to closed position and vice versa. A first jaw structure  141  on the first leg  101  extends proximal to a transverse axis “T” which is perpendicular to both the longitudinal axis L and lateral pivot axis P, all intersecting at a point “X” centered on the clip hinge  130 , as shown in  FIG. 1 . As used throughout herein, the term “lateral” shall directionally mean orthogonal to both the directions of the longitudinal axis L and transverse axis T, and parallel to pivot axis P as shown in the figures. The first jaw structure  141  includes a first curved inner surface  143  extending from the clip hinge  130 , the first curved inner surface  143  having a complex surface which is oriented at changing angles with respect to, but is generally facing towards, the longitudinal axis L, as shown in  FIG. 1 . The curved inner surface  143  is therefore substantially concave when viewed from the longitudinal axis (or plane spanning the longitudinal axis and pivot axis). As used herein, the term “substantially concave” shall mean a surface which is concave in overall curvature, but which may include one or more component areas which may have convex segments or protrusions, such as a notch surface or recess for mating thereto. A second jaw structure  142  is on the second leg  102  extending proximal to the transverse axis T and has a second curved inner surface  144  extending from the clip hinge  130 . As used herein, the “curved inner surface” can include either a single smoothly curved surface segment, or a series of connected curved or straight planar segments, which, taken together, form an overall generally curving surface. As described herein, the surgical clip of the present invention provides that the jaws  141  and  142  are each substantially proximal to a transverse plane extending through transverse axis T and lateral pivot axis P, thus behind the clip hinge  130 , thereby providing a means for actuating the clip legs  101  and  102  and biasing or locking the clip and its mating faces  131 ,  132  in a closed position, which biasing or locking means can be actuated and/or applied by acting only on the proximal end portions of the clip  100 , without having to lock the distal ends  123 ,  124  to each other or use a clip applier tool which acts on said distal ends  123 ,  124 , thereby obviating the need to dissect tissue around the distal end of the clip as in previously known surgical ligation clips. 
     As shown in  FIG. 1 , the means for biasing or locking the clip closed includes a wedge or buttress body  150  which extends from and is connected to the second jaw structure  142  by a first living hinge  160  at a proximal end of said second jaw structure  142 , the buttress body  150  having an outer surface  151  at a proximal first end portion thereof, which is also disposed approximately as the proximal end of the clip  100  overall. The first and second jaw structures  141 ,  142  are spaced on opposite sides of the longitudinal axis L and define a locking space  170  therebetween. The wedge or buttress body  150  is pivotable about the living hinge  160  to move into the locking space  170  such that the outer surface  151  of the proximal first end portion of the buttress body  150  abuts against a proximal portion  145  of the curved inner surface  143  of the first jaw structure  141  to bias the clip in a closed position (as best shown in  FIGS. 11 a   , and  12 - 14 ). Although the clip  100  is shown in  FIG. 1  in a closed position, this is with the locking means of the first and second jaws  141 ,  142  and buttress body  150  being in the “unlocked” position as shown in  FIGS. 1, 2   a , and  3 - 7 . Once the buttress body is in the “locked” position as shown in  FIGS. 11 a    and  12 - 14 , the first and second jaws  141 ,  142  are urged or spread apart (shown, as an example, by arrows “J 1 ” and “J 2 ” in  FIGS. 13 a  and 14 a   ) by action of surfaces of the wedge/buttress body  150  acting on portions of curved inner surfaces  143 ,  144 , which act as moments about the clip hinge  130  and lateral pivot axis P to urge the legs  101 ,  102  and its inner clamping surfaces  131 ,  132  to become more closely apposed to each other, thereby providing additional clamping and closing force over a vessel around which the clip is applied. 
     A variety of means may be used to actuate the wedge or buttress body  150  from the unlocked position in  FIG. 1  to the locked position shown in  FIGS. 11 a   ,  12 - 14 . As shown in  FIG. 1 , an external force, shown, for example, as arrow “F” in  FIG. 1 , may be applied to a proximal end of the pivoting buttress body  150 , in this example the external force F being substantially aligned with the longitudinal axis L. Alternatively, the external force applied may be at a small angle to the longitudinal axis L, such as, for example, a force shown by arrow “F*” shown in  FIG. 1 . In either case, the applied external force will create a moment about living hinge  160  to pivot the buttress body  150  into the locking space  170 . The external force may be applied by an actuating rod or other structural means in an applier instrument, or may be another clip as fed through a multi-clip applier. As one example, the clip  100  may be inserted through an instrument having a bore or channel for receiving the clip  100 , through which the clip  100  may travel distally for positioning near a vessel during a surgical procedure. The clip may be inserted in a legs closed position, but with the proximal locking means including buttress body  150  in open, unlocked position. Because the clip  100  can be inserted in such fashion in closed form, the clip forms a narrow profile and can fit in smaller sized surgical instruments, thereby allowing for smaller incisions and tissue dissection or damage during surgery. A rod or other actuating mechanism translating or moveable on the instrument inserting the clip, or a second instrument or second clip used in conjunction with the instrument used for inserting and positioning the clip in place, maybe used to lock the clip by application of an external force on the proximal end portion of the clip as discussed above. 
     Thus, a method of applying a surgical ligation clip on a vessel in accordance with an embodiment of the invention includes positioning a clip, such as, for example, clip  100 , in an open position proximate a vessel, the clip having first and second legs each extending along a longitudinal axis of the clip and having proximal and distal end portions with respect to said longitudinal axis, a clip hinge means joining the first and second legs at a point on their respective proximal end portions, the first and second legs each having inner clamping surface means between the clip hinge and the distal end portions of said first and second legs, the clamping surface means being apposed when the clip is in a fully closed position. A locking means for biasing the legs closed may extend proximal to a transverse axis perpendicular to the longitudinal axis intersecting at a point centered on the clip hinge. The method includes applying an external force to a proximal end portion of the clip or of one of the legs which forms a portion of the locking means, to move a body formed as a first part of said locking means from a first position to a second position to provide an abutment force between said body and a surface formed on a second part of said locking means to bias the clip in a closed position. In the method, an instrument may be used, wherein, in moving the clip through the instrument prior to positioning the clip proximate a vessel, a portion of the instrument opens the clip from a closed position to an open position, such that the legs of the clip open for placement of the clip around a vessel. The locking means may then be applied to the proximal end portion of the clip to move and bias the legs closed and clamp the clip more fully over the vessel. 
     In  FIG. 1 , the clamping surfaces appear substantially parallel to each other, oriented, in the clip closed position, substantially or very close to parallel to a plane extending through the longitudinal axis L and lateral pivot axis P. However, in an embodiment of the invention, the inner clamping surfaces  131 ,  132  may be slightly curved concave when facing said surfaces, such that the surfaces bow away from the longitudinal axis L and straighten slightly when clamping force is applied by action of the locking mechanism of the buttress body  150  acting against jaws  141 ,  142 . This allows for enhanced grasping and occlusion of vessels around which the clip  100  is applied, wherein the clamping force is spread more evenly across the clamping surface. 
     The living hinge  160  connecting the wedge or buttress body  150  to the second jaw  142  can be integral to the second jaw  142  such that the clip body of second leg  102  proximal to transverse axis T extends as a single unitary structure including the second jaw  142  and entire wedge or buttress body  150 . Accordingly, in the wedge or buttress body  150 , a lateral beam or curved body  152  connects the living hinge  160  to the rest of the buttress body  150 , which beam  152  curves from the living hinge  160  (which is separated by a distance from the longitudinal axis L) towards the longitudinal axis L. As shown in  FIG. 1  portions of wedge of buttress body  150  can be oriented on both sides of longitudinal axis L. The pivot axis of living hinge  160  extends in a lateral direction parallel the lateral pivot axis P of the main clip hinge  130 . 
     The present invention provides, in various embodiments, a locking mechanism cooperating between the buttress body  150  and another portion of the clip. In the clip  100  shown in  FIG. 1 , the proximal end portion  145  of the curved inner surface  143  of the first jaw structure  141  defines a notch  147  recessed from said curved inner surface  143 , and the buttress body  150  defines a detent  157  formed on the outer surface thereof, the detent  157  mating with the notch  147  when the buttress body  150  is pivoted into the locking space  170  to bias the clip in the closed position, as best shown in  FIGS. 11 a   ,  12 , and  14 . 
       FIGS. 2 a , 2 b , and 2 c    show side, top, and bottom views respectively, of the clip shown in  FIG. 1 . As shown in  FIG. 2 b   , the wedge or buttress body  150  can be divided into two lateral sections or portions  150   a  and  150   b , each on opposite sides of the longitudinal axis L as shown, and can form approximate lateral halves of the buttress body  150 , with a possible space or small channel in-between. Lateral portion  150   b  of the buttress body  150  can have a width in a plane spanning the transverse and longitudinal axes sufficient to exceed a complementary width formed by the locking space  170  to create an interference fit between the proximal end portion  145  of the curved inner surface  143  of the first jaw structure  141  and the outer surfaces  151   a ,  151   b  on the proximal first end portion outer surface  151  of the buttress body  150 , to bias the clip in a closed position. An example of the transverse width of said lateral portion  150   b  is shown as distance “TW 1 ” in  FIG. 7 a   , with complementary width “TW 2 ” being formed by the locking space  170 , it being understood that TW 1  is slightly greater than TW 2  in order to create the interference fit. In the embodiment as shown in  FIGS. 1, 2   b , and  7   a , on lateral portion  150   b  there is no detent  157 , and said lateral portion  150   b  of the buttress body is formed by a partial lateral width of the buttress body  150 . Thus, as shown in  FIG. 2 b   , the notch  147  and detent  157  are formed on corresponding partial lateral sections or slices of the buttress body  150  and first jaw structure  141 , respectively, this lateral section  150   a  of buttress body  150  being on the opposite side thereof to the lateral section  150   b . In this manner, the buttress body  150 , once locked into place as shown in  FIG. 12 , is prevented from moving laterally from side to side since the notch  147  and detent  157  interlock only extends laterally partially across the clip, the detent  157  being limited in lateral movement by a shoulder  187  formed by a termination of the notch  147  laterally into the first jaw structure  141 , as shown in  FIG. 9 . As shown in  FIG. 8 b   , the lateral slice of buttress body  150  only extends for a lateral width LW 1  which includes detent  157 , which the lateral slice LW 2  of buttress body  150  on the other side of the clip does not include the detent  157 . In this manner, the proximal locking mechanism of the clip  100  is more stable in lateral directions, which is also useful for keeping all parts of the clip together in the event the living hinge  160  may break. 
     As best shown on  FIG. 5 , the outer surface  151  on proximal first end portion of buttress body  150  on a proximal end of the clip  100  defines one or more surfaces which form a curved planar segment abutment portion, which in the embodiment as shown includes curved planar segment abutment portions  151   a  and  151   b . As used herein, the “curved planar segment abutment portion” formed by a surface may include a single curved surface segment or a series of curved or straight planar surface segments connected to one another which form an overall generally curved surface, each of the surface segments extending as a surface at least laterally. In the embodiment shown in  FIG. 5 , curved planar segment abutment portion  151   a  included planar and curved surface segments formed by the notch  157  and extends laterally for about one-half of the lateral width of clip  100 , curved planar segment abutment portion  151   b  includes planar and curved surface segments which also extend laterally for about one-half of the lateral width of clip  100 . Each of the curved planar segment abutment portions  151   a  and  151   b  on outer surface  151  forms a substantial abutment surface that pushes against complementary curved inner surfaces of jaw  141  to provide a stronger and more stable locking mechanism for clip  100 . This is provided, at least in part, by the relatively larger and wider surface areas, lateral spans, and segmented surfaces with interlock and abut against each other to provide enhanced holding strength and stability, beyond what has been previously known or practiced in the field of surgical ligation clips. 
     As best shown in  FIG. 6 a   , the second curved inner surface  144  on the second jaw structure  142  forms a first laterally spanning recessed groove  146  separated from the clip hinge  130  and a first laterally spanning ball-shaped or rounded protruding surface  148  proximal to said recessed groove  146 , and a distal second end portion of the buttress body  150  forms a second laterally spanning recessed groove  158  and a second laterally spanning ball-shaped or rounded protruding surface  156  distal to said second recessed groove which are shaped complementary to the first rounded surface  148  and first recessed groove  146 , respectively, so as to mate in abutment when the buttress body  150  is pivoted into the locking space  170  to further stabilize and bias the clip in a closed position. The first recessed groove  146 , first rounded surface  148 , second recessed groove  158 , and second rounded surface  156  may extend laterally all the way across the lateral width of the buttress body  150 , such that the first rounded surface  148  and second rounded surface  156  are not spherically shaped but rather form an extended, laterally-spanning, rounded, semi-cylindrical surface which can mate in corresponding semi-cylindrical shaped grooves formed by first recessed groove  146  and second recessed groove  158 . 
     As shown in  FIG. 6 a   , the buttress body  150  can further define a second living hinge  162  extending laterally between the proximal first end portion  150   c  of buttress body  150  and a distal second end portion  150   d , wherein the proximal first end portion  150   c  including outer surface  151  further pivots about said second living hinge  162  when the buttress body  150  moves into the locking space  170 , allowing the outer surface  151  of the proximal first end portion  150   c  of the buttress body to flex towards the longitudinal axis L prior to abutment against the curved inner surface  143  of the first jaw structure  141 . 
     As best shown in  FIGS. 5 and 12 , the outer surface of the proximal end of the buttress body  150 , or clip  100  itself, defines a V- or L-shaped laterally spanning notch  150   x  on the proximal end of the clip  100  and further defines a laterally spanning flange  150   y  extending from said notch  150   x  adjacent to the curved planar segment abutment portions  151   a  and  151   b . Each of notch  150   x  and flange  150   y  may be divided into two lateral sections or components divided by a small space or channel there between as they are disposed on the lateral sectional halves  150   a  and  150   b  of the buttress body  150 . The notch  150   x  provides a receiving space for the tip of an instrument, pushing or actuating rod, or another clip, so as to enable a more stable actuation of the buttress body  150  into locking space  170  to lock the clip  100 . The flange  150   y  may act to limit the movement of buttress body  150  once fully inserted into locked position inside space  170 , and also further stabilizes the locking mechanism for the clip  100 . 
     In the embodiment shown in  FIGS. 1-15 , the buttress body may occupy a majority of a volume defined by locking space  170  when it is moved into clip locked position so as to bias the legs  101 ,  102  in a closed position. The volume defined by the locking space is limited by the lateral width of the clip legs  101 ,  102  near the hinge  130  and the jaws  141  and  142 . As shown in  FIG. 13 a   , the remaining locking space  170 ′ between jaws  141  and  142 , once the clip is locked by movement of the buttress body  150  into space  170 , is less than half the volume of the locking space  170  as shown in  FIG. 6 a   . The presence of a bulky body like buttress body  150  which occupies the majority of the volume or space between proximal extending jaws  141  and  142  when the clip  100  is in the locked position further provides a greater strength and stability to the locking of said clip. 
     In the embodiment shown in  FIGS. 1-15 , and as shown in  FIG. 6 a   , the buttress body  150  can be characterized in one way as having a core mass which has, in a transverse plane spanning the longitudinal and transverse axes, a cross-section which approximately spans a trapezoidal shape, having rounded curved sides extending from the sides TP 1 , TP 2 , TP 3 , TP 4  of the trapezoid. Side TP 1  defines the longest side and one of the parallel sides of the trapezoid, while side TP 2  defines the shorter parallel side. Side TP 3  defines the longer and more distal of the non-parallel sides, while side TP 4  defines the shorter and more proximal non-parallel side. Side TP 1  is therefore connected to sides TP 3  and TP 4 . When the clip is in the unlocked position as shown in  FIG. 6 a   , and the buttress body  150  is fully extended away from the clip hinge  130  out in the most proximal position, the vertex TPX 1  of sides TP 1  and TP 4  lies approximately on or near the longitudinal axis L, and side TP 1  makes an angle α below the longitudinal axis, towards proximal jaw  142 , such angle α being, in one embodiment, approximately 30 degrees. As shown in  FIG. 6 a   , the rounded laterally-spanning protuberance  156  extends substantially from side TP 3 . 
     The clip hinge  130  can also be a resilient hinge providing additional biasing force to maintain the inner clamping surfaces  131 ,  132  of the legs towards a closed position. A span of each leg extending from the clip hinge  130  to its respective distal tip  123 ,  124 , can be, in one embodiment of the present invention, at least 75% to 80% of an overall length of the clip. As shown in  FIGS. 2 b  and 2 c   , the clip hinge  130  can define lateral bosses which extend laterally from the side surfaces of the clip legs, defining a bossed width or span which is greater than the clip width. 
     In the embodiment shown in  FIGS. 1-15 , the clip hinge  130  is formed as a laterally extending bar  130   x  integrally formed with the first and second legs  101 ,  102 , each leg being resiliently coupled to first and second transverse sides of said bar, the bar  130   x  further defining laterally spanning grooves  130   a  and  130   b  on longitudinally distal and proximal sides of the bar, respectively. These grooves  130   a  and  130   b  further enable the clip  100  to flex as pivoting about the lateral axis of hinge  130 , and further provide a resilient pivoting moment or force about said hinge. 
     Furthermore, in the embodiment shown in  FIGS. 1-15 , flanges  191  and  192  extend longitudinally across respective outer surfaces of each of the first and second legs  101 ,  102  which are on opposite sides to the inner clamping surfaces  131 ,  132  of each respective leg, the flange  191  of the first leg  101  extending from the first jaw structure  141  to the distal end portion  121  of the first leg  101 , the flange  192  of the second leg  102  extending from the second jaw structure  142  to the distal end portion  122  of the second leg  102 . Each of the flanges  191 ,  192  defines a transverse indentation  191   a ,  192   a  proximate the distal end portions  121 ,  122  of the legs  101 ,  102 . The flanges  191  and  192  provide a rigidity to legs  101  and  102 , respectively, such that said legs do not easily bend. Transverse indentations  191   a  and  192   a  provide a means for a clip applier to better actuate or grip the legs  101 ,  102 . 
     The clip  100  further includes serrations, ridges, or teeth  181 ,  182  on the inner clamping surfaces  131  and  132 , respectively, as shown in  FIGS. 6 b  and 7 b   , and  9 ,  10 , and  15   a . The teeth or ridges  181 ,  182  provide additional grasping means to better attach and clamp the clip  100  onto a vessel when closed. The teeth or ridges  181 ,  182  are disposed to fit into complementarily arranged grooves  183  and  184  on the clamping surfaces  131  and  132 , respectively. The teeth  181 ,  182  may have a slanted orientation, extending proximally, so as to better grip tissue. As best shown in  FIGS. 6-6   a  and  7 - 7   a , a pair of distal hook elements  194  and  195  may be disposed on the absolute distal tips of legs  101  and  102 , respectively, each hook  194  and  195  offset laterally with respect to each other to form a scissor-like configuration, such that each hook  194  and  195  fit into corresponding recesses  195   a  and  194   a , respectively, on the distal tips of legs  102  and  101 , respectively. This mechanism provides means to further grip and contain tissue with the space between the clamping surfaces  131 ,  132  when the clip  100  is applied to body vessel, as illustrated in  FIGS. 19 and 20 . 
     The clip  100  may be in a range of sizes. As shown in  FIG. 15 , an overall length “S 1 ” of the clip  100  may be approximately 0.50 inches; the length “S 2 ”, between the intersection of transverse axis T and longitudinal axis L centered at clip hinge  130  and the distal tip of the clip, may be approximately 0.40 inches, and the radius of curvature of the inner mating or clamping surfaces  131 ,  132  of the legs  101 ,  102  may be approximately 3.0 inches. Such sizes and dimensions are given as an example, and it is understood that the clip may, in one or more embodiments of the invention, vary in size ranging from approximately 0.15 to 0.80 inches in overall longitudinal length, and from approximately 0.03 to 0.15 inches in lateral width. As one embodiment of the invention, the illustration of clip  100  in  FIG. 15  is shown as a scaled magnification of actual size, and shows all the parts of the clip  100  in actual proportion to each other. 
     The instrumentation used to deploy the clips discussed herein may include a manually loaded device that can apply a single clip at a time, or an automatically fed, multiclip applier. Both appliers can be endoscopic instruments suitable for use in laparoscopic surgery applications. In both cases the applier will clamp over the vessel to flatten the section to be ligated. The clip will then be opened, positioned over the vessel and closed. Once closed, a mechanism will engage the locking feature on the proximal end of the clips disclosed herein, to maintain the clamping pressure of the clip. A manual applier will load/apply a single clip at a time. An automatic applier will be able to load/apply multiple clips before the instrument has to be removed from the surgical site. The sequence of clip application is as follows:
         1. The clip is presented in the partially closed condition.   2. A device, such as a set of applier jaws clamps down on the vessel or tissue to be ligated or clamped. The applier jaws have a channel down the center that is just large enough to allow the clip to fit in the channel.   3. The clip is opened by pressing the proximal legs together lightly.   4. The clip is advanced over the vessel or tissue that is clamped within the jaws of the applier (the clip traveling in the channel area of the applier jaws).   5. Once fully advanced, the proximal legs are released and the clip springs back to the partially closed condition.   6. The proximal locking mechanisms discussed for the clip embodiments disclosed herein are actuated or pressed, causing the legs or ‘clamping section’ of the clips to close tightly on the vessel or tissue.       

     The various embodiments of the clips disclosed herein therefore can start in an as-molded state; can be opened further to better encapsulate the vessel; and can then be closed further (into a third state). This process of opening and closing the clip can be repeated as needed, prior to locking. When closed and locked, the clip provides an active clamping force which can also squeeze the vessel, which is beneficial if the vessel necroses and/or shrinks over time. 
     The various embodiments of the surgical clips of the present invention are preferably made of one or more polymer materials, such as, by example, acetyl homopolymer, but could also be made of a variety of other materials, including one or more metals, or a combination of metal and polymer or plastic. In selecting the material(s) used, the radiopacity of the clip can be “tuned” to a desirable level, or can be tuned to be radiopaque. 
     The various embodiments of surgical clips of the present invention are an improvement over the known polymeric surgical ligation clips, as well as standard metal clips. Among the resulting advantages of the surgical clip of the invention as disclosed herein are: the ability to deliver a larger clip through a smaller endoscopic instrument; the ability to place a clip on a vessel just like a prior art malleable and deformable metal clip, with no need for added dissection or cleaning around the vessel, but with greater retention force than metal clips, which results in a reduced risk of clips slipping off the vessels. The greater clip locking stability and clip retention force is accomplished by the locking feature applying an active biasing or clamping force as discussed above, versus the passive clamping action created by plastic deformation of malleable metal clips. A brief discussion with reference to the FIGS. will now be discussed with a more detailed discussion referencing the FIGS. and referencing reference characters will follow. 
     The distal portion of the applier would be attached to a proximal handle with components that achieve the proper sequence to successfully apply a ligation clip. 
     One particular embodiment, of the distal portion of the invention, consists of nine parts which make up the distal end, or shaft of the applier, parts are shown and labeled in  FIG. 20 . There are two identical wedges used, shown in  FIG. 21 , one catch, shown in  FIG. 22 , one punch, shown in  FIG. 23 , one clip indicator, shown in  FIG. 24 , one inner tube, shown in  FIG. 25 , two jaws, shown in  FIG. 28  and one outer tube, shown in  FIG. 29 . Each of these parts are put together to form the applier shaft.  FIG. 30  shows the distal end of the shaft assembly and  FIG. 31  shows the proximal end of the shaft assembly. There is a varied length between the distal and proximal portions of the shaft which is a function of standard endoscopic instrumentation suitable for use in laparoscopic surgery applications. 
     The manual applier has a clip loaded into the applier before it can apply a clip. The clips may be loaded into the applier with, but are not limited to, the use of a clip cartridge where clips are presented to the applier in a particular orientation. A version of a clip cartridge, for illustration purposes only, is shown in  FIG. 32-36 . 
       FIG. 37  shows the distal end of the applier on approach to the cartridge and  FIG. 38  shows the distal end of the shaft in the clip load position. Following images will exclude the Clip cartridge so that the specific actuation of the individual parts can be seen. 
       FIG. 39  shows the applier in a free state which is the same state the applier will be in on approach to the clip cartridge. Note the location of the parts in the assembly as this will be used as a reference location of the parts during actuation of the applier (images not to scale). 
     The outer tube remains stationary and is the base for the shaft components. On the distal end of the outer tube there are spring fingers that force the wedges together as they move within the assembly. The end of the outer tube has two tabs with holes that the jaws mount into. 
     The inner tube is inserted into the outer tube and controls the actuation of the jaws, which are assembled to the distal end of the outer tube in the tabs on the end; see  FIG. 29  for tab location. The jaws use the hole in the tab of the outer tube as a bearing surface in which they rotate. As the inner tube is slid toward the proximal end of the shaft the jaws are cammed open and when the inner tube is slid distally the jaws are cammed closed, see  FIGS. 26 &amp; 27 . The actuation of the inner tube and jaws are independent of all other parts in the applier shaft. This allows the jaws to be used in grasping and dissecting with or without a clip in the load position. During the loading of the clip the jaws are fully open. 
     The clip is loaded into the distal end of the applier shaft by pressing the clip bosses into the clip catch. The catch is inserted into the outer and inner tubes. There are two sets of legs cut into the distal end of the catch, see  FIG. 22 . The legs on each side of the catch spread apart when the clip bosses are pressed into them. Once the clip bosses reach the circular cutout, on the distal end of the catch, the legs spring back together and capture the clip bosses. The catch also has tabs that orient the wedges. 
     During loading the clip is forced open by the fingers on the distal ends of the wedges, see  FIG. 21 . The wedges are inserted into the catch and orientated by the tabs on the catch to capture the upper and lower halves of the clip. The distal ends of the wedges are forced together by the spring fingers on the outer tube; this is where the force to open the clip comes from. The wedges capture and orient the punch, which in turn biases the wedges into the tabs of the catch, see  FIG. 56 . 
       FIG. 57  and  FIG. 59  show different views of a loaded clip in the applier with the jaws open. On the side of the outer tube there may be a view port cut into the shaft to allow a visual of a loaded clip. This would allow the presence of a clip to be confirmed through the use of a camera during a laparoscopic surgery without having to remove the applier to confirm. The view port is located to view the boss of a clip from either side of the applier and is position so the boss can only be viewed in the loaded position, see  FIG. 60 . 
     As the clip is loaded it presses against the clip indicator which is mounted inside the punch, see  FIG. 41 . The clip indicator is spring loaded so that the distal end is always biased toward the distal end of the applier until it is pushed against by the clip. When the clip is loaded a flag on the proximal end of the clip indicator signals the operator visually that the clip is present. 
     At this point the clip is loaded and the jaws can move freely without disturbing the clip, see  FIG. 41  and  FIG. 42 . The jaws are then used to grab the vessel intended to be ligated. The jaws flatten out and hold the vessel so that the loaded clip can be advanced over the vessel, closed, and locked. The compression of the vessel allows for a thinner cross-section for the clip to advance over and holds the vessel in place while the clip is being closed to ensure that the clip is fully seated on the vessel before it is locked. The jaws have half circle cutouts to allow fluid to flow out of the vessel when the clip is closed. This keeps the vessel from forming a “bubble” in the jaw cavity. 
     Once the jaws are closed on the vessel the clip is advanced into the jaws from the load location. The catch, wedges, and punch move toward the distal end of the shaft in unison, see  FIG. 43 . The legs of the clip are stopped by the inner end surface of the jaws. The catch then remains stationary as the wedges advance over the clip legs forcing the clip to close. At the same time the wedges are advancing the punch is advancing up to the buttress of the clip, see  FIG. 47 . Once the wedges have advance to their furthest point toward the distal end of the jaws the punch continues forward forcing the locking mechanism on the clip to rotate into the clip&#39;s locked position, see  FIG. 48-50 . 
     Once the clip is locked the wedges and catch begin to retract toward the proximal end of the applier shaft, see  FIG. 51 . Once they are fully retracted, see  FIG. 52 , the punch begins to retract toward the proximal end of the applier shaft, see  FIG. 53 . At this point the jaws can be opened and the clip is now free from the applier, see  FIG. 54 . At the same time the punch is quickly returned to its start position. The punch may be, but is not limited to being, spring loaded for the quick return. At this point, the punch is fully retracted and all parts are returned to their start positions, see  FIG. 55 . 
     In a second embodiment of the invention the wedges and catches are separate pieces attached to a catch tube, see  FIGS. 60-63 , and have the same forward actuation sequence as the first embodiment to lock the clip but does not require a dwell on the punch when the punch returns to the start position. In this embodiment the wedge and catch assembly stop just short of the clip stopping on the inner end surface of the jaws. The punch is then pushed forward to engage with the locking feature of the clip. The clip is first pushed out of the catch and wedges until the legs of the clip stop on the inner end surface of the jaws. The punch continues forward forcing the locking mechanism on the clip to rotate into the clip&#39;s locked position. During the rotation of the locking mechanism of the clip the legs are clamped together with the locking mechanism instead of the wedges as previously described. This embodiment also has internal leaf springs attached to the inner tube that bias the ends of the wedges together to open the clip during advance. 
     The proximal end of the applier, or applier handle, is made up of many parts that provide a user interface portion of the applier. Each of the distal end actuations are accomplished through the use of the proximal handle. 
     The handle has a two piece outer shell which stages the internal actuating components and provides a bearing surface for a multi stage transmission to allow 360° continuous rotation of the distal end. There is a two piece rotation knob clamped onto the distal portion of the multi stage transmission which is shaped to facilitate the 360° continuous rotation of the distal end. 
     In one embodiment of the handle there are two triggers, both triggers rotate around the same centroid, see  FIGS. 65-67 . The lower trigger actuates the jaws and the upper trigger actuates the clip delivery sequence. The lower trigger is attached to the multistage transmission through two mirrored linkages which have features that allow the trigger to lock down when the jaws are closed. This feature is an over center cam. The linkages also have an inner profile which allows them to drive the section of the multistage transmission that actuates the jaws while allowing the 360° continuous rotation. The return stroke of the lower trigger is accomplished through a return spring attached to a cable that wraps around the front of the trigger and based on a pin at the proximal side of the handle. There is a interlock on the upper trigger that locks the upper trigger until the lower trigger is pulled and locked down to ensure a clip is not prematurely delivered. The upper trigger is attached to the multistage transmission through a linkage which has and inner profile that drives the section of the multistage transmission that actuates the clip delivery mechanisms and also allows the 360° continuous rotation. The return stoke of the upper trigger is accomplished through a return spring attached to the back side of the trigger and based on a pin at the proximal side of the handle. For both the actuation and return strokes there is a one way pawl that limits the direction of the upper trigger until a full stroke is completed, see  FIGS. 65-68  for trigger and actuating components. 
     In a second embodiment of the handle, the trigger functions are reversed so that the upper trigger actuates the jaws and the lower trigger actuates the clip delivery mechanisms. 
     The distal portion of the applier is connected to the handle through the multi stage transmission, see  FIGS. 65-68 . One embodiment of the transmission is made up of a two piece outer shell which acts as the bearing to allow the rotation of the distal end. Internal to the shell are features that guide the internal components during the actuation sequences of the applier. There are two jaw links that connect to the inner tube of the distal end and provide the grove for the inner features of the lower trigger linkages. The jaw links snap together and ride on the internal surface of the transmission shell. The area between the jaw links is open to allow for additional transmission parts. There are two center spindles that snap together and attach to the wedges, the interior surface of the center spindles provide a guide for the spring loaded punch and the outer surfaces provide a guide for the catch pusher latch and the punch interlock. The catch pusher latch and the punch interlock move over the center spindles and are guided in slots on the outer shell of the transmission. Small pins move in and out of groves in the two pieces and the outer shell to achieve the appropriate timing for the clip delivery mechanisms in the shaft, see  FIGS. 69-76  for the transmission assembly and  FIGS. 77-86  for actuation sequence. 
     In a second embodiment of the transmission there is no punch latch interlock or return spring on the punch. The reduced movement of the wedges does not require a two stage pull back of the punch after the clip is locked. There is no requirement for the punch to dwell until the rest is pulled back because the clip is pushed out of the catch and wedges and released from the applier when the jaws are opened, see  FIGS. 87-88  for a view of the second embodiment of the transmission and  FIGS. 89-92  for the actuation sequence. A more detailed description of the apparatus shown in  FIGS. 16-97  will follow with reference to reference characters and FIGS. 
       FIG. 16  is a side view of an applier  1000  in accordance with an embodiment of the invention. The applier  1000  has a clam shell housing  1020 , a handle  1040 , a jaw trigger  1060 , and a ligate trigger  1080 . A jaw trigger  1060  and ligate trigger  1080  are actuated by pulling the triggers  1060  and  1080  toward the handle  1040 . Applier  1000  also includes a shaft  1120  which carries the jaws  1140  on the distal end  1160 , which is opposite from the proximal end  1180 . 
       FIG. 17  is a partial isometric view of the applier  1000  clamped onto a blood vessel  1580  or other tissue  1580 . The jaws  1140  have clamped onto and deformed the vessel  1580 . The portion of the shaft  1120  is also shown carrying the top jaw  1600  and the lower jaw  1620  which together comprise the jaws  1140 . 
       FIG. 18  is an isometric view of a clip  100  clamped onto a blood vessel  1580  or tissue  1580 . The clip  100  is in a clamping position and is attached to the vessel/tissue  1580 . The top leg or first leg  101  is shown above the second or bottom leg  102 . 
       FIG. 19  is a side view of a clip  100  clamped onto a vessel  1580  or tissue  1580 . The clamp  100  includes a top first leg  101  above the bottom or second leg  102 . The locked locks the first leg  101  and the second  102  is accomplished by locking the buttress body  150 . The buttress body  150  has moved to a position where the first rounded surface  148  is fit into a first recess groove  158 . Further, the protruding surface  156  is fit within the second recessed groove  146 . The first living hinge  1400  is deformed to allow a first rounded surface  148  and second protruding surface  156  to fit into the first recess groove  158  and second recess groove  146  respectively. The second living hinge  162  is deflected to permit the detent  157  to fit within the notch  147  as shown in a locking manner, thereby keeping the first leg  101  clamped and nearly in contact with the second leg  102 . 
       FIG. 20  is a side view of several of the parts used in the clamp applier  1000 . These parts are for the most part only partially shown and shown in a disassembled state. A top jaw  1600  and the bottom jaw  1620  are shown. The outer tube  1640  and the inner tube  1660  are also shown. The wedges  1680  including the top the wedge  1760  and bottom wedge  1780  are also shown. The catch  1700  is shown as well as the punch  1720 . At the bottom of  FIG. 20 , the clip indicator  1740  is shown. 
       FIG. 21  is a partial isometric view of the wedges  1680 , specifically the top wedge  1760 . In many embodiments in accordance with the invention, the top wedge  1760  is a mirror image of the bottom wedge  1780  and that the bottom wedge  1780  may be similar to the top wedge  1760  only placed in an in inverted position as shown in  FIG. 20 . Turning to  FIG. 21 , the top wedge  1760  includes a thicker portion  1820 , thicker portion  1820  may include a slanted surface  1840  which provides a transition between a thicker portion  1820  and the standard portion of the top wedge  1760 . In some embodiments of the invention and as shown  FIG. 21  the wedges  1680  may have a U-shaped cross-section resulting in a channel  1850 . At the proximal end  1880  of the wedge  1760  a bracket  1860  may be attached. The purpose of the bracket  1860  will be discussed in more detail later below. 
       FIG. 22  is a partial isometric view of catch  1700  in accordance with some embodiments of the invention. The catch  1700  may include a shaft portion  1900 . At the distal end  1920  of the catch  1700  there may be forked ends  1960  of the catch  1700 . The fork end  1960  may include a slot  2020 . The slot  2020  may start with a rounded cut out portion  2000  and terminate with a second cut out portion  2040 . The forked work end  1960  may start with slanted surfaces  1980 , but the proximal end  1940  of the catch  1700  there may be an attached bracket  1950  which will be shown in additional figures and discussed in more detail later below. The catch  1700  may also include guides  1970 . 
       FIG. 23  is a partial isometric view of the punch  1720 . The punch  1720  may include projections  2060  which project up from the punch  1720  at the top and bottom. As shown in  FIG. 23 , the punch  1720  may also have a longitudinal hole  2090  at the end as shown. The punch  1720  may also include a slot  2070  and a hole  2080  located at the opposite end of the punch  1720  and the longitudinal hole  2090 . 
       FIG. 24  is a partial isometric view of a clip indicator  1740 . The clip indicator  1740  may include a rectangular portion  2100  and a distal cylindrical portion  2140  and a proximal cylindrical portion  2120  located on the opposite side of the rectangular portion  2100 . 
       FIG. 25  is a partial isometric view of an inner tube  1660  in accordance with some of the embodiments of the invention. The inner tube  1660  may include a viewing port or a pair of viewing ports  2180 . The inner tube  1660  at the front end as oriented in  FIG. 25  may include a T-shaped structure  2200  located on both the top and the bottom as oriented in  FIG. 25  of the inner tube  1660  and U-shaped grooves  2220  on both the right and left side is oriented in  FIG. 25  of the inner tube  1660 . The inner tube  1660  may also include a longitudinal running slit  2230 . On the opposite end of the inner tube  1660  and the T-shape structures  2200  may be a bracket  2160  located on the approximate end of the inner tubes  1660 . The bracket  2160  may be shown in later figures and discussed in additional details later below. 
       FIG. 26  is a side view of the jaws  1140 . Atop jaw  1600  is located above the bottom jaw  1620  as shown in  FIG. 26 . Both the top  1600  and bottom  1620  jaws may include grooves  2240 . The jaws  1140  may include T-shape structure holes  2250  configured to accommodate and have T-shaped structure  2200  as shown and described in  FIG. 25 , as shown also in  FIG. 26 .  FIG. 26  also shows the first portion of the inner tube  1660  in the U-shaped groves  2220  as described with respect to the inner tube  1660  in  FIG. 25 . 
       FIG. 27  is a partial close up view of a portion of  FIG. 26 . In  FIG. 27 , the top jaw  1600  is shown with the T-shape structure  2200  of the inner tube  1660 . The T-shape structure  2200  is shown in the T-shape structure hole  2250 . The T-shape structure hole  2250  has a geometry that allows the jaws  1140  to open and close while the T-shape structure  2200  remains within the T-shape structure holes  2250 . The top jaw  1600  also has a caming surface  2280  that cams against a caming surface  2260  of the inner tubes  1660  as the jaws  1140  opens and closes. While only a partial close-up view of the top jaw  1600  is shown, one of ordinary skill in the art will understand that the bottom jaw  1520  is similarly configured in a mirror type image fashion. The top jaw  1600  also engages a bottom jaw  1620  at a push point  2300  when the jaws  1140  open and close. 
       FIGS. 28 a , 28 b  and 28 c    are isometric top and bottom views of the top jaw  1600 . The top jaw  1600  includes the T-shape structure hole  2250 , hinge pin  2620  and hinge pin cap  2630  as shown in the various views. In some instances, in the FIGS. the hinge pin cap  2630  has been removed to expose the hinge pin  2620 . 
       FIG. 29  is a partial isometric view of the outer tube  1640 . The outer tube  1640  may include a viewing port  2320 , spring legs  2420  which in some embodiments bias the wedges  1680  to a radially inward position. The outer tube  1640  may also include eye brackets  2340  having holes  2400 . The eye brackets  2340  and holes  2400  may be used for attaching the jaws  1140 . Inner tube  1640  also includes a shaft portion  2360  and a rim  2380  located at the end of the shaft  2360 . 
       FIG. 30  is a partial isometric view of the applier  1000  in a partially assembled state. As shown in  FIG. 30 , an outer tube  1640  with the jaws  1140  comprising of the top jaw  1600 , the lower jaw  1620 . The jaws  1140  contain the clip  100 . The catch  1700  is located behind the clip  100 . The punch  1720  is shown along with the hole  2090  in the end of the punch  1720 . The distal cylindrical portion  2140  of the clip indicator  1740  is shown, located in the slot  2070 . 
       FIG. 31  is a partial isometric view of the applier  1000  where some of the outer portions removed so the inner portions can be shown. The applier  1000  includes the outer tubes  1640 , the wedges  1680  are shown inside the outer tubes  1640 . Within the wedges  1680 , the punch  1720  is shown, the slot  2070  is shown with the rectangular portion  2100  fit into the slot  2070  from the punch  1720 . A spring  2440  is located forward of the rectangular portion  2100 . A hole  2080  in the punch  1720  is shown with a pin  2460  located in the hole  2080 . The top wedge  1760  and bottom wedge  1780  are also shown along the brackets  1860  attached to the top wedge  1760  and bottom wedge  1780 . 
     The manual applier  1000  attains the clip  100  from a cartridge  2480  as shown in  FIG. 32 . The clips  100  are removed from the cartridge ports  2500  and the cartridge  2480  and placed into the applier  1000 . The loading process will be illustrated in  FIGS. 33-38 . 
     In  FIG. 33  a cross-sectional view of the cartridge  2480  is shown. The cartridge ports  2500  is shown having a clip  100  inside the cartridge port  2500 . A detent  2520  holds the cartridge  100  within the cartridge port  2500 . 
       FIG. 34  is a cross-sectional view of the cartridge  2480  showing the detent  2520  securing the cartridge  100  within the cartridge port  2500 . 
       FIG. 35  is an end view of the cartridge  2480 . 
       FIG. 36  is a side view of the cartridge  2480  showing the cartridges  100  located in the cartridge port  2500 . Protrusions  2540  are also shown on the cartridge  2480 . 
       FIG. 37  is a partial cross-sectional view of cartridge  2480 , showing the applier  1000  approaching the cartridge  2480  in order to obtain clip  100  from the cartridge  2480 . The jaws  1140  of the applier  1000  are open and approaches the cartridge port  2500  in order to obtain a cartridge  100 . 
       FIG. 38  is a cross-sectional view of a cartridge  2480  where the applier  1000  as entered the cartridge port  2500  in order to obtain a clip  100 . The applier  1000  has moved into the cartridge port  2500 . The jaws  1140  have entered the jaw channels  2560  and the clip  100  is now inside the applier  1000 . 
       FIG. 39  is a partial cross-sectional view of the applier  1000  as it approaches the clip cartridge  2480 . The jaws  1140  are in an open position. The inner tube  1660  has moved to a forward position causing jaws  1140  to open. The catch  1700  is in a position ready to receive the clip  100  (not shown in  FIG. 39 ). 
       FIG. 40  is a partial cross-sectional view of the applier  1000  as it loads the clip  100 . The cartridge has not been shown for clarity. The jaws  1140  are in an open position. While the clip  100  is shown in a closed position, in reality the standard position for some clip in accordance with the invention and as should be shown in  FIG. 40  is in a slightly open position, not fully opened and not fully closed. In other embodiments of the invention, the clip  100  may be in other positions. 
       FIG. 41  is a partial cross-sectional view of the applier  1000  with a clip  100  lowered inside. The distal cylindrical portion  2140  of the clip indicator  1740  is in contact with the buttress body  150  of the clip  100 . 
       FIG. 42  is a partial cross-sectional side view of the applier  1000 , showing the clip inside the applier  1000  and the jaws  1140  closed. 
       FIG. 43  is a close up view of the jaws  1140  of the applier  1000 , showing that the jaws  1140  have closed over a vessel or tissue  1580 . The clip  100  is starting to advance into the jaws  1140 . 
       FIG. 44  is a close up cross-sectional partial view of the applier  1000  showing the jaws  1140  clamped or a vessel or tissue  1580 . The clip  100  has advanced into the jaws  1140  and the wedges  1760  and  1780  have started to move into the jaws  1140 . 
       FIG. 45  is a partial cross-sectional view of the jaws  1140  of the applier  1000  showing the clip  100  has advanced into jaws  1140 . The vessel or tissue  1580  is currently being clamped by the jaws  1140  but not the clip  100 . The upper leg  101  of the jaw  100  is contacting the inner slanted surface  2580  and the lower leg  102  is contacting the inner slanted surface  2600  of the jaws  1140 . The wedges  1760  and  1780  continue to advance to close the clip  100 , the thick portions  1820  have moved into the jaws  1140  sufficient so that as the punch continues to urge on the clip  100 , the thick portions  1820  will not be in the way of the legs  101  and  102  of the clip  100  from shutting. 
       FIG. 46  is a partial cut away of the applier  1000  and the jaws  1140 , where the leg  101 , the lower leg  102  have closed to clamp onto the vessel or tissue  1580 . 
     As best shown in  FIG. 47 , the punch  1720  pushes the clip  100  forward and continues to push against the buttress body  150  to cause the clip  100  to lock in a clamping position. As shown in  FIG. 47 , the wedges  1760  and  1780  have advanced far enough to not prevent the clip  100  from locking. 
       FIG. 48  illustrates punch  1720  continuing to move the buttress body  150  toward a latching position on the clip  100 . 
       FIG. 49  shows the punch  1720  continuing to move the buttress body  150  so that the detent  157  moves towards the notch  147  and the clip. 
       FIG. 50  shows the punch  1720  moving the buttress body  150  sufficiently forward such that the detent  157  is locked into the notch  147 , thereby locking the clip  100  in a closed position. 
       FIG. 51  shows the wedges  1760  and  1780  retracting into the applier  1000  leaving the clip  100  in place. 
       FIG. 52  shows the wedges  1760  and  1780  in a fully retracted position within the applier  1000  and the clip  100  in place in the jaws  1140 . 
       FIG. 53  shows the punch  1720  retreating away from the clip  100  into the applier  1000 . 
       FIG. 54  illustrates the jaws  1140  on the applier  1000  opening exposing the clip  100 . Removal of the applier  1000  to the right as shown in  FIG. 54  will leave the clip  100  in place and it will be able to exit the applier  1000 . 
       FIG. 55  shows the jaws  1140  in an open position, the punch  1720  is fully retreated into the applier  1000 . 
       FIG. 56  is a front view of the applier  1000  showing various portions of the applier  1000 , for example the outer tube  1640  is shown. The catch  1700  is also shown as well as the spring legs  2420  of the outer tube  1640 . The punch  1720  can also be seen. Projections  2060  are shown to be riding in the wedges  1760  and  1780 . The wedge guides  1970  can also be shown as part of the wedges  1680 . Inner tube  1660  is also illustrated. 
       FIG. 57  is an end-view of the applier  1000 , the jaws  1600  and  1620  are open and the clip  100  is within the applier  1000 . The top jaw  1600  and bottom jaw  1620  are in an open position. The outer tube  1640  is shown. The hinge pin  2620  of the jaws  1600  and  1620  are shown. The hinge pin  2620  connects the upper jaw  1600  and the lower jaw  1620  to the eye brackets  2340  on the outer tube  1640 . The clip  100  as shown the upper leg  101  and the lower  102  in the spread part, open position. 
       FIG. 58  is an isometric view of the distal end  1160  of the applier  1000 . The viewing port  2180  can be seen in the outer tube  1640 . The viewing port  2180  allows the user to see if there is a clip  100  in the applier  1000  or whether, as shown in  FIG. 58 , there is no clip in the applier  1000 . The punch  1720  can be seen along with the projections  2060  of the punch  1720 , the projections are riding in the wedge  1680 . The slot  2020  can be seen in the catch  1700 . 
       FIG. 59  is similar to  FIG. 58  with the exception that a clip  100  is shown within the applier  1000 . The distal end  1180  of the applier  1000  is shown. The first leg  101  and the second leg  102  of the clip  100  in the open position. The jaws  1140  of the applier  1000  are also shown in the open position. 
       FIG. 60  is a side-view of a portion of the applier  1000 . The viewing port  2180  in the outer housing  1640  allows a user to see that a clip  100  is loaded into the applier  1000 . The eye brackets  2340  of the outer tube  1640  are also seen, the jaws  1140  are in the open position. 
       FIG. 61  illustrates another embodiment of the applier  1000  where the wedges  1760  and  1780  and catch  1700  are visible in a cutaway. As shown in  FIG. 61  applier  1000  has an outer tube  1640 . The top wedge  1760  and bottom wedge  1780  are both located in the applier  1000 . Spring legs  2420  are located on the outer tube  1640  and configured compress wedges  1760  and  1780  as the wedges  1760  and  1780  pass by. The spring legs  2420  push the wedges  1760  and  1780  inward towards each other. Catch  1700  is also shown. The thicker portion  1820  of the wedges  1760  and  1780  are also shown. The thicker portions  1820  will actuate part of the clip  100  (as shown in  FIG. 61 ) as the wedges pass by the spring legs  2420 . The punch  1720  can be seen as well as the catch  1700 . A spring loaded tab  2640  connects the catch  1700  to the outer tube  1640 . 
       FIG. 62  illustrates another view of the embodiment shown in  FIG. 61  of the applier  1000 . In this embodiment there is a catch wedge combination  2700 . The catch  1700  is connected to the wedges  1680 . The forked end  1960  of the catch  1700  can be shown as well as the slot  2020 . The spring loaded button or tab  2640  is shown or tabbed and shown connecting the catch wedge combination  1700  to the outer tube  1640 . 
     In  FIG. 63  the outer tube  1640  has been removed to better show the catch wedge combination  2700 . The upper wedge  1760  and lower wedge  1780  are shown and they are integrated with the catch  1700 . The spring loaded tab  2640  is shown as well as the flex spring  2680  which connects the spring loaded tab  2640  to the catch wedge combination  2700 . 
       FIG. 64  is a side-view illustrating a proximal end  1180  of a portion of the applier  1000 . The applier  1000  includes a housing  1020  which in some embodiments may be a clam shell type housing. A handle  1040  is also included along with a jaw actuating trigger  1060  and a ligate trigger  1080 . A transmission housing  1100 , houses a transmission to be discussed later and provides a transition between the housing  1020  and the shaft  1120 . 
       FIG. 65  illustrates a portion of the applier  1000  as shown in  FIG. 64 , however, part of the housing  1020  is removed in order to illustrate interior components. 
       FIG. 66  is an exploded view of the interior components. 
       FIG. 67  is similar to  FIG. 65  in that the housing  1020  has been removed. 
       FIG. 68  illustrates interior components where the housing  1020  is removed. 
     The following description will apply to  FIGS. 65-68 , however, not all of the reference numerals may be called out in all the figures nor will they be necessary be all visible in  FIGS. 65-68 . Both the jaw triggers  1060  and the ligate trigger  1080  pivot about the trigger pivot shaft  2940 . The user may pull either ligate trigger  1080  or the jaw trigger  1160  toward the handle  1040 . Both of these triggers are spring loaded. There is a ligate lever spring  2760  and a grasper lever spring  2770  which bias the triggers  1080  and  1060  to an outward position. However, the triggers do not always remain in an outward position, even when a user has let go of the triggers  1080  and  1060  due to the ratchet plates  2800 . The ratchet plates  2800  are similar but have slightly different ratcheting systems that will be described herein. Ratchet plates  2800  contain ratchet teeth  2860 . The ratchet plates  2800  are connected to a spring bias first pawl  2880  and second pawl  2890 . The first pawl  2880  and the second pawl  2890  are connected by a pawl pivot pin  2900 . The first and second pawls  2880  and  2890  are spring loaded by a pawl spring  2910  which urges against a pawl spring anchor  2930  which is attached to the back of the housing  2720 . The first pawl  2880  engages the ratchet teeth  2860  until a pawl lift projection  2920  lifts either the first pawl  2880  or the second pawl  2890 . When the first pawl was disengaged by the pawl lift projection  2920  then the second pawl  2890  is engaged with the ratchet teeth  2860 . If it is the second pawl  2890  that is disengaged with the ratchet teeth  2860  by the pawl lift projection  2920 , than the first pawl  2880  becomes engaged with the ratchet teeth  2860 . In this manner, the first pawl  2880  prevents undesired trigger movement in one direction and the second pawl  2890  prevents undesired trigger movement in the second direction. 
     Ratchet plates  2800  are connected to the ligate lever pivot shaft  2980  via pivot pins  2820 . The pivot pins  2820  have locking clamps  2840  to prevent the pivot pins  2820  from disengaging or coming off the ratchet plates  2800 . Though ligate lever pivot shaft  2980  includes a ligate lever slot  3140  and allows the pivot pins  2820  to slide through ligate lever slot  3140 , the dimensions of the ligate lever slot  3140  may be selected to achieve desired inputs into the transmission which will be described in further detail below. The ligate trigger  2800  also has a trigger interlock projection  3120  just configured to interacting lock with the trigger lock  3080 . The trigger lock  3080  is biased by a spring  2780  to a forward position. The trigger lock  3080  includes a trigger interlock hook  3100  which interacts with the trigger interlock projection  3100  to lock the ligate trigger  1080  with a ligate trigger  1080  is at a specific position. The specific dimensions of the ligate trigger interlock projection  3120  and the trigger interlock may be selected in order to provide a desired input into transmission  3180  one of ordinary skill in the art. A jaw trigger  1060  is connected to a grasper lever  3000 . The grasper lever  3000  includes a grasper lever pivot shaft  3020  and a curve slot  3040 . A curved slot pin  3060  may travel through the curved slot  3040  and is acted upon by spring extension  3160  which is controlled by the grasper lever spring  2770 . Actuation of the jaw trigger  1060  will cause the grasper lever  3000  and the grasper lever pivot shaft  3020  to act upon the transmission  3180  to provide input to the transmission  3180  which will be discussed further detail below. 
     In some the components described and as shown in  FIGS. 65-68  are designed to provide inputs into the transmission  3180 . Various connecting mechanisms may be used to connect various inputs such as the ligate trigger  1080  and the jaw trigger  1060  provide inputs to a transmission  3180  to actuate the applier  1000  in a manner desired by a user. The ligate lever spring  2760  and grasper lever spring  2770  may be anchored to the housing by the spring anchors  2740 . The size and dimension of the curve slot  3040  can be selected by one of ordinary skill in the art in order to provide the desired input into the transmission  3180  at a desired trigger  1060  position. 
     As shown specifically in  FIG. 68 , a grasper lever pivot shaft  3020  engages the jaw actuator link  3200  of the transmission  3180 . The center actuator link  3220  engages the ligate lever  2960  via the pivot pins  2820 . In some embodiments of the invention, the pawls  2880  and  2890  and the ratchet teeth  2860  along with the pawl lift projection  2920  are configured so that once the ligate trigger  1080  starts to move in a direction, it cannot reverse course until it is completed movement in that direction and, at that point, it may reverse course. In other words, once the user starts to pull that trigger  1060 ,  1080 , the trigger  1060 ,  1080  may not move forward until the trigger  1060 ,  1080  has first become all the way back. Once the trigger  1060 ,  1080  has come all the way back, then it may move forward, but once a trigger  1060 ,  1080  starts a forward position it cannot move back until it first moves all the way forward. 
       FIG. 69  is an exploded view of the transmission  3180  according to an embodiment of the invention. The transmission  3180  includes an outer clam shell housing  3240  and  3260 . The Leur port  3320  connects to a hole  3340  in the clam shell housing  3240 . The Leur port  3320  is used to connect the transmission  3180  to a cleaning fluid for flushing and cleaning not only the transmission  3180  but the entire applier  1000  between uses. Cleaning of surgical tools as well known in the art and will not be described further here. Inside the outer clam shells  3240  and  3260  are jaw actuator links  3280  and  3300 , they are also in a clam shell configuration. The jaw actuator links  3300  and  3280  include attaching structure  3360  at the front for attaching to various components which will be described later. The jaw actuator links  3300  and  3280  also define a jaw actuator input  3200 . The jaw actuator input  3200  defines an engaging groove  3380  which allows the jaw actuator input  3200  to attach to pin  3020  as shown in  FIG. 68 . In the jaw actuating links  3280  and  3300 , between the jaw actuator links  3280  and  3300  and the catch pusher latches  3400  and  3420  are connecting pins  3460 . Connecting pins  3460  reside in slots  3440  in the catch pusher latches  3400  and  3420 . The catch pusher latches  3400  and  3420  also include attaching structure  3430  for attaching components which will be described later below. The catch pusher latches  3400  and  3420  contain the center spindle  3600 . The center spindle  3600  is attached to the center actuator link  3220 . Center actuator link  3220  is connected to pivot pins  2820  (shown in  FIG. 66 ) which allows the center actuator link  3220  to be actuated by a user. The center spindle  3600  also houses and is attached to punch return spring  3580 . A punch latch interlock  3480  attaches to the center spindle  3600  and provides slots  3520  for pins  3500  to reside. The punch latch interlock  3480  also defines a pin slot  3540  for pin  2460 . The purpose for these pins and slots will be described in more detail later blow. 
       FIG. 70  is a perspective view of transmission  3180 . The outer clam shell housing  3240  and  3260  are shown as well as the Leur port  3320 . The jaw actuator input  3200 , the center spindle  3600  and the center actuator link  3220  are also shown. 
     In  FIG. 71  the outer clam shell housing  3240  and  3260  have been removed in order to better show the interior components. The jaw actuator links  3280  and  3300  are shown as well as the catch punch latches  3420 , the pin grooves  3520  and punch latch interlock pins  3500  are set therein. The slot  3440  is also shown with the connecting pin  3460  shown therein. The jaw actuator link  3200 , the center spindle  3600  and the center actuator link  3220  are also shown. 
     In  FIG. 72 , the jaw actuator link is removed to better show various aspects of the transmission  3180 . Other features are also shown in showing connections to the transmission. For example, the outer tubes  1640  is shown with the rim  2380 . The brackets  2160  on the proximate end of the inner tube  1660  are also shown as well as the catch  1700  connected to the transmission  3180 . The catch puncher latches  3400  and  3420  are also shown as well as the center actuator link  3220 . 
     In  FIG. 73 , the catch pusher latches are removed. The outer tube  1640  is shown as well as the inner tube  1660  and the attaching brackets  2160  are attached to the inner tube  1660 . The catch  1700  is shown having its attaching brackets  1950  also shown. The punch latch interlock  3480  is shown as well as the punch latch interlock pins  3500 . The pin slot  3540  and the connecting pin  3460  residing in the pin slot  3540 . The punch latch interlock  3480  is attached to and carried on the center spindle  3600 . 
     In  FIG. 74 , the punch latch interlock and pins are removed thus showing the center spindle  3600 , the pin  2460  residing in a pin slot  3540 . The wedges  1680  can also be seen in part. 
     In  FIG. 75 , the center spindle  3600  has been removed. The top  1760  and bottom  1780  wedges are shown and the punch  1720  is shown in between the top  1760  and bottom wedge  1780 . The hole  2080  in the punch  1720  is the same hole  2080  in which the pin  2460  shown in  FIG. 74  resides. The punch return spring  3580  is also shown urging against the punch  1720  and fit between the wedges  1760  and  1780 . Connecting brackets  1860  on the wedges  1760  and  1780  are also shown. Connecting brackets  1860  connect the wedges  1760  and  1780  to the center spindle  3600  found in  FIG. 74 . 
       FIG. 76  is similar to  FIG. 75  but it shows the punch return spring  3580  removed. The outer tube  1640  is shown along with the rim  2380 . The inner tube  1660  is shown with the brackets  2160  on the approximate end of the inner tube  1660 . The catch  1700  is shown along with the attaching bracket  1950 . The punch  1720  is also shown riding along in between the top wedge  1760  and bottom wedge  1780 . The hole  2080  and the punch  1720  is also shown. The connecting bracket  1860  on the wedges  1760  and  1780  are also shown. The transmission is, for the most part, absent from the drawing shown in  FIG. 76 , but rather the only components left are those the transmission connects to and provides movement to. 
       FIG. 77  is a cross-sectional view of the transmission  3180  and various elements that the transmission connects to. In  FIG. 77 , the outer clam shell housing  3240  and  3260  are shown as well as the jaw actuator link clam shell  3380  and the jaw actuator input  3200 . The jaw actuator link or input  3200  is not contacting the outer clam shell housing  3240  and  3260 . The actuator link or input  3380  is in a position to allow the jaws (not shown in  FIG. 77 ) being open in order to load a clip  100  (not shown) into the applier  1000 . 
       FIG. 78  is a cross-sectional view of the transmission  3180  where the jaws  1140  (not shown in  FIG. 77 ) are closed. The jaw actuator link or input  3200  has moved forward and is contacting the outer clam shell housing  3240  and  3260 . Note that the center actuator link  3220  riding on the center spindle  3600  is about the same distance from the jaw link or input  3380  as shown in  FIG. 77 . Thus the center actuator link  3220  moved forward about the same distance as the jaw actuator link or input  3380  when it moved up against the outer clam shell housing  3240  and  3260 . 
       FIG. 79  is a cross-sectional view of a transmission  3180  where the center spindle  3600  has advanced. The jaw actuator link or input  3200  is still pressed against the outer clams shell housing  3240  and  3260 . The connecting pin  3460  resides within the pocket  3680  in the outer shell  3240  and  3260 . Further, punch latch interlock pins  3500  have cam surfaces  3700  and will urge against the fingers  3720  on the outer shell  3240  and  3260 . As the center spindle  3600  advances, the catch pusher latch  3420  and the punch latch interlock  3480  move forward. Tension begins to build in the punch return spring  3580 . The pins  3460  and  3500  are pins that act as connection points to allow everything to advance together and thus the clip  100  (not shown in  FIG. 79 ) is advanced. 
     Turning now to  FIG. 80  the transmission  3180  is shown where the clip  100  (not shown in  FIG. 80 ) is closed. The center spindle  3600  continues to advance by actuation of the center, actuator link  3220 . The catch pusher latch  3420  disengages as the pins  3460  come out of the pocket  3780  of the outer shell  3240  and  3260 . Thus, the catch pusher latch  3420  stops. The punch latch interlock  3480  moves forward and the cam surface  3700  causes the  FIG. 3720  of the outer shell  3240  and  3260  to move aside and allow a punch latch interlock  3480  to move forward. While the fingers  3720  in the outer shell  3240  and  3260  are not shown in a more spread apart position in  FIG. 80 , they should be as they have moved regularly outward slightly by way of the caming surface  3700  acting upon the fingers  3720 . 
       FIG. 81  illustrates a position of the transmission  3180  where the clip  100  (not shown) is latched. The center spindle  3600  is fully advanced by means of the center actuator link  3220  being pressed forward into the transmission  3180 . The punch latch interlock  3480  moves forward and the punch latch interlock pins  3500  moves forward and drop into pockets  3740  behind the outer shell fingers  3720 . 
       FIG. 82  illustrates the transmission  3180  when the wedges  1680  return. The center spindle  3600  moves outward by the input placed on the center link  3220 . The jaw actuator link or input  3200  remains in a position but up against the outer clam shell housing  3240  and  3260 . The punch latch interlock  3480  stays in position. The catch pusher latch  3420  began to return allowing the connecting pins  3460  to return to the pin connecting groove  3780 . 
       FIG. 83  illustrates the transmission  3180 . The center spindle  3600  continues to return via an input on the center actuator link  3220 . A jaw actuator or link  3200  is still butted against the outer clam shell housing  3240  and  3260 . The punch latch interlock  3480  continues to pull back and the catch pusher latch  3420  continues to return. The punch latch interlock pins  3500  cause the fingers  3720  on the outer shell  3240  and  3260  to spread apart. The connecting pins  3460  are no longer in the pocket  3680  of the outer shell  3240  or  3260 . 
       FIG. 84  shows the position of the transmission  3180  where the punch  1720  is unlatched. The center spindle  3600  continues to return to an extended position. The punch latch interlock  3480  continues to pull back. The catch pusher latch  3400  continues to return. The pins  3500  force the fingers  3720  apart. 
       FIG. 85  illustrates a transmission  3180  in a position to free the clip  100  (not shown). The center spindle  3600  reaches a fully extended end position by input placed on the center spindle  3220 . A punch latch interlock  3480  continues to pull back. The catch pusher latch  3400  reaches an end position. The punch latch interlock pins  3500  are passed the fingers  3720  and the outer shell  3240  and  3260  and the punch latch interlock  3480  is therefore free to return. 
       FIG. 86  illustrates the transmission  3180  in a position for the punch return spring  3580  to be relieved. A center spindle  3600  is at the end position. The punch latch interlock  3480  pulls back to an end position under force from the extension spring of punch return spring  3580 . 
       FIG. 87  illustrates a second embodiment of the transmission  3180  wherein the second embodiment there is no punch latch interlock. As shown in  FIG. 87 , part of the clam shell housing  3260  is removed to expose interior elements. The outer clam shell housing  3240  is shown along with various elements such as but not limited to a jaw actuator input link  3200 , the center spindle  3600  and the center actuator link  3220 . 
       FIG. 88  is an exploded view of a transmission  3180  in accordance within a second embodiment.  FIG. 88  shows outer clam shell housing  3260  and  3240 . The outer clam shell housing  3240  has a hole  3340  for connecting to a Leur port  3320  which is used to connect a cleaning device with cleaning solution to clean a transmission and a  3180  and the rest of the tool. Cleaning of surgical tools will not be discussed in detail here. 
     Inside the outer clam shell housing  3260  and  3240  are jaw actuator links  3280  and  3300 . The jaw actuator links  3280  and  3300  include attaching structure  3360  at one end and jaw actuator input link  3200  at another end. The jaw actuator input or link  3200  includes an engaging groove  3380 . Between the jaw actuator links  3280  and  3300  resides a connecting pin  3460  for connecting the jaw actuator links  3280  and  3300  with catch puncher latches  3400  and  3420 . The catch puncher latches  3400  and  3420  include attaching structure  3430  at one end. The catch puncher latches  3400  and  3420  also include slots  3440  for the pin  3460 . The catch puncher latches  3420  and  3400  house the center spindles  3640  and  3660 . The center spindles  3640  and  3660  may be in a clam shell configuration as shown and may entrap a pin  3460 . 
       FIG. 89  is a side cross-sectional view of the transmission  3180  according to the second embodiment. The jaw actuator link or input  3200  is shown spaced away from the outer clam shell  3240 . The center spindle clam shell  3640  and  3660  as shown as well as the center actuator link  3220 . The jaws  1140  are open when the transmission  3180  is in the position as shown in  FIG. 89 . The clip  100  (not shown) may be loaded when the jaws  1140  are open in the transmission  3180  is in the position shown in  FIG. 89 . 
       FIG. 90  shows a transmission  3180  in an position where the jaws  1140  are closed and the clip  100  may be loaded inside the jaws  1140 . The jaw actuator link  3200  is pressed against the clam shell housing  3240  and  3260 . The center spindle clam shell  3640  and  3660  are shown and carry the center actuator link  3220 . Center actuator link  3220  and the jaw actuator link or input  3200  are located about the same distance from each other in  FIG. 90  as they are shown in  FIG. 89 . 
       FIG. 91  shows a side view of the transmission  3180  where the clip  100  advances into the jaws  1140 . The wedges  1680  and catch  1700  (not shown in  FIG. 91 ) can move together. The center spindle  3640  and  3660  began to advance by an input placed on the center actuator link  3220 . The jaw actuator link or input  3200  remains in position. Connecting pins  3460  are in the pocket  3680  in the outer shell  3240  and  3260 . The locking pin grooves  3760  moved away from the connecting pin  3460 . The punch  1720  and catch puncher latch  3420  and  3400  work together. 
       FIG. 92  is a side sectional view of transmission  3180  and the clip  100  (not shown) is closed or latched. The center spindle  3640  and  3660  continues to advance. Connecting pins  3460  are located in the pockets  3680  in the outer shell  3240  and  3260 . The catch puncher latch  3400  stops. The punch  1720  continues forward with the center spindle  3640  and  3660  until the clip  100  (not shown) is latched, everything returns in reverse order after latching. 
       FIG. 93  is a side view with part of the housing removed of the applier  1000 . The jaws  1140  are shown on the shaft  1120 . The shaft  1120  extends from the transmission housing  1100 . Part of the housing  1020  is open to show interior elements. The ligate trigger  1080  is shown as well as the jaw trigger  1060 . The applier  1000  as shown in  FIG. 93 , shows the applier  1000  ready to receive a clip  100  as shown. 
       FIG. 94  is a side view of an applier  1000  with part of the transmission housing  1100  and clam shell housing  1120  removed to show interior elements. Applier  1000  is retrieving a clip  100  (not shown) from a cartridge  2480  into the jaws  1140  of the applier  1000 . The ligate trigger  1080  is shown as well as the jaw trigger  1160 . Position of the jaw trigger  1160  and the ligate trigger  1080  are shown when the applier  1000  is in a cartridge loading position. 
       FIG. 95  is a side view of the applier  1000 . The transmission housing  1100  is cut away and the clam shell housing  1020  is cut away to show positions of interior elements. Part of the jaws  1140  and the top part of the shaft  1120  are missing to better show interior elements. The positions of the ligate trigger  1080  and the jaw trigger  1060  are shown where the applier  1000  is ready to have the clip  100  to move forward into the jaws  1140 . 
       FIG. 96  illustrates an applier  1000  where part of the transmission housing  1100 , clam shell housing  1020 , the shaft  1120  and the jaws  1140  are missing. The ligate trigger  1080  and the jaw trigger  1060  are in a position for allowing the clip  100  to move forward. 
     The applier  1000  shown in  FIG. 97  shows an applier where the ligate trigger  1080  and the jaw actuator  1060  are in a position where the clip  100  (not shown) is to be latched. Transmission housing  1100  and the clam shell housing  1020  are shown intact. 
     In another embodiment, a different clip  12000  and adapter  12040  is used. This clip  12000  and adapter  12040  is shown and described in  FIGS. 98-122 .  FIG. 98  shows a side view of the clip  12000 . The clip  12000  includes an upper leg  12002  and a lower leg  12004 . Both legs  12002  and  12004  include teeth  12006  and grooves  12007 . The upper leg  12002  includes an upper front end and  12008  in the lower leg  12004  includes a lower front and  12010 . The upper front end  12008  includes an upper slanted edge  12012  and the lower front end  12010  includes a lower slanted edge  12014 . The upper leg  12002  and the lower leg  12004  pivot about a hinge portion  12016  which is part of a body portion  12018 . 
     The body portion  12018  includes a locking void  12020 . The clip  12000  is locked by moving a buttress  12022  into the locking void  12020 . The buttress  12022  includes a buttress void  12024 . The body portion  12018  includes locking wings  12026 . The locking wings  12026  help retain the buttress  12022  into the locking void  12020  when the clip  12000  is in a locking position. The buttress void  12024  includes locking interior surfaces  12030 . The buttress  12022  includes locking exterior surfaces  12032 . When the buttress  12022  is in the buttress void  12024  the locking interior surfaces  12030  and the locking exterior surfaces  12032  will be in contact with each other. 
     The buttress  12022  is attached to the body portion  12018  the connectors  12034 . The connectors  12034  are resilient and will flex to permit the movement of the buttress  12022  with respect to the body portion  12018 . The connectors  12034  are equipped with projections  12036 . The projections  12036  are useful when the clips  12000  are arranged in an automatic applier in a nose to tail fashion. In such an instance, the upper front end  12008  and lower front end  12010  of a clip  12000  behind a first clip  12000  will engage the projections  12036  of the clip  12000  in front. 
       FIG. 99  illustrates a top view of the clip  12000 . The upper leg  12002  and the upper front end  12008  are visible. The connector  12034  connecting the buttress  12022  and having the projection  12036  is also shown in  FIG. 99 . 
       FIG. 100  illustrates an isometric view of the clip  12000 . The upper leg  12002 , the lower leg  12004 , the grooves  12007 , and teeth  12006  are visible. The lower slanted edge  12014  can also be seen. The hinge portion  12016 , the buttress void  12024 , and the buttress  12022  are also visible in the isometric view shown in  FIG. 100 . 
       FIGS. 101 and 102  illustrate the clip  12000  clamping onto a vessel  12038 . The grooves and teeth are not shown and are removed for clarity in  FIGS. 101 and 102 . The vessel  12038  is clamped between the upper leg  12002  and the lower leg  12004 . The buttress  12022  has been moved into the buttress avoid  12024  causing the locking interior surfaces  12030  and a locking exterior surfaces  12032  to be in contact with each other. Movement of the buttress  12022  into the buttress avoid  12024  has caused the upper leg  12002  and the lower leg  12004  to be locked in a closed position. It will be appreciated that closing of the clip  12000  will cause the hinge portion  12016  to rotate thereby enlarging the buttress avoid  12024  and allowing the buttress  12022  to be pushed or moved into the buttress void  12024  thereby locking the clip  12000  in the closed position. Once the clip  12000  is in the closed position the vessel  12028  is clamped. 
     A manual applier  12040  may be used with the clip  12000  shown and described in  FIGS. 98 through 102 . A partial isometric view of a manual applier  12040  that may be used with the clip  12000  is shown in  FIG. 103 . The manual applier  12040  includes a pair of jaws  12042 . The jaws  12042  may include an upper jaw  12044  and a lower jaw  12046 . The jaws  12042  may be pivotally attached to a distal locking clevis tube  12048 . The distal locking clevis tube  12048  may include a boss  12050  having a hole  12052 . The distal locking clevis tube  12048  may also include a slot  12054  through which part of the jaws  12042  extend. The jaws  12042  may attached to the distal locking clevis tube  12048  via a pivot rivet  12056  extending through the hole  12052  in the distal locking clevis tube  12048  and the jaws  12042 . Behind distal locking clevis tube  12048  is a proximal locking clevis tube  12058  and an actuation shaft  12108  (See  FIG. 117 ). 
       FIG. 104  illustrates a shaft tube assembly  12060 . The shaft tube assembly  12060  includes a handle interface  12062  located at the proximal end  12064  of the shaft tube assembly  12060 . The shaft tube assembly  12060  also includes a distal end  12066 . In some embodiments, the shaft tube assembly  12060  fits over the actuation shaft  12108  (hidden in  FIG. 117 ) and part of the proximal locking clevis tube  12058 . The shaft tube assembly  12060  provides a housing for the actuation shaft  12108 . The shaft tube assembly  12060  is removed in the other figures to show the internal comport parts of the manual applier  2040 . 
       FIG. 105  is an isometric view of a handle assembly  12068 . In some embodiments of the invention, the handle assembly to  12068  may be standard off-the-shelf feature. For example, the handle  12068  sold as the Hem-o-loc® handle identified as number  544965 P may be used. The handle  12068  may include a pivoting lever  12070  attached to the handle  12072 . A rotator  12074  is configured to allow an operator to rotate the rotator  12074  and thereby rotate also the shaft tube assembly  12060  (See  FIG. 103 ) and jaws  12042  along with the components located at the distal end of the applier  12040 . This rotation capability allows a user to orient the jaws  12042  to a desired angular rotation. The handle  12068  also includes an actuation shaft interface  12076 . It is the actuation shaft interface  12076  that communicates with the handle interface  12062  on the shaft tube assembly  12060  to cause the rotation of the shaft tube assembly  12060 , its internal components, the jaws  12042 , and other complements located at the distal end of the applier  12040  when the rotator  12074  is rotated by a user. The lever  12070  is biased away from the handle  12072  by the leaf spring assembly  12078 . 
     According to some embodiments, the applier  12040  is capable of applying only a single clip  12000  at a time. In order to load a clip  12000  into the jaws  12042 , a clip cartridge  12080  as shown in  FIG. 106  may be used. The clip cartridge  12080  may include several clips  12000  located in clip retainers  12082  within the clip cartridge  12080 . To obtain a clip  12000  from the clip cartridge  12080 , the jaws  12042  are placed over a clip  12000  and then the jaws  12042  are removed from the clip cartridge  12080  thereby causing the clip  12000  to be removed from the clip retainer  12082  and stay in the jaws  12042 . 
       FIGS. 107 through 114  illustrate single components of the manual applier  12040 .  FIGS. 115 through 122  illustrate how these components are assembled together. Each will be discussed in turn.  FIG. 107  illustrates an upper jaw  12044 . In some embodiments, the upper jaw  12044  and the lower jaw  12046  are the same part just installed in opposite orientations. The jaw  12044  includes a slot  12084 . The jaw  12044  also includes bosses  12086  which define holes  12088 . The rear of the jaw  12044  includes an actuation body  12090  which defines an actuation slot  12092 . It is by moving a part through the actuation slot  12092 , which will be discussed in further detail below that the jaw  12044  will pivot about a pivot rivet  12056  that extends through the holes  12088  in the bosses  12086 . 
       FIG. 108  is an isometric view of the pivot rivet  12056  which, as shown in  FIG. 103  extends through the hole  12052  in the boss  12050  of the distal locking clevis tube  12048 . The pivot rivet  12056  also extends through the holes  12088  in the bosses  12086  in the jaw  12044  to pivotally connect the jaw  12044  to the distal locking clevis tube  12048 . The pivot rivet  12056  will attach both the upper jaw  12044  and the lower jaw  12046  to the distal locking clevis tube  12048 . 
       FIG. 109  is an isometric view of the distal locking clevis tube  12048 . The distal locking clevis tube  12048  includes bosses  12050  defining holes  12052  a guiding slot  12096  and a narrow diameter portion  12094 . The narrow diameter portion  12094  defines a hole  12095 , or is another words, is hollow. 
       FIG. 110  is an isometric view of the proximal locking clevis tube  12058 . The proximal locking clevis tube  12058  includes a large diameter housing  12098  which has slits  12100  the large diameter housing  12098  also defines a guiding slot  12102 . The large diameter housing  12098  is dimensioned to fit over and ride on the narrow diameter portion  12094  of the distal locking clevis tube  12048  as illustrated in  FIG. 109 . An illustration of the proximal locking clevis tube  12058  fit over the narrow diameter portion  12094  of the distal locking clevis tube  12048  will be described and illustrated in later figures described further below. The guiding slot  12102  on the proximal locking clevis tube  12058  will align with the guiding slot  12096  in the distal locking clevis tube  12048  when the proximal locking clevis tube  12058  is mounted onto the narrow diameter portion  12094  of the distal locking clevis tube  12048 . 
     The proximal locking clevis tube  12058  also includes a narrow diameter portion  12104  which defines a hole  12105 , or in other words, is hollow. The narrow diameter portion  12104  of the proximal locking clevis tube  12058  includes trunnions  12106 . The trunnions  12106  are useful for attaching or locking the proximal locking clevis tube  12058  to the shaft tube assembly  12060  when the shaft tube assembly  12060  is fit over the narrow diameter portion  12104  of the distal locking clevis tube  12048 . The trunnions  12106  fit into corresponding internal slots with in the shaft tube assembly  12060  to lock the shaft tube assembly  12060  to the proximal locking clevis tube  12058 . 
       FIG. 111  illustrates the actuation shaft  12108 . The actuation shaft  12108  includes ends  12110  and  12112 . The end  12110  interacts with the handle  12068  so the actuation of the lever  12070  on the handle  12068  causes the actuation shaft  12108  to move. 
       FIG. 112  illustrates a spring  12114 . The spring  12114  is used to bias the jaws  12042  in a distal position. This will be discussed further below.  FIG. 113  illustrates a clip lock actuator  12116 . The clip lock actuator  12116  includes legs  12118  and a locking projection  12120 . The clip lock actuator  12116  also includes a slot  12122 .  FIG. 114  is a isometric view of a distal pushrod  12124 . The distal pushrod  12124  includes a flat portion  12126  having projections  12128  located at one end. The projections  12128  are what ride with in the slot  12092  illustrated in the jaws  12044  of  FIG. 107 . By moving axially, the distal pushrod  12124  causes the jaws  12044  to open and close. 
       FIGS. 115 through 122  are partial, isometric, assembly views of the parts described in  FIGS. 104 through 114 .  FIG. 115  illustrates the clip  12000  contained within the jaws  12042 . The distal locking clevis tube  12048  has the boss  12050  defining the hole  12052  through which the pivot rivet  12056  extends to provide a pivot shaft for the jaws  12042 . The pivot rivet  12056  extends through the hole  12052  in the boss  12050 , the holes  12088  in the jaws  12042  (as shown in  FIG. 107 ) and through the slot  12122  in the clip lock actuator  12116  (shown in  FIG. 113 ). 
       FIG. 116  shows the jaws  12042  and a generally open position. Legs  12118  of the clip lock actuator  12116  are shown extending through the guiding slot  12096  on the distal locking clevis to  12048  and the guiding slot  12102  in the housing  12098  of the proximal locking clevis tube  12058 . In some embodiments, the legs  12118  of the clip lock actuator  12116  are welded into the guiding slot  12102  of the proximal locking clevis tube  12058 . The actuation bodies  12090  of the jaws  12042  extend through the distal locking clevis tube  12048 . The spring  12114  is shown through the slits  12100  in the housing  12098  of the proximal locking clevis tube  12058 . A relief  12130  is shown between the distal locking clevis tube  12048  and the housing  12098  of the proximal locking clevis tube  12058 . The housing  12098  rides on the narrow diameter portion  12094  of the distal locking clevis tube  12048 . The jaws  12042  are in the open position and are therefore in a distal position making the relief  12130  to be relatively large. 
       FIG. 117  is a partial cross-sectional view illustrating the actuation shaft  12108  attached to the end  12112  of the distal pushrod  12124 . The end  12112  of the distal pushrod  12124  is placed into the hole  12132  in the actuation shaft  12108 . In some embodiments, the end  12112  of the distal pushrod  12124  is welded into the hole  12132  in the actuation shaft  12108 . The distal pushrod  12124  extends through the spring  12114 , proximal locking clevis tube  12058 , the narrow diameter portion  12094  of the distal locking clevis tube  12048 , and the legs  12118  of the clip lock actuator  12116 . The spring  12114  urges the narrow diameter portion  12094  of the distal locking clevis tube  12048  to bias the distal locking clevis tube  12048  to a distal position. 
       FIG. 118  shows the clip  12000  located in the jaws  12042  and an upper slanted edge  12012  is butted against an angled surface  12134  in the upper jaw  12044 . Likewise a lower slanted edge  12014  of the clip  12000  is butted against an angled surface  12136  in the lower jaw  12046 . In this manner, the clip  12000  is retained within the jaws  12042 . A locking projection  12120  on the clip lock actuator  12116  is located near the buttress  12022 . The pivot rivet  12056  is shown to be located in the slot  12122  within the clip lock actuator  12116 . 
       FIG. 119  illustrates a partial cross-sectional view with some of the parts removed for clarity. The jaws  12042  are in an open position. The pivot rivet  12056  is located in the slot  12122  within the clip lock actuator  12116 . The distal pushrod  12124  is shown in cross-section so the front portion is removed. However, the back projection  12128  of the distal pushrod  12124  is located in the actuation slot  12092  in the actuation body  12090  of the jaw  12044 . It will be appreciated that rearward or proximal movement of the distal pushrod  12124  will cause the projection  12128  to slide through the slot  12092  causing the jaw  12044  to move to a closed position. Once the projection  12128  reaches the end of the slot  12092  and the distal pushrod  12124  still continues to move rearward or in a distal direction, the jaws  12042  will then be moved also in the distal direction. 
       FIG. 120  shows the jaws  12042  in a closed position. The projection  12128  on the distal pushrod  12124  has moved to the end of the slot  12092 . The pivot rivet  12056  is shown residing in the slot  12122  of the clip lock actuator  12116 . 
       FIG. 121  illustrates additional features where the jaws  12042  are in the closed position as shown in  FIG. 120 . The clip lock actuator  12116  and its legs  12118  are shown in the distal locking clevis tube  12048 . The spring  12114  has become compressed within the proximal locking clevis tube  12058 . The compression of the spring  12114  was caused by movement of the jaws  12042  and the distal locking clevis tube  12048  to the rearward or proximal position. The relief  12130  between the distal locking clevis tube  12048  and the proximal locking clevis tube  12058  has shrunk drastically. In some embodiments, the relief  12130  may disappear completely. 
       FIG. 122  has some of the parts removed for clarity. The jaws  12042  and clip  12000  are in the closed position. The jaws  12042  have moved to a distal position causing the buttress  12022  to contact the locking projection  12120  on the clip lock actuator  12116 . Not only has the buttress  12022  contacted the projection  12120  but continued proximal movement has caused the buttress  12122  to move into the locking void  12020  thereby locking the clip  12000  in the closed position. In this manner, the clip  12000  is closed and locked. 
     Actuation of the jaws  12042  is accomplished by the proximal movement or pulling on the actuation shaft  12108  (see  FIG. 117 ). Proximal movement of the actuation shaft  12108  can be accomplished by actuating a handle assembly  12068  (see  FIG. 105 ) or by any other means. For example, the actuation shaft  12108  may be attached to a robot or any other suitable instrument. Because the actuation shaft  12108  is positively connected to the distal pushrod  12124  (see  FIG. 119 ), proximally pulling on the actuation shaft  12108  will cause proximal movement of the distal pushrod  12124 . Distal movement of the distal pushrod  12124  will cause the projections  12128  (see  FIG. 119 ) to slide through the actuation slot  12092  in the jaws  12042 . 
     Proximal movement of the projections  12128  will cause the jaws  12042  to close. Once the jaws  12042  are closed, continued proximal movement of the distal pushrod  12124  will cause the jaws  12042  to move distally. Proximal movement of the distal pushrod  12124  will cause the jaws  12042  to move proximally and continued proximal movement of the distal pushrod  12124  will cause the jaws to open. In some embodiments of the invention, the proximal movement of the distal pushrod  12124  is provided by the spring  12114 . 
       FIGS. 123-123  illustrate another clip  12000  that may be used in some embodiments of the invention. The clip  12000  shown in  FIGS. 123-125  is similar to the clip illustrated in  FIGS. 98-102 . Differences between the clip  2000  shown in  FIGS. 123-125  include the buttress  12022  having a different exterior geometry. The buttress  12022  is attached the connectors  12034  which, in turn, are connected to the locking wings  12026  of the clip  12000 . The locking wings  12026  have a slightly different geometry as the clips  12000  shown earlier figures, but are shaped to correspond to the exterior geometry of the buttress  12022 . The different exterior geometry of the buttress  12022  provides desired locking and unlocking characteristics for facilitating insertion or removal of the buttress  12022  from the locking void  12020 . The clip  12000  also has bulges  12138  mounted on the upper leg  12002  and the rear bottom leg  12004 . In some embodiments, the bulges  12138  assist in the retention and removal of the clip  12000  in the jaws  12042  of the applier  12040 . In other embodiments of the invention, appliers  1000  can be used with various shaped clips and are not limited to the various clips described herein. For example, other clips are shown and described in the application titled “Narrow Profile Surgical Ligation Clip” filed Sep. 14, 2012 and identified as U.S. patent application Ser. No. 13/616,120 which is incorporated by reference in its entirety herein. 
     The many features and advantages of the invention are apparent from the detailed specification, and, thus, it is intended by the appended claims to cover all such features and advantages of the invention which fall within the true spirit and scope of the invention. Further, since numerous modifications and variations will readily occur to those skilled in the art, it is not desired to limit the invention to the exact construction and operation illustrated and described, and, accordingly, all suitable modifications and equivalents may be resorted to that fall within the scope of the invention. All ranges cited herein specifically incorporate all values and sub-ranges within the cited range.