Patent Publication Number: US-2021177405-A1

Title: Stapler apparatus and methods for use

Description:
RELATED APPLICATION DATA 
     The present application claims benefit of co-pending U.S. provisional application Ser. No. 62/947,903, filed Dec. 13, 2019, the entire disclosure of which is expressly incorporated by reference herein. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates generally to apparatus, systems, and methods for performing medical procedures, and, more particularly, to stapler apparatus for performing laparoscopic or other surgery, e.g., to remove an appendix of a subject, and systems and methods for using such apparatus. 
     BACKGROUND 
     Appendicitis is seen in approximately 5-10% of the population in their life time. Since 1983, laparoscopic appendix surgery is the mainstay for treatment. In an example of conventional surgery to remove an appendix, the following steps may be performed. First, the appendix and its vessel may be initially identified e.g., lying within a fold of tissue called the mesoappendix. A window or surgical field may be created within the subject&#39;s body, and a stapler apparatus is then used, e.g., to initially staple and divide the structure closest to the operator, and then to staple and divide the remaining structure. 
     For example,  FIG. 1  shows exemplary anatomy of an appendix, which may have one of a variety of orientations relative to the intestine, most commonly retrocecal (64%) or pelvic (32%), although less common positions may also be encountered, as shown. An appendicular artery and other blood vessels (not shown) deliver blood to the appendix, whose location relative to the intestine may also vary depending on the orientation of the appendix. The appendix and artery may be separated by fat and/or other tissue. Thus, during a procedure, upon accessing the abdominal cavity, the operator must identify the relative locations of the appendix and vessels before removing the appendix. For example, after identification, the operator may identify the intra-operative manifestation or positioning of the appendix and its vessel, i.e., to identify whether the appendix is closer to the operator and the vessel is positioned further away or vice-versa, and then sequentially staple and divide the closer structure, and then the more distant structure. 
     To perform laparoscopic or open surgery, a device may be introduced carrying a camera that is independent from the stapler, e.g., to enable visualization of the surgical space and anatomy from the side, e.g., when the stapler is introduced and used to remove the appendix. Existing laparoscopic staplers generally include a cartridge having multiple rows of staples equally distributed on either side of a knife. 
     One of the most common complications from such surgery is post-operative bleeding. The bleeding is generally sub-clinical in approximately 15%, and clinical in approximately 5% patients, i.e., requiring further intervention. The majority of bleeding occurs from the staple line on individual vessels or vessels within the wall of intestine. For example, “B” shaped clips may create a lumen between the tines that may allow blood or other fluid to escape. Other complication include leaking of intestinal fluid from the intestinal lumen. 
     Accordingly, apparatus and methods that facilitate laparoscopic surgery, e.g., to remove an appendix would be useful. 
     SUMMARY 
     The present invention is directed to apparatus, systems, and methods for performing medical procedures, and, more particularly, to stapler apparatus for performing surgery, such as laparoscopic surgery, e.g., to remove an appendix of a subject or to perform other intestinal procedures, vascular surgery, lung surgery, and the like, and to systems and methods for using such apparatus. 
     In accordance with an exemplary embodiment, an apparatus is provided for performing a medical procedure that includes a shaft including a proximal end and a distal end sized for introduction into a patient&#39;s body; first and second jaws on the distal end of the shaft that are movable relative to one another between open and closed positions, thereby directing first and contact surfaces of the first and second jaws away from and towards one another, respectively, the first jaw carrying one or more staples deployable from the first contact surface; a Doppler radar or other sensor on one of the first and second contact surfaces; and a handle on the proximal end of the shaft comprising a first actuator for opening and closing the jaws, e.g., a trigger to close the second jaw adjacent the first jaw to capture tissue between the contact surfaces, a second actuator for deploying one or more staples from the first jaw into tissue between the first and second contact surfaces, e.g., after locking the jaws closed using the trigger or a separate locking mechanism, and a third actuator for activating the Doppler or other sensor to detect blood flow in the tissue. 
     In an exemplary embodiment, the first and second jaws may be carried on an end effector removably coupled to the distal end of the shaft. The first jaw may carry first and second sets of staples, e.g., each set arranged in rows adjacent one another, optionally arranged within a replaceable cartridge. A cutting element may be disposed on the distal end, e.g., movable between the first and second sets of staples, e.g., using a fourth actuator on the handle to advance the cutting element to sever the stapled tissue. In addition or alternatively, a thermal element or other hemostasis element may also be provided on one of the first and second jaws, e.g., opposite the Doppler sensor, and the handle may include a fifth actuator for activating the hemostasis element to deliver thermal energy to the stapled tissue. Optionally, the handle may include one or more additional actuators, e.g., one or more controls for positioning and/or activating a light and/or camera carried on the distal end of the shaft or the end effector. 
     In accordance with another embodiment, an end effector is provided for a stapler apparatus including a shaft including a proximal end including a handle and a distal end sized for introduction into a patient&#39;s body. The end effector may include one or more connectors for removably connecting the end effector to the distal end of the shaft and, optionally, a cartridge insertable into a recess of one of the jaws. The first and second jaws are movable relative to one another between open and closed positions, thereby directing contact surfaces of the first and second jaws away from and towards one another, respectively. For example, the first jaw may be fixed and the second jaw may be pivotally mounted to open and close relative to the first jaw, e.g., to capture tissue between the contact surfaces. One or more staples are carried by the first jaw, e.g., in a replaceable cartridge, such that actuation of a staple actuator on the handle deploys one or more staples from the first jaw into tissue between the contact surfaces and towards the second jaw to deform the one or more staples. Optionally, a Doppler radar sensor and/or hemostasis element may be provided on one of the contact surfaces to detect blood flow in the tissue. 
     In accordance with still another embodiment, a method is provided for performing a surgical procedure within a patient&#39;s body that includes introducing first and second jaws on a distal end of a shaft into a region within the patient&#39;s body; with the jaws in an open position, placing tissue within the region between contact surfaces of the first and second jaws; closing the jaws to engage the tissue; actuating a staple actuator to deploy one or more staples from the first jaw into the tissue towards the second jaw to deform the one or more staples and secure the tissue. For example, the second jaw may be closed to squeeze the tissue between the contact surfaces and, optionally, may be locked in the closed position. The staple(s) may be then be deployed from the first jaw using the staple actuator such that they are directed through the tissue and engage anvils or shaping surfaces on the second jaw to deform tines of the staple(s). A Doppler or other sensor on one of the contact surfaces may be activated to detect blood flow in the stapled tissue; and after confirming that blood flow has discontinued in the stapled tissue, a cutting element may be actuated to sever the stapled tissue from adjacent tissue at the region. 
     In accordance with yet another embodiment, a method is provided for performing an appendectomy within a patient&#39;s body that includes introducing first and second jaws on a distal end of a shaft into an abdominal cavity of the patient&#39;s body; placing an appendix and appendicular artery within the abdominal cavity between contact surfaces of the first and second jaws; actuating one or both of the first and second jaws to secure the appendix and artery between the contact surfaces; and deploying one or more staples from the first jaw through the appendix and artery to staple the appendix and artery. Thereafter, a Doppler sensor on one of the contact surfaces may be activated to detect blood flow in the stapled appendix and artery, and, if blood flow is detected, a thermal element may be activated to deliver thermal energy to stop blood flow, e.g., alternately to detect and cauterize the tissue. Once blood flow ash stooped, a cutting element may be actuated to simultaneously sever the appendix and artery. 
     In accordance with another embodiment, an apparatus is provided for performing a medical procedure that includes a shaft including a proximal end, a distal end sized for introduction into a patient&#39;s body, and a longitudinal axis extending between the proximal and distal ends; first and second jaws on the distal end of the shaft that are movable relative to one another between open and closed positions, thereby directing first and contact surfaces of the first and second jaws away from and towards one another, respectively, the first jaw carrying first and second sets of staples positioned on opposite sides of a cutting element, wherein at least some of the staples are a different size than other staples; and a handle on the proximal end of the shaft. For example, each set of staples may include one to five rows of staples aligned along the longitudinal axis, with two to fifty staples in each row. The staples in each set and/or each row may have different sizes depending on the anatomy encountered. For example, the apparatus may include a plurality of available cartridges, each including different arrangements of staples, that may be selected and inserted into a cavity of the first jaw. The handle includes a first actuator for driving the staples from the first jaw into tissue between the first and second contact surfaces and towards the second jaw to deform the staples; and a second actuator for advancing the cutting element from a retracted position to an advanced position aligned with the longitudinal axis to sever the stapled tissue. 
     In accordance with yet another embodiment, an end effector is provided for a stapler apparatus including a shaft comprising a proximal end including a handle, a distal end sized for introduction into a patient&#39;s body, and a longitudinal axis extending between the proximal and distal ends. The end effector may include one or more connectors for removably connecting the end effector to the distal end of the shaft; first and second jaws that are movable relative to one another between open and closed positions using a first actuator on the handle, thereby directing first and contact surfaces of the first and second jaws away from and towards one another, respectively; and a cartridge carried by the first jaw comprising first and second sets of staples arranged in rows on opposite sides of a cutting element such that actuation of a second actuator on the handle deploys the staples into tissue between the first and second contact surfaces and drives the staples against the second jaw to deform the one or more staples, wherein at least some of the staples are a different size than other staples. 
     In accordance with still another embodiment, a staple is provided for delivery into tissue that includes a substantially straight base element including first and second ends; a first tine extending from the first end substantially perpendicular to the base, the first tine having a first length and including one or more notches adjacent a tip of the first tine; and a second tine extending from the second end substantially perpendicular to the base to a second tip, the second tine having a second length longer than the first length and longer than the length of the straight base such that, when the second tine is bent adjacent the base, the second tip of the second tine is engaged in the one or more notches located on the first tine. 
     In accordance with another embodiment, a port is provided for introducing one or more instruments into a patient&#39;s body that includes an elongate tubular member comprising a proximal end, a distal end sized for introduction into a patient&#39;s body, and a lumen extending between the proximal and distal ends, thereby defining a longitudinal axis there between; a display; and one or more deployment arms on the tubular member adjacent the distal end carrying an imaging device, each deployment arm comprising a first end pivotably coupled to the tubular member and a second free end that is movable from a retracted position wherein the second end is aligned with a wall of the tubular member and a deployed position wherein the second end moves outwardly relative to the longitudinal axis for presenting images on the display. 
     In accordance with still another embodiment, a port is provided for introducing one or more instruments into a patient&#39;s body that includes an elongate tubular member comprising a proximal end, a distal end sized for introduction into a patient&#39;s body, and a primary lumen extending between the proximal and distal ends for receiving an instrument therethrough, and a plurality of secondary lumens positioned around the primary lumen and extending between the proximal and distal ends; and a video module. The video module may include a hub; a display; and a plurality of elongate imaging elements mounted to the hub and sized for introduction simultaneously into respective secondary lumens of the tubular member such that distal tips of the imaging elements are positioned adjacent the distal end of the tubular member for acquiring images beyond the distal end. 
     Other aspects and features of the present invention will become apparent from consideration of the following description taken in conjunction with the accompanying drawings. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The drawings illustrate exemplary embodiments of the invention, in which: 
         FIG. 1  is a detail showing exemplary anatomy of an appendix, which may have a variety of orientations relative to the intestine. 
         FIG. 2A  is a side view of an exemplary embodiment of a stapler apparatus including a reusable portion including a shaft extending from a handle and a disposable end effector coupled to the shaft. 
         FIGS. 2B and 2C  are side and perspective views, respectively, of the apparatus of  FIG. 2A  with a display on the reusable portion. 
         FIGS. 3A and 3B  are perspective and side views, respectively, of an exemplary embodiment of an end effector that may be coupled to the shaft of the apparatus of  FIG. 2A , the end effector including a first jaw carrying a plurality of staples within a cartridge and a second jaw pivotable relative to the first jaw between an open position ( FIG. 3A ) and a closed position ( FIG. 3B ). 
         FIG. 3C  is a cross-sectional view of the end effector of  FIGS. 3A and 3B  with the jaws spaced apart. 
         FIG. 4A  is a top view of the first (bottom) jaw of the end effector shown in  FIGS. 3A and 3B  with a cartridge carrying staples received in a cavity of the jaw. 
         FIGS. 4B and 4C  are top views of alternative embodiments of first jaws and cartridges that may be provided that include different size staples and receptacles. 
         FIGS. 5A-5C  are cross-sectional views showing alternative embodiments of jaws and cartridges including a Doppler sensor and/or thermal element at different locations on the jaws. 
         FIGS. 6A and 6B  are perspective views of an exemplary embodiment of an access port including a deployable imaging system carried on deployment arms in retracted and deployed configurations, respectively. 
         FIG. 6C  is a perspective view of the access port of  FIGS. 6A and 6B  with a portion of the tubular shaft removed to show details of the deployment arms of the imaging system. 
         FIGS. 6D and 6E  are top views of the access port of  FIGS. 6A and 6B , respectively, with a portion of the tubular shaft removed to show details of the deployment arms of the imaging system. 
         FIGS. 7A and 7B  are perspective views of an exemplary embodiment of a staple or clip that may be delivered using the stapler apparatus herein. 
         FIG. 7C  is a side view of the staple of  FIGS. 7A and 7B . 
         FIG. 7D  is a side view of the staple of  FIGS. 7A and 7B , showing a first tine of the staple being deformed and engaged with a second tine of the staple. 
         FIGS. 8A-8E  are side views of alternative embodiments of staples or clips that may be delivered using the stapler apparatus herein. 
         FIGS. 9A and 9B  are perspective and side views, respectively, of another exemplary embodiment of an access port including a disposable tubular member and a reusable video module that may be coupled to the tubular member. 
         FIG. 9C  is a perspective view of the access port of  FIGS. 9A and 9B  with imaging elements of the video module activated. 
         FIG. 10  is a perspective view of the tubular member of  FIGS. 9A-9C . 
         FIG. 11  is a perspective view of a video module that includes elongate imaging sleeves receivable in corresponding lumens of the tubular member. 
         FIGS. 12A and 12B  are details of the distal end of the tubular member of  FIG. 10  before and after inserting the imaging sleeves of the video module into secondary lumens of the tubular member. 
         FIG. 13A  is a perspective view of the access port of  FIGS. 9A-9C  with a stapler apparatus inserted through a primary lumen of the tubular member. 
         FIG. 13B  is a detail of a distal end of the access port of  FIG. 13A  showing an end effector of the stapler apparatus. 
         FIG. 14  is a perspective view of another embodiment of a stapler apparatus including an integral video module including a display and a plurality of imaging sleeves extending from a handle of the apparatus and insertable into an end effector (not shown). 
         FIGS. 15A-15D  are details showing a wedge actuation mechanism for deploying a staple from a cartridge received in a jaw of an end effector. 
         FIG. 16  is a flowchart showing an exemplary method for using the apparatus herein to perform an appendectomy. 
         FIG. 17  is a flowchart showing an exemplary method for using an access port and stapler to perform a surgical procedure. 
     
    
    
     DETAILED DESCRIPTION OF THE EXEMPLARY EMBODIMENTS 
     Before the exemplary embodiments are described, it is to be understood that the invention is not limited to particular embodiments described, as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the present invention will be limited only by the appended claims. 
     Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limits of that range is also specifically disclosed. Each smaller range between any stated value or intervening value in a stated range and any other stated or intervening value in that stated range is encompassed within the invention. The upper and lower limits of these smaller ranges may independently be included or excluded in the range, and each range where either, neither or both limits are included in the smaller ranges is also encompassed within the invention, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included. 
     Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, some potential and exemplary methods and materials are now described. 
     It must be noted that as used herein and in the appended claims, the singular forms “a,” “an,” and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to “a compound” includes a plurality of such compounds and reference to “the polymer” includes reference to one or more polymers and equivalents thereof known to those skilled in the art, and so forth. 
     Turning to the drawings,  FIG. 2A  shows an exemplary embodiment of a stapler apparatus  8  that may be used during a medical procedure, e.g., during laparoscopic surgery to remove a patient&#39;s appendix (not shown). Generally, the apparatus  8  includes a reusable shaft/handle portion or handpiece  10  including a shaft  20  and a handle  30 , and a disposable, single-use portion or end effector  40 , e.g., configured to receive a single-use cartridge (not shown), which may be removably coupled to the shaft  20  before or during a procedure, as described further below. Alternatively, at least some of the components of the end effector  40  may be permanently incorporated into the reusable portion  10 , e.g., such that the entire apparatus  8  may be single-use or may be cleaned between procedures and reused. 
     As shown, the shaft  20  is an elongate member, e.g., a substantially rigid tubular body, including a proximal end  22  and a distal end  24 , defining a longitudinal axis  26  extending there between. The shaft  20  may include one or more lumens or passages (not shown) extending between the proximal and distal ends  22 ,  24 , e.g., for receiving actuator elements, wires, and/or other components, as described elsewhere herein. At least the distal end  24  of the shaft  20  is sized for introduction into a patient&#39;s body, e.g., having a diameter sufficiently small enough to be received through a port or cannula to allow introduction into a laparoscopic surgical space within a patient&#39;s body. 
     Optionally, at least a portion of the shaft  20  may be malleable, e.g., such that at least a distal region of the shaft  20  may be deformed into a desired shape outside the patient&#39;s body, which the shaft  20  may maintain during introduction. Alternatively, at least a distal region of the shaft  20  and/or the end effector  40  may be flexible, e.g., for introduction into body passages, such as blood vessels, GI passages, and the like, such that the distal region follows the passages during introduction. Optionally, in this alternative, the shaft  20  may include one or more steering wires or other elements therein (not shown) that may be actuated to change the shape of the shaft  20 , e.g., to facilitate introduction into a desired location and/or manipulation within the patient&#39;s body. 
     The handle  30  may include a handgrip  32 , e.g., shaped and/or otherwise configured to facilitate holding and/or manipulating the apparatus  8  during use. In addition, the handle  30  may include one or more actuators, e.g., for operating mechanical and/or electrical components on the stapler assembly  40 . For example, a trigger or other jaw actuator  34  may be provided, e.g., adjacent the handgrip  32 , that may be pulled or otherwise actuated to jaws  46 ,  47  and a separate actuator (not shown) may be provided to subsequently deploy one or more staples (not shown) from the stapler assembly  40 . For example, the trigger  34  may be pulled to close the second jaw  48  immediately adjacent the first jaw  46  to engage tissue between contact surfaces  46   a,    48   a,  e.g., as described further elsewhere herein. Optionally, the trigger  34  may include a ratchet mechanism to allow the second jaw  48  to move towards the first jaw  46  while preventing opening, e.g., to squeeze tissue between the jaws  46 ,  48 , e.g., until a release mechanism is actuated. Alternatively, a separate locking mechanism may be provided on the handle  30 , which may be selectively activated to lock and release the second jaw  48 , as described elsewhere herein, In addition or alternatively, several other actuators may be included on the handle  30  or shaft  20   10  to achieve independent actuation of various functions/parts of the end effector, such as a staple actuator that be advanced to deploy one or more staples and/or retracted, a cutting actuator for blade actuation (forward and backward), a Doppler sensor trigger, an electrical cautery power switch, and/or an actuator for controlling end effector orientation. 
     Optionally, as shown in  FIGS. 2B and 2C , a display or other output device  38  may be provided on the handle  30 , e.g., to facilitate observing or otherwise monitoring the procedure. For example, a camera, light, and/or other imaging device (not shown) may be provided on the stapler assembly  40  and/or the distal end  24  of the shaft  20  that may be used to acquire images of a surgical space into which the stapler assembly  40  is introduced, as described further elsewhere herein. In one embodiment, a display  38  may be removably mounted on the handle  30 , which may include one or more connectors or cables (not shown) that may be coupled to corresponding connectors on the handle  30 , which are, in turn, coupled to one or more wires extending to the imaging device on the stapler assembly  40 . Alternatively, the display  38  may be permanently mounted to the handle  30  and one or more wires or other elements may communicate with the imaging device. In another alternative, a display (not shown) may be provided that is separate from the apparatus  8 , and the apparatus  8  may include a communications interface, e.g., a wireless transmitter, that may transmit signals from the imaging device wirelessly, e.g., using Bluetooth or other communications protocols, to allow images to be presented on the display. 
     For example, a CMOS, CCD, or other imaging element (not shown) may be provided on the distal end  24  of the shaft  20  (or alternatively on the end effector  40 ) that is oriented to acquire images of the region beyond the stapler assembly  40  and/or between jaws  46 ,  48  of the end effector  40 . One or more wires and/or optical fiber may transmit signals to the display  38 , which may include a processor to process the signals and present the images on a screen of the display  38 . In addition or alternatively, one or more LEDs or other light sources may be provided on the distal end  24  of the shaft  20  (or alternatively on the end effector  40 ), e.g., adjacent the imaging element to provide illumination for the images. For example, one or more lights may be arranged circumferentially on the distal end  24  of the shaft  20 , such as a circular Xenon LED lamp (not shown), e.g., operating at 200-2500 W, that may provide dispersed illumination (due to internal reflections in the lamp) without generating thermal energy that may damage nearby tissue. Alternatively, one or more LEDs or other light sources (not shown) may be provided in the handle  30 , and light may be transmitted using light conductive material such as optical fiber or transparent plastic to provide illumination to the distal end  24 . The handle  30  and/or display  38  may include one or more controls (not shown), e.g., to turn the illumination source(s) and/or imaging element(s) off and on, as desired. Optionally, the imaging element(s) and/or illumination source(s) may be movable relative to the end effector  40 , e.g., rotated about the longitudinal axis  26  and, if so, one or more actuators (not shown) may be provided on the handle  30  to rotate or otherwise adjust their position during a procedure. 
     Returning to  FIG. 2A , generally, the end effector  40  on the distal end  24  of the shaft  20  includes first and second jaws  46 ,  48  carrying one or more staples (not shown) and, optionally, one or more additional components for use during a procedure. For example, as shown in  FIGS. 3A-3C , the end effector  40  may include a removable cartridge  50  receivable within a recess, track, or other cavity  46   c  within the first jaw  46 . The end effector  40  may also include a tubular housing  42  from which the first jaw  46  extends that includes a proximal end  44  that may be connected to the distal end  24  of the shaft  20 , e.g., using one or more detents, latches, sockets, threads and/or other connectors (not shown) on the proximal end  44  of the housing  40  and/or the distal end  24  of the shaft  20 . When the end effector  40  is mechanically connected to the shaft  20  by the connector(s), additional connectors may automatically engage, e.g., to mechanically couple actuatable components on the end effector  40  with actuator elements in the shaft  20  and/or electrically couple electrical components on the end effector  40  with corresponding wires in the shaft  20  (not shown), as will be appreciated by those skilled in the art. For example, a wedge mechanism (not shown, see, e.g.,  FIGS. 15A-15D ) may be provided within the housing  42  adjacent the first jaw  46  that may be coupled to an actuator shaft (also not shown) within the shaft  20  such that actuation of a staple actuator on the handle  30  may be activated to advance and retract the actuator shaft and wedge to deliver the staples, as described elsewhere herein. 
     As shown, the first jaw  46  may be integrally formed with or otherwise fixed relative to the housing  42 , e.g., such that the first jaw  46  remains aligned with the axis  26  of the shaft  20  during use. The second jaw  48  may be movably mounted to the housing  42 , e.g., by one or more hinges or other features (not shown) such that the second jaw  48  may be pivotable between an open position, e.g., as shown in  FIG. 3A , and a closed position, e.g., as shown in  FIG. 3B . In the open position, contact surfaces  46   a,    48   a  of the jaws  46 ,  48  may be spaced apart from one another, e.g., to allow a tissue structure to be positioned between the jaws  46 ,  48 , e.g., on the first contact surface  46   a,  while in the closed position, the contact surfaces  461 ,  48   b  may be immediately adjacent one another, e.g., substantially parallel to one another, as shown in  FIG. 3B . For example, in the closed position, the contact surfaces  46   a,    48   a  may have sufficient clearance between them to squeeze, secure, and/or otherwise engage tissue positioned between the jaws  46 ,  48 . 
     The jaws  46 ,  48  may be biased to one of the open and closed positions or may be actuatable between the open and closed positions. For example, the jaws  46 ,  48  may be provided initially in a closed position, e.g., to facilitate introduction into a patient&#39;s body, whereupon a lock or other mechanism may be released, whereupon the second jaw  48  may automatically move to the open position, and the actuator  34  on the handle  30  may become active to deploy staples and/or close the second jaw  48 , as described further elsewhere herein. Alternatively, the trigger  34  on the handle  30  may be pulled or released to close and open the second jaw  48  without deploying staples to facilitate introduction and/or manipulation of the cartridge  40 , e.g., until a switch or other control is actuated to activate deployment of the staples. A locking mechanism, e.g., a ratchet or other lock (not shown), may be provided to prevent the second jaw  48  from opening until released. 
     With particular reference to  FIG. 3A , the first jaw  46  may receive a disposable cartridge  50  which may be received in cavity  46   c  of the first the jaw  46  such that an exposed surface  50   a  of the cartridge  50  defines the first contact surface  46   a.  The cartridge  50  may carry a plurality of staples (not shown), e.g., in arranged in a plurality of rows aligned with the axis  26  of the shaft  20 . For example, in the embodiment shown, the contact surface  50   a  of the cartridge  50  includes recesses or receptacles  52  arranged in three rows  52   a,    52   b,    52   c  from which staples may be deployed simultaneously and/or in rapid succession. 
     Optionally, the cartridge  50  or first jaw  46  may include a thermal element  56  on the first surface  46   a  adjacent the rows of staples. For example, the cartridge  50  may include sets of staples disposed on opposite sides of the thermal element  56 , e.g., with the sets aligned with the axis  26  of the shaft  20 . Alternatively, as shown in  FIGS. 5A-5C , the thermal element may be omitted from the jaws/cartridge, if desired. If the staples are carried by a cartridge  50  that is removable from the first jaw  46 , the thermal element  56  may be mounted on an exposed surface of the cartridge  50 , e.g., if the cartridge  50  provide the first contact surface  46   a.  Alternatively, the thermal element  56  may be permanently mounted on the first jaw  46  and the cartridge  50  may define the portions of the first contact surface  46   a  on either side of the thermal element  56  (not shown). 
     In the example shown in  FIGS. 3A and 4A , a first row or set of staple receptacles  52   a  may be located on the right side of the thermal element  56  (from the perspective of a user holding the handle  30  of the apparatus  8 ), and second and third rows or sets of staple receptacles  52   b,    52   c  may be located on the left side of the thermal element  56 . For example, in this configuration, the first set of staples may be delivered into the appendix being removed, while the second set of staples may be delivered into the intestine and remain within the patient&#39;s body after the appendix is removed. Alternatively, the arrangement of the receptacles  52  may be reversed if desired, e.g., with the first set on the left and the second set on the right for approaches where the appendix is on the left (from the perspective of the operator of the apparatus  8 ) and the intact intestine is on the right. As shown, the second set of receptacles  52   b,    52   c  may include two rows of staples that are staggered relative to one another along the axis  26 , e.g., to enhance stapling a tissue structure captured in the jaws  46 ,  48 , as described elsewhere herein. 
     In the embodiment shown in  FIGS. 3A and 4A , the receptacles  52  have similar dimensions, e.g., having the same length aligned with the axis  26 , and the staples deployable from the receptacles  52  may have the same dimensions. Alternatively, the dimensions of the receptacles and, consequently, the staples, may be varied along each row and/or in different rows, as described further elsewhere herein. 
     For example,  FIG. 4B  shows an alternative embodiment of a first jaw  146  (generally similar to jaw  46 ) except that the rows of staple receptacles  152  include a first or proximal set of receptacles  153   a  and a second or distal set of receptacles  153   b  that have different sizes. For example, as shown, the first two receptacles in each row  152  (in the proximal set  153   a ) are larger than the remaining five receptacles (in the distal set  153   b ). In this alternative, when the staples are deployed, the larger, proximal staples will be deployed first followed by the smaller, distal staples, e.g., as the staple actuator (e.g., a piston and/or sledge, not shown) advances and the pushes the staples against the second jaw  48  (also not shown) to deform the deployed staples. 
     Alternatively, as shown in  FIG. 4C , different size staples may be provided in one or more of the rows on the first jaw  246 . For example, as shown, the first row may include receptacles  252   a  that are larger than the second and third rows of receptacles  252   b,    252   c.  Consequently, larger staples may be deployed from the first row of receptacles  252   a  than the others. For example, it may be desirable to use larger staples to staple an appendix while smaller staples may be used to staple the blood vessel delivering blood to the appendix. Many smaller staples may enhance cutting off blood flow to the vessel, which may reduce risk of subsequent bleeding when the appendix is severed and removed. Thus, cartridges may be provided with multiple rows on either the left or right side of the cutting element  60  and with larger staples on the other side such that an appropriate cartridge may be selected and connected to the handpiece  30  based on the actual anatomy encountered. Optionally, one or more additional rows or sets of staples may be provided adjacent the first, second, and/or third rows. For example, multiple sets of staples (e.g., 1-5) may be delivered into the appendix being removed and/or into the intestine. 
     Returning to  FIG. 3A , the contact surface  48   a  of the second jaw  48  may include corresponding recesses  54 , e.g., arranged in rows opposite the receptacles  52 , e.g., such that the recesses  54  are disposed directly above respective receptacles  52  in the closed position, e.g., to deform and/or otherwise close staples deployed from the receptacles  52 , as described further elsewhere herein. For example, the recesses  54  may include ramped surfaces, anvils, and/or other features to deform one or both of the tines of the staples as they are deployed, as described further elsewhere herein. 
     Optionally, the second jaw  48  may include a Doppler radar or other sensor  58 , e.g., located on the second contact surface  48   a  generally opposite the thermal element  56 . For example, the Doppler sensor  58  may be an elongate crystal element mounted on the second contact surface  56  and aligned along the axis  26  (when the second jaw  48  is closed). The Doppler sensor  58  may be configured to transmit radar signals and receive reflections from the tissue captured between the jaws  46 ,  48  to identify whether blood is flowing within the tissue, e.g., using systems and methods known in the art. 
     As can be seen in  FIG. 3C , the thermal element  56  and Doppler sensor  58  may be located opposite one another on the first and second jaws  46 ,  48 , respectively, between the rows of staple receptacles  52  and recesses  54 . This configuration may facilitate identifying blood flow within tissue captured between the jaws  46 ,  48  and then delivering thermal energy to cauterize, ablate, or necrose the tissue, e.g., to stop subsequent blood flow, as described elsewhere herein. 
     In an exemplary embodiment, the thermal element may include one or more electrodes, e.g., a single elongate electrode  56 , e.g., extending axially along the first contact surface  46   a,  which may be coupled to a source of electrical energy, e.g., a generator (not shown), in the handle  30  and/or connected to the handle  30 , as described further elsewhere herein. For example, as shown in  FIG. 3C , the electrode  56  may include a thermal insulator block  56   a,  e.g., formed from ceramic and/or other material that is not electrically conductive, and an electrode element  56   b  supported by the block  56   a,  e.g., to prevent conduction from the electrode  56  to other components of the end effector  40  and/or delivering energy to tissue that is not directly contacted by the electrode element  56   b.  In the embodiment shown, a single electrode  56  may be provided for delivering radiofrequency energy in a mono-polar configuration to cauterize the contacted tissue, e.g., similar to Bovie® devices, as described elsewhere herein. Alternatively, multiple electrodes may be provided that are spaced apart from one another on the first contact surface  46   a,  which may be used to deliver RF energy in a bi-polar configuration. In a further alternative, other elements may be provided for delivering other forms of energy, e.g., laser, energy to cauterize contacted tissue. 
     Alternatively, the location of the thermal element  56  and Doppler sensor  58  may be reversed, if desired, e.g., with the thermal element on the second contact surface and the Doppler sensor on the first contact surface (not shown). In a further alternative, the thermal sensor may be omitted entirely and only a Doppler sensor  58  may be provided on one of the jaws, e.g., on the second jaw  48 , as shown in  FIG. 5A . Thus, in this alternative, the first jaw  46 ′ does not include a thermal element. 
     In yet another alternative, the Doppler sensor may be provided at other locations on the second contact surface on any of these embodiments. For example, as shown in  FIG. 5B , a Doppler sensor  58  may be provided along one side of the second jaw  48 , i.e., adjacent the third row of recesses  54   c  opposite the third row of staple receptacles  52   c.    
     In the embodiments shown in  FIGS. 3C, 5A, and 5B , the Doppler sensor is oriented substantially perpendicular to the second contact surface. In this configuration, the centerline of the radar signals transmitted will also be perpendicular to the second contact surface. Alternatively, it may be desirable to orient the Doppler sensor at a non-perpendicular angle relative to the contact surface. For example, as shown in  FIG. 5C , another example is shown in which a Doppler sensor  58 ″′ is mounted on the second jaw  48 ″′ such that the sensor defines an angle relative to the second contact surface  58   a ″′. Thus, in this alternative, the centerline of transmitted radar signals may directed diagonally from the second contact surface  58   a ″′. Such a configuration may be useful, e.g., to direct the radar signals towards a tissue structure of particular interest, e.g., towards the blood vessel of the appendix, e.g., defining an angle relative to the direction of blood flow rather than perpendicular to the direction of blood flow. 
     Returning to  FIGS. 3A-3C , the end effector  40  may also include a blade or other cutting element  60  slidably disposed relative to the jaws  46 ,  48 . For example, the first and second jaws  46 ,  48  may include respective slots or grooves  62 ,  64  aligned with the axis  26  that receive the blade  60 , e.g., when the blade is advanced from a retracted position (not shown), e.g., received within the housing  42  immediately adjacent the contact surfaces  46   a,    48   a,  to an advanced position, i.e., where a sharpened edge  60   a  of the blade  60  is advanced distally along the slots  62 ,  64  towards distal tips  46   b,    48   b  of the jaws  46 ,  48  (the blade  60  is shown partially advanced in  FIG. 3A ). As can be seen in  FIG. 3B , the blade  60  may extend between the contact surfaces  46   a,    48   a  of the jaws  46 ,  48 , such that the edge  60   a  cuts through or otherwise severs tissue (not shown) positioned between the jaws  46 ,  48  in the closed position, as described further elsewhere herein. 
     Optionally, the cartridge  40  may include one or more additional components for use during a procedure. For example, an illumination source and/or imaging element may be mounted on the housing  42 , e.g., to facilitate imaging and/or monitoring use of the apparatus  8  during a procedure. In an exemplary embodiment, a CMOS, CCD, or other imaging element and/or one or more LEDs or other light sources (not shown) may be provided on the end effector  40 , e.g., adjacent the proximal end of the first jaw  46  where the second jaw  48  pivots, that may be oriented distally to acquire images of the region beyond the stapler assembly  40 . For example, the field of view of the imaging element may include the first contact surface  46   a  of the first jaw  46  such that an operator may use the images to position and/or orient a desired tissue structure on the contact surface  46   a  before actuating the second jaw  48  to close. 
     The apparatus  8  may be used to deliver staples into tissue during a medical procedure, e.g., during a laparoscopic surgical procedure, such as an appendectomy. Initially, a surgical space may be created, e.g., by introducing a trocar and/or cannula device (not shown) through the patient&#39;s skin and intervening tissue to a target region, e.g., the patient&#39;s abdominal cavity, and insufflating or otherwise opening the space to access a desired tissue structure, such as an appendix indicated for removal. 
     An end effector  40  and cartridge  50  may be selected and connected to the distal end  24  of the shaft  20  before introduction into the patient&#39;s body. For example, based on the anatomy encountered, the operator may select a cartridge  50  including a particular arrangement of staples, e.g., including uniform-size staples or different size staples, such as those described elsewhere herein, insert the cartridge  50  into the cavity  46   c  of the first jaw  46 , e.g., before or after connecting the end effector  40  the shaft  20 . Once the apparatus  8  is ready, the distal end  24  of the shaft  20  carrying the end effector  40  may be introduced into the surgical space, e.g., through a cannula or other port (not shown), until the jaws  46 ,  48  are located the surgical space. For example, the surgical space may be initially accessed using a needle, trocar, and/or dilator device, e.g., punctured through the patient&#39;s skin and intervening tissue into the abdominal cavity to approach the appendix, and a cannula may be positioned through the puncture. Gas may be delivered through the cannula or other device to insufflate and create a surgical cavity or space. 
     The distal end  24  of the shaft  40 , carrying the selected end effector  40  and/or cartridge  50 , may then be introduced through the cannula into the surgical space. For example, the jaws  46 ,  48  may be initially locked in the closed position to facilitate introduction through the cannula and then may be released once located within the surgical space, whereupon the second jaw  48  may open. Alternatively, the second jaw  48  may be biased to open but may be manually or otherwise closed to allow insertion through the cannula. 
     With the jaws  46 ,  48  in the open position within the surgical space, tissue within the region, e.g., the patient&#39;s appendix, may be placed on the contact surface  46   a  of the first jaw  46  and/or otherwise positioned between the jaws  46 ,  48 . For example, both the appendix and the appendicular artery may be positioned between the jaws  46 ,  48 , e.g., with one distal to the other depending on the orientation of the appendix. 
     Once the tissue is positioned as desired, the trigger actuator  34  may be manipulated to close the second jaw  48  and lock the tissue in place between the contact surfaces  46   a,    48   a.  For example, the trigger  34  may include a ratchet mechanism that allows the second jaw  48  to close while preventing it from reopening, or a separate locking mechanism (not shown) may activated once the second jaw  48  is closed to engage the tissue. A separate staple actuator (not shown) may then be used to deploy one or more staples from the first jaw  46  into and through the tissue and towards the second jaw  48  to deform the staples(s) and engage the tissue. 
     For example, as the stapler actuator is pushed, an actuation shaft (not shown) within the shaft  20  may advance a wedge or other staple actuation element (not shown) within the cartridge  50  or end effector  40  to begin deploying staples from the receptacles  52  out of the first contact surface  50   a/   46   a  of the first jaw  46  upwardly towards the second jaw  48 , thereby causing one or more tines of the staples to contact the corresponding recesses  54  in the second contact surface  48   a  and deform to staple the tissue.  FIGS. 15A-15D  show an exemplary embodiment of a wedge actuator  66  slidable within a passage  53  within a cartridge  50  that includes an angled or ramped distal surface  66   a  that may push corresponding ramped surfaces  68   a  of pistons (one piston  68  shown) within respective receptacles  52  upwardly to push the corresponding staples  90  towards the second jaw  48  (not shown in  FIGS. 15A-15D ), where tines of the staples  90  are deformed within the corresponding recesses  54 , as described elsewhere herein. For example, the wedge  66  may be coupled to a stapler actuator shaft (not shown) that may be advanced and retracted within the passage  53 , e.g., to advance the wedge  66 , thereby slidably engaging the ramped surface  66   a  of the wedge  66  with ramped surfaces  68   a  of the pistons  68  and directing the pistons  68  upwardly in the respective receptacles  52 , as shown in  FIGS. 15B-15D . The wedge  66  may then be retracted back to the position shown in  FIG. 15A . It will be appreciated that other stapler mechanisms may be used instead, such as those disclosed in U.S. Pat. Nos. 4,608,981, 4,633,874, 5,104,025, 5,307,976, 5,709,680, and European Patent No. 1,157,666, the entire disclosures of which are expressly incorporated by reference herein. 
     The deployment of the staples may be sequential within each set, e.g., simultaneously delivering first staples from each of the sets  52   a - 52   c  at the proximal end of the first jaw  46  and, as the trigger  34  continues to be pulled, additional staples are deployed until the desired length of stapling, whereupon actuation may be discontinued, which may leave one or more staples closest to the distal tip  46   a  of the first jaw  46  undeployed. In this manner, the operator may control how many staples are deployed based on the extent to which the staple actuator is pulled. Alternatively, the actuator  34  may be binary, i.e., wherein, when the trigger  34  is initially pulled, all of the staples in the first jaw are deployed in rapid succession. 
     If the apparatus  8  includes a Doppler sensor  58 , e.g., on the second jaw  48 , the Doppler sensor  58  may be activated, e.g., using a radar actuator (not shown) on the handle  30 , to detect blood flow in the stapled tissue. For example, signals from the sensor  58  may be transmitted, e.g., via one or more wires (not shown) in the shaft  20  to a processor in the handle  30 , which may analyze the signals to confirm whether blood flow has discontinued in the stapled tissue. The apparatus  8  may include an output device, e.g., an indicator light, speaker, and the like (not shown), e.g., on the handle  30  that may provide a positive indication that blood flow has stopped. The operator may then manipulate another actuator, e.g., a slider, dial, and the like (not shown) on the handle  30  to advance the blade  60  to sever the stapled tissue from adjacent tissue. 
     If the output device indicates that blood is still flowing in the stapled tissue, additional actions may be taken to cauterize the tissue and/or stop blood flow. For example, if the apparatus  8  includes the thermal element  56 , the operator may activate the thermal element to deliver thermal energy to the stapled tissue. For example, a button or switch (not shown) on the handle  30  may be activated to deliver RF energy from a power source coupled to the handle  30  via one or more wires (not shown) in the shaft  20  to the electrode(s)  56   a  on the first jaw  46  to cauterize the stapled tissue. Energy may be delivered until the output device/Doppler sensor  58  provides a confirmation that blood flow has stopped, whereupon the blade  60  may be advanced to sever the tissue, e.g., to simultaneously sever the appendix and the appendicular artery. 
     Optionally, before severing the tissue, the second jaw  48  may be released and opened and the jaws  46 ,  48  repositioned relative to the stapled tissue and then closed and locked at one or more subsequent positions, e.g., to use the Doppler sensor  58  to confirm blood flow has stopped and/or deliver further thermal energy to cauterize the tissue. Once desired, the blade  60  may be used to sever the tissue. 
     The apparatus  8  may then be removed from the surgical space and the procedure completed using conventional methods. For example, the blade  60  may be retracted, and the Doppler sensor  58  and/or hemostasis element  56  may be deactivated (if not already). The end effector  40  may be removed from the patient&#39;s body with the second jaw  48  remaining locked to remove the excised tissue. 
     Optionally, the procedure may be illuminated and/or monitored using an illumination source and/or imaging element on the end effector  40  and/or shaft  20 , as described elsewhere herein. In addition or alternatively, other light sources and/or imaging devices may be provided to monitor the procedure. For example, a separate endoscope may be introduced into the surgical space, e.g., via a different cannula or port (not shown) than the cannula used to introduce the apparatus  8 . 
     In another alternative, a cannula or access port may be provided that includes one or more illumination and/or imaging elements, and the apparatus  8  may be introduced using the access port. For example, turning to  FIGS. 6A-6E , an exemplary embodiment of an access port  70  is shown that generally includes an elongate tubular body  72  including a proximal end  74 , a distal end  76  sized for introduction into a patient&#39;s body, and one or more lumens or passages  78  extending at least partially between the proximal and distal ends  74 ,  76 . For example, the tubular body  72  may include a primary lumen  78   a  sized to receive one or more instruments therethrough that extends from an outlet in the proximal end  74  to an outlet in the distal end  76 , such as any of the stapler apparatus described elsewhere herein. In addition, the tubular body  72  may include one or more secondary lumens (not shown), e.g., extending at least partially from thee proximal end  74  towards the distal  76 , e.g., for receiving actuator elements, wires, and/or other components, as described elsewhere herein. The tubular body  72  may be substantially rigid or alternatively at least a portion of the tubular body  72 , e.g., a distal portion, may be malleable or flexible (not shown). 
     A handle or hub  80  may be provided on the proximal end  74 , e.g., to facilitate manipulation of the access port  70  during use. The hub  80  may include one or more valves or seals (not shown), which may seal the primary lumen  78   a  yet facilitate inserting an instrument into the primary lumen  78   a,  e.g., providing a substantially fluid-tight seal around the instrument. In this manner, the seal(s) may prevent insufflation gas or other fluid to escape through the primary lumen  78   a,  e.g., when the access port is introduced into a patient&#39;s body, as described elsewhere herein. 
     In addition, a display or other output device  82  may be provided on the hub  80 , e.g., to facilitate observing or otherwise monitoring the procedure using one or more imaging devices on the access port  80 . For example, a distal portion of the tubular body  72  may include a pair of deployable arms  84  including first ends  84   a  pivotally coupled to the tubular body  72  and second or free ends  84   b  that may carry one or more cameras, light sources, and/or other imaging device, as described further below. 
     In one embodiment, the display  82  may be removably mountable on the hub  80 , which may include one or more connectors or cables (not shown) that may be coupled to corresponding connectors on the hub  80 , which are, in turn, coupled to one or more wires extending to the imaging device(s) on the arms  84 . Thus, in this alternative, the display  82  may be reusable and the tubular body  72  may be disposable/single-use. Alternatively, the display  82  may be permanently mounted to the hub  80  and one or more wires or other elements may communicate with the imaging device(s). Thus, in this alternative, the entire access port  80  may cleaned and reused or may be single-use. In a further alternative, the access port  80  may include a communications interface that may transmit signals from the imaging device wirelessly, e.g., using Bluetooth or other communications protocols, to allow images to be presented on a remote display. 
     In an exemplary embodiment, a CMOS, CCD, or other imaging element (not shown) may be provided on the free end  84   b  of one of the arms  84  and one or more LEDs or other light sources may be provided on the free end  84   b  of the other arm  84 . Alternatively, separate light sources and imaging elements may be provided on both arms, e.g., to provide multiple images simultaneously on the display  82 . In a further alternative, only one arm may be provided, if desired, including one or more light sources and/or imaging elements on its free end. 
     In any of these embodiments, one or more wires may transmit signals from the imaging element(s) to the display  82 , which may include a processor to process the signals and present the images on a screen of the display  82 . The imaging element(s) may include a field of view oriented distally beyond the distal end  76  of the tubular body  72 , e.g., to illuminate and/or image an instrument deployed within a region beyond the distal end  76 . 
     The arms  84  are movable between a retracted configuration, e.g., as shown in  FIGS. 6A and 6D , which may facilitate introduction into a patient&#39;s body, and a deployed configuration, e.g., as shown in  FIGS. 6B, 6C, and 6E , where the imaging device may be used to acquire images during a procedure. In one embodiment, the arms  84  may be biased to the retracted configuration, but may be directed to the deployed configuration when an instrument is inserted into the primary lumen  78   a,  as described further below. Alternatively, the arms  84  may be actuated (or moved) by a user selectively between the retracted and deployed configurations, if desired. 
     For example, with particular reference to  FIGS. 6D and 6E , the first ends  84   a  of the arms  84  may include ramps or other features  84   c  that extend partially into the primary lumen  78   a.  Consequently, when an instrument is inserted into the lumen  78   a,  the instrument may contact the ramps  84   c,  thereby deflecting the arms  84  outwardly to the deployed configuration. As can be seen in  FIG. 6E , in the deployed configuration, the ramps  84   c  may be substantially flush with the wall of the tubular body  72  such that the ramps  84   c  do not interfere with manipulation of the instrument. When the instrument is removed, the arms  84  may return automatically back towards the retracted configuration. Alternatively, the arms  84  may remain deployed until actuated or until the access port  70  is removed, e.g., whereupon the arms may be collapsed inwardly as they contact tissue along the exit path. In another alternative, a circumferential light source, such as a circular Xenon LED lamp (not shown) may be provided on the distal end of the access port instead of the arms. 
     Turning to  FIGS. 7A-7D , an exemplary embodiment of a staple or clip  90  is shown that may be delivered using any of the stapler apparatus herein. Generally, the staple  90  includes a base  92 , e.g., a substantially straight segment, from which first and second tines  94 ,  96  extend, e.g., substantially perpendicular to the base  92 . The tines  94 ,  96  may be substantially straight terminating in respective tips  95 ,  97 . Thus, for example, the base  92  and tines  94 ,  96  may define a substantially rectangular “U” shape, e.g., with rounded transitions between the base  92  and the tines  94 ,  96 . As shown, the first tine  94  has a length that is substantially shorter than the second tine  96 . In addition, the second tine  96  has a length from the base  92  to its tip  97  that is longer than the length of the base  92 . Consequently, the second tine  96  may be bent or otherwise deformed towards the first tine  94 , e.g., as shown in  FIG. 7D . 
     In the example shown, the staple  90  has a cross section that is substantially uniform along the length of the staple  90 , e.g., along a length of the first tine  94 , along the base  92 , and along the second tine  96 . For example, the staple may have a substantially rectangular (with or without sharp corners), oblong, or other generally flattened cross-section, e.g., having a width “w” that is thicker than a thickness “t,” as indicted in  FIGS. 7A-7D . 
     In addition, the first tine  94  includes a notch  98  adjacent its tip  95  configured to receive the tip  97  of the second tine  96  when it is deformed. For example, as shown, the tip  97  of the second tine  97  may be beveled such that the tip  97  tapers towards the first tine  94 , which may enhance the tip  97  being locked into the notch  98 . Alternatively, as shown in  FIG. 8A , the tip  97   a  of the second tine  96   a  may be beveled in the opposite direction, i.e., away from the first tine  92   a.  In addition, or alternatively, the staple may include different ridges for different thickness compression. 
     Optionally, as shown in  FIG. 8C , the first tine  94   c  may include a plurality of notches  98   c  spaced apart from one another along the length of the first tine  94   c.  Thus, in this embodiment, the tip  97   c  of the second tine  96   c  may be ratcheted sequentially into the notches  98   c,  e.g., simply locked into the top notch  98   c  or down into one of the notches further down on the first tine  94   c.  Although three notches  98   c  are shown in  FIG. 8C , it will be appreciated that any desired number of notches (two or more) may be provided on the first tine  94   c.  Alternatively, the first tine may be provided without any notches (not shown), and the stapler actuator may be configured to bend or otherwise deform the tip of the first tine over the second tine (after the second tine has been bent). 
     In another option, shown in  FIG. 8B , a radius of the transition between the base  92   b  and the second tine  96   e  may be increased, e.g., compared to the staple  90  shown in  FIG. 7C , which may reduce the force to bend the second tine  96   e  during use. In yet another option, shown in  FIG. 8D , the tip  95   d  of the first tine  94   d  may include a bevel that is oriented towards the second tine  96   d  (as opposed to being oriented away from the second tine  96 , as in the staple  90  shown in  FIG. 7C ). In still another option, shown in  FIG. 8E , a staple  90   e  may be provided that includes a bump  93   e  in the base  92   e,  which may be configured to enhance the pinching/closure of the tissues entrapped within the staples. It will be appreciated that any of these options may be included in one or more of the staples included in any of the stapler apparatus described elsewhere herein. 
     With additional reference to  FIGS. 3A-3C , a plurality of staples, such as staple  90  shown in  FIGS. 7A-7D  (or any of the alternatives) may be provided in each of the receptacles  52  in the first jaw  46 . With the receptacles  52  aligned along the axis  26  of the shaft  20 , the base  92  of each staple  90  may be seated at the bottom of the respective receptacle with the first tine  94  closer to the distal tip  46   b  of the first jaw  46  and the second tine  96  closer to the proximal housing  42  (or reverse). Consequently, as the staples are deployed upwardly from the receptacles  52 , both tines  94 ,  96  may be driven through the tissue adjacent the contact surface  46   a  of the first jaw  46 , and the second tines  96  may then be received in the respective recesses  54  in the second jaw  48  as the staples are pushed upward toward the second jaw  48 . This action may facilitate bending the second tines  96  distally towards the first tines  94 . Thus, the second tines  96  may be bent or otherwise deformed above the tissue towards the tips  93  of the first tines  94  until the tips  97  of the second tines  96  are received in the respective notches  98 , thereby locking the staples  90  and compressing the captured tissue. 
     Turning to  FIGS. 9-12 , another exemplary embodiment of an access port  170  is shown that includes an elongate tubular body  172  and a video module  180  that may be coupled to the tubular body  172 , e.g., to allow introduction of one or more instruments through the port  170  into a surgical space within a patient&#39;s body while acquiring images within the surgical space, generally similar to other embodiments herein. As shown in  FIG. 10 , the tubular body  172  includes a proximal end  174 , a distal end  176  sized for introduction into a patient&#39;s body, and one or more lumens or passages  178  extending between the proximal and distal ends  174 ,  176 . For example, the tubular body  172  may include a primary lumen  178   a  sized to receive one or more instruments therethrough, such as the stapler apparatus  8  shown in  FIGS. 13A and 13B  and/or described elsewhere herein. In addition, the tubular body  172  includes one or more secondary lumens  178   b,  e.g., positioned within a sidewall of the tubular body  172  around the primary lumen  178   a.  For example, as best seen in  FIGS. 12A and 12B , three secondary lumens  178   b  may be positioned together on one side of the primary lumen  178   a  and a fourth secondary lumen  178   b  may be provided on an opposite side of the primary lumen  178   a  to acquire two sets of images simultaneously, as described further elsewhere herein. Outlets  179   b  of the secondary lumens  178   b  at the distal end  176  may be open or may include a transparent cover, membrane, and the like (not shown) to prevent bodily fluids or other materials from entering the secondary lumens  178   b  from the distal end  176 . The tubular body  172  may be substantially rigid or alternatively at least a portion of the tubular body  172 , e.g., a distal portion, may be malleable or flexible (not shown). 
     The video module  180  generally includes an annular hub  182  from which a plurality of elongate sleeves, tubes, or other imaging elements  184  extend, e.g., provided in an arrangement corresponding to the secondary lumens  178   b  in the tubular body  172 . The imaging sleeves  184  may be sized to be inserted into the secondary lumens  178   b  simultaneously from the proximal end  174  of the tubular body  172  such that distal tips  184   b  thereof are disposed adjacent the distal end  176  of the tubular body  172 , e.g., extending slightly from the outlets  184   b  for acquiring images beyond the distal end  176 . 
     Optionally, the proximal end  174  of the tubular body  172  and the hub  182  may include cooperating connectors (not shown) to removably couple the hub  182  to the tubular body  172 , e.g., such that the access port  170  may be manipulated as a unitary device. 
     In addition, one or both of the proximal end  174  of the tubular body  172  and the hub  182  may include one or more valves or seals (not shown), e.g., to seal the primary lumen  178   a  yet facilitate inserting an instrument into the primary lumen  178   a,  e.g., providing a substantially fluid-tight seal around the instrument. In this manner, the seal(s) may prevent insufflation gas or other fluid to escape through the primary lumen  178   a,  e.g., when the access port  170  is introduced into a patient&#39;s body, as described elsewhere herein. 
     In addition, a display or other output device  186  may be provided on the hub  182 , e.g., to facilitate observing or otherwise monitoring the procedure using one or more imaging devices on the access port  170 . In one embodiment, the display  186  may be removably mountable on the hub  182 , which may include one or more connectors or cables (not shown) that may be coupled to corresponding connectors on the hub  182 . Alternatively, the display  186  may be permanently mounted to the hub  182 . In a further alternative, a display may be provided separate from the access port  170  and images may be transmitted wirelessly or via wired connection from the access port  170 , similar to other embodiments herein. 
     Each sleeve  184  may include an elongate tubular body, e.g., formed from stainless steel or other metal, plastic, and/or composite material including a lumen for carrying one or more imaging components. The sleeves  184  may be substantially rigid or, alternatively, may be sufficiently flexible to follow the shape of the lumens  178   b,  e.g., if the tubular body  172  is malleable or flexible and directed to a nonlinear shape. 
     In an exemplary embodiment, at least one of the imaging sleeves  184  may carry a CMOS, CCD, or other camera (not shown) on its distal tip  184   b  to acquire the images. Alternatively, a lens may be provided on the distal tip  184   b  and a fiberoptic cable or other optical conductor (also not shown) may extend through the imaging sleeve  184  to the proximal end  184   a,  where the conductor may be coupled to a camera to acquire the images. 
     Similarly, at least one of the imaging sleeves  184  may carry an illumination source, e.g., an LED or other light source, on its distal tip  184   b  for transmitting light beyond the distal end  176  of the tubular body  172 . Alternatively, the LED or other light source may be provided within the hub  180 , and an optical conductor may extend from the proximal end  184   a  of the imaging sleeve  184  to its display tip  184   b.  In the example shown, the video module  180  includes a pair of sleeves  184  on opposite sides of the primary lumen  178   a  carrying cameras on distal tips  184 ( 1 ), and a pair of sleeves  184  on opposite sides of one of the camera sleeves carrying an LED or other illumination source on the distal tips  184 ( 2 ) (or may carry lenses coupled to cameras or LEDs), e.g., providing a field of view as shown in  FIG. 9C . In this configuration, images may be acquired substantially simultaneously from opposite distal tips  184   b ( 1 ) to provide binocular imaging on either side of the end effector  40  (as shown in  FIG. 13B ), with the distal tips  184   b ( 2 ) providing off-axis illumination to minimize shadows or otherwise enhance illumination within a surgical space. 
     During use, the imaging elements  184  may be inserted into inlets  175   b  from the proximal end  174  of the tubular body  172  into the corresponding secondary lumens  178   b  until the distal tips  184   b  are positioned adjacent the distal end  176  of the tubular body  172 , e.g., extending a desired distance from the outlets  179   b  to allow acquisition of images. Optionally, when the imaging elements  184  are fully inserted, connectors on the hub  182  and/or proximal end  174  may engage to secure the video module  180  relative to the tubular body  172 . The assembled access port  170  may then be introduced into a patient&#39;s body to allow introduction of one or more instruments to be introduced to perform a surgical procedure while acquiring images of the procedure, similar to other embodiments herein. For example, as shown in  FIGS. 13A and 13B , an end effector  40  of a stapler apparatus  8  may be inserted through the primary lumen  178   a  to staple and/or remove tissue, as described elsewhere herein. 
     Upon completing the procedure, any instruments may be removed from the primary lumen  178   a,  and the port  170  may be removed from the patient&#39;s body using conventional methods. The video module  180  may be removed from the tubular body  172  and then cleaned, sterilized, and/or otherwise prepared for use again in a subsequent procedure. The tubular body  172  may be single-use, and may be discarded after the procedure. Alternatively, the tubular body  172  may also be cleaned, sterilized, and/or otherwise prepared for reuse. 
     Turning to  FIG. 14 , another exemplary embodiment of a stapler apparatus  208  is shown that includes a video module  280  integrated into a reusable shaft/handle portion  210 . Generally, the handle portion  210  includes a shaft  220  extending from a handle  230  including actuation components (not shown), e.g., such that a disposable end effector (not shown) may be coupled to a distal end  224  of the shaft  220 , similar to other embodiments herein. 
     Unlike the previous embodiments, a plurality of elongate imaging sleeves  284  also extend from the handle portion  210 , e.g., from a hub  282  from which the shaft  220  also extends. As shown, the imaging sleeves  284  may be positioned radially around the shaft  220  and may have a length longer than the shaft  220  such that distal tips  284   b  of the imaging sleeves  284  extend distally beyond the distal end  224  of the shaft  220 . The video module  280  may also include a display  286  mounted on the hub  282  (or elsewhere on the handle portion  210  and/or remote from the apparatus  280 , as desired) coupled to one or more cameras and/or illumination sources (not shown) that may be used to acquire images beyond the distal tips  184   b.    
     An end effector (not shown) may be coupled to the distal end  224  of the shaft  220  generally similar to other embodiments, e.g., to staple, cauterize, and/or remove tissue. In addition, the housing of the end effector may include a plurality of secondary lumens (also not shown) that may receive the imaging sleeves  284  such that the distal tips  284   b  are disposed adjacent jaws of the end effector, e.g., similar to the configuration shown in  FIG. 13B . 
     During use, a desired end effector may be received over the imaging sleeves  284  and coupled to the distal end  224  of the shaft. Optionally, a cartridge (not shown) may be loaded into one of the jaws of the end effector and then the end effector may be introduced into a patient&#39;s body to perform a surgical or other medical procedure, similar to other embodiments herein. IN this manner, the video module  280  may be used to acquire images during the procedure. Upon completing the procedure, the apparatus  208  may be removed, the end effector may be removed and, optionally discarded, and the handle portion  210  may be cleaned and/or otherwise prepared for use in another procedure, also similar to other embodiments herein. 
     Alternatively, it will be appreciated that other staples or clips may be delivered using any of the stapler apparatus herein, such as those described in the provisional application incorporated by reference herein. 
     It will be appreciated that elements or components shown with any embodiment herein are exemplary for the specific embodiment and may be used on or in combination with other embodiments disclosed herein. In addition, although the apparatus herein have been described for particular use during an appendectomy procedure. It will be appreciated that the apparatus and methods herein may be used in a variety of surgical procedures, e.g., including open, minimally invasive, laparoscopic, and other procedures, where it is desired to staple and remove target tissues, e.g., within a patient&#39;s intestine, lungs, vasculature, and other locations. 
     While the invention is susceptible to various modifications, and alternative forms, specific examples thereof have been shown in the drawings and are herein described in detail. It should be understood, however, that the invention is not to be limited to the particular forms or methods disclosed, but to the contrary, the invention is to cover all modifications, equivalents and alternatives falling within the scope of the appended claims.