Patent Publication Number: US-2020289113-A1

Title: Devices and methods for endoluminal plication

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
     The present application is a continuation of U.S. patent application Ser. No. 16/377,533, entitled “Devices and Methods for Endoluminal Plication” filed Apr. 8, 2019, which is a continuation of U.S. patent application Ser. No. 14/880,537, entitled “Devices And Methods For Endoluminal Plication” filed Oct. 12, 2015, now U.S. Pat. No. 10,292,703, which is a continuation of U.S. patent application Ser. No. 13/326,669, entitled “Devices And Methods For Endoluminal Plication” filed Dec. 15, 2011, now U.S. Pat. No. 9,173,657, which are hereby incorporated by reference in their entireties. 
    
    
     FIELD 
     This invention is related generally to devices and methods for performing surgical procedures, and more particularly to endoscopic devices and methods for forming an endoluminal plication to reduce the volume of the gastric cavity. 
     BACKGROUND 
     Metabolic disease is a serious medical condition that affects more than 30% of the U.S. population and can contribute significantly to morbidity and mortality. Complications associated with metabolic disease include obesity, hypertension, diabetes, coronary artery disease, stroke, congestive heart failure, multiple orthopedic problems, pulmonary insufficiency, sleep apnea, infertility, and markedly decreased life expectancy. Additionally, the complications or co-morbidities associated with metabolic disease, such as obesity, often affect an individual&#39;s quality of life. Accordingly, the monetary, physical, and psychological costs associated with metabolic disease can be substantial. For example, it is estimated that costs related to obesity alone exceed more than 100 billion dollars annually. 
     A variety of bariatric surgical procedures have been developed to treat complications of metabolic disease, such as obesity. The most common of these is the Roux-en-Y gastric bypass (RYGB). In a RYGB procedure, a small stomach pouch is separated from the remainder of the gastric cavity and attached to a resectioned portion of the small intestine. However, because this complex procedure requires a great deal of operative time, as well as extended and often painful post-operative recovery, the RYGB procedure is generally only utilized to treat people with morbid obesity. 
     In view of the highly invasive nature of the RYGB procedure, other less invasive bariatric procedures have been developed such as the Fobi pouch, bilio-pancreatic diversion, gastroplasty (“stomach stapling”), vertical sleeve gastrectomy, and gastric banding. In addition, implantable devices are known which limit the passage of food through the stomach. Gastric banding procedures, for example, involve the placement of a small band around the stomach near the junction of the stomach and the esophagus to restrict the passage from one part of the digestive tract to another, thereby affecting a patient&#39;s feeling of satiety. 
     While the above-described bariatric procedures are commonly used for the treatment of morbid obesity (i.e., greater than 100 pounds over one&#39;s ideal body weight), the risks of these procedures often outweigh the potential benefits for the growing segment of the population that is considered overweight. The additional weight carried around by these persons can still result in significant health complications, but does not justify more invasive treatment options. However, because conservative treatment with diet and exercise alone may be ineffective for reducing excess body weight, there is a need for treatment options that are less invasive and lower cost than the procedures discussed above. 
     It is known to create cavity wall plications through both laparoscopic and endoscopic procedures. Laparoscopic plication techniques can be complicated and complex, however, as one or more surgical entry ports must be employed to gain access to the surgical site. Furthermore, laparoscopically approaching the stomach often requires separating the surrounding omentum prior to plication formation. In endoscopic procedures, plication depth has traditionally suffered due to the size restrictions of the endoscopic lumen. For example, the rigid length and diameter of a surgical device are limited based on what sizes can be reliably and safely passed trans-orally into the stomach. Furthermore, access and visibility within the gastric and peritoneal cavities is progressively limited in an endoscopic procedure as the extent of the reduction increases because the volume of the gastric cavity is reduced. 
     In addition, prior art devices for forming endoluminal plications often utilize opposing jaws and a grasper element to draw tissue between the jaws. The prior art devices approach the cavity wall such that a longitudinal axis of the device is perpendicular to the cavity wall. The grasper element can then be advanced from the center of the open jaws, and used to draw tissue between the jaws to create the fold. However, the geometry of these devices limits the size of the plication that can be formed to approximately the length of the jaws, as the grasper can only draw the cavity wall tissue to the center of the jaws and no farther. Moreover, in order to secure a plication with a plurality of fasteners, prior art devices must release the tissue and be repositioned anew to apply each fastener. 
     With the foregoing in mind, it is desirable to have methods and devices for forming tissue folds, such as serosa-to-serosa tissue folds within the gastric lumen, that overcome any of the aforementioned problems. 
     SUMMARY 
     The present invention generally provides devices and methods for forming and securing plications of tissue. More particularly, the devices and methods of the present invention can be used to create and secure plications of gastric tissue on the anterior and posterior walls of a patient&#39;s gastric cavity to reduce the volume of the cavity. 
     In one aspect of the invention, a tissue acquisition and fixation system is provided that includes a staple applying assembly having first and second jaws. At least one of the jaws is movable such that the first and second jaws have an open position for receiving tissue and a closed position for engaging tissue. The first and second jaws can be effective to apply at least one staple to tissue engaged between the first and second jaws. The system also includes a tissue acquisition member positioned in a first plane that extends substantially parallel to a second plane extending through each of the first and second jaws. The tissue acquisition member can be effective to engage tissue and to position the engaged tissue between the first and second jaws. 
     In some embodiments, the tissue acquisition member can be movable between a first position in which the tissue acquisition member is disposed substantially between the first and second jaws, and a second position in which the tissue acquisition member is offset from the first and second jaws. The tissue acquisition member can be, for example, offset vertically above the first and second jaws. 
     In other embodiments, the staple applying assembly can include an elongate shaft having proximal and distal ends. The staple applying assembly can be coupled to the distal end of the elongate shaft to facilitate inserting the staple applying assembly into, for example, the stomach of a patient via the esophagus. 
     In still other embodiments, the first jaw of the staple applying assembly can be pivotally connected to the second jaw and can include an anvil portion configured to form a staple ejected from the second jaw. 
     In some embodiments, the second jaw of the staple applying assembly can include a stapler portion configured to retain a plurality of staples. The second jaw can also include a staple former configured to eject at least one of the plurality of staples from the stapler portion. In certain embodiments, the staple former can be configured to eject more than one staple simultaneously. In an exemplary embodiment, the second jaw can include a forming link slidably connected to the staple former and a firing link slidably and pivotally connected to the forming link. Further, the forming link and the firing link can both be pivotally coupled to the second jaw. These components can form a firing linkage effective to eject one or more staples from the stapler portion of the second jaw. 
     In order to adjust the relative position of the jaws, the system can, in some embodiments, include a positioning cable connected to the first jaw and configured to move the first jaw relative to the second jaw. 
     The tissue acquisition member, in some embodiments, can include a vacuum pod configured to draw tissue against the tissue acquisition member. Furthermore, the tissue acquisition member can include a hinge assembly configured to permit movement of the tissue acquisition member between a first position, in which the tissue acquisition member is disposed below a superior surface of the first and second jaws, and a second position, in which the tissue acquisition member is disposed above the superior surface of the first and second jaws. The hinge assembly can include, for example, a hinge member pivotally connected to the first jaw. In some embodiments, the hinge assembly can also include a positioning cable connected to the hinge assembly and configured to control movement of the tissue acquisition member between the first and second positions. 
     In another aspect of the invention, a tissue acquisition and fixation system is provided that includes an elongate shaft having proximal and distal ends, first and second jaws extending from the distal end of the elongate shaft, and a tissue acquisition member coupled to the first jaw. At least the first jaw can be movable between an open position in which the jaws are configured to receive tissue, and a closed position in which the jaws are effective to engage tissue. The jaws can be effective to apply at least one staple to tissue engaged between the jaws, and the tissue acquisition member can be effective to engage tissue and to position tissue between the first and second jaws. Further, movement of the first jaw between the open and closed position can be effective to cause corresponding movement of the tissue acquisition member. 
     In some embodiments, the tissue acquisition member can be movable in at least one of a vertical direction and a longitudinal direction relative to the first and second jaws. This freedom of relative movement can allow the tissue acquisition member to draw tissue through the first and second jaws. 
     In other embodiments, the tissue acquisition member can include a surface configured to engage tissue, and the surface can extend along a plane that is parallel to the first and second jaws. Further, the surface can include at least one vacuum port formed therein and configured to draw tissue against the surface. 
     In another aspect of the invention, a tissue acquisition and fixation system is provided that includes a stapling member having first and second jaws and a tissue acquirer coupled to at least one of the first and second jaws. The first and second jaws can be configured to move between an open position for receiving tissue and a closed position for engaging tissue. Further, the first and second jaws can be effective to apply at least one staple to tissue engaged between the first and second jaws. The tissue acquirer can be configured to engage tissue and to draw tissue up through the first and second jaws. 
     In some embodiments, the tissue acquirer can be coupled to at least one of the first and second jaws by a linkage configured to allow movement of the tissue acquirer with respect to the first and second jaws. The linkage can include a hinge mechanism and a connecting arm extending between the tissue acquirer and at least one of the first and second jaws. In some embodiments, the linkage can further include a second hinge mechanism and a second connecting arm extending between the tissue acquirer and at least one of the first and second jaws. The second hinge mechanism can be effective to maintain an orientation between the tissue acquirer and at least one of the first and second jaws throughout a range of motion of the linkage. The range of motion of the linkage can include moving the tissue acquirer any of vertically and longitudinally with respect to the first and second jaws. 
     In certain embodiments, the system can further include an indexing mechanism coupled to the tissue acquirer and the stapling member and configured to translate the tissue acquirer longitudinally relative to the stapling member. This indexing mechanism can, in some embodiments, be selected from the group consisting of a lead screw, a rack, and a pinion gear set. 
     In still other embodiments, the system can include a secondary acquirer coupled to the tissue acquirer and configured to engage tissue to maintain its position relative to the tissue acquirer. The secondary acquirer can, in some embodiments, be selected from the group consisting of a hook, a grasper, and a clamp pivotally connected to the tissue acquirer. The secondary acquirer can aid in holding tissue to the tissue acquirer, which can be configured to couple a vacuum source such that the tissue acquirer is effective to suction tissue against the tissue acquirer. 
     In another aspect of the invention, a tissue acquisition and fixation system includes an elongate shaft having proximal and distal ends, an end effector coupled to the distal end of the elongate shaft and having first and second jaws, and a tissue acquisition member coupled to the end effector by a linkage assembly. The first and second jaws can have an open position configured to receive tissue therebetween, and a closed position in which the first and second jaws are effective to engage tissue positioned therebetween. Further, at least a portion of at least one of the tissue acquisition member and the linkage assembly can be slidably movable along a longitudinal axis extending parallel to a longitudinal axis of at least one of the first and second jaws. The tissue acquisition member can also be vertically movable relative to the end effector such that a distance between a longitudinal axis of the tissue acquisition member and a longitudinal axis of at least one of the first and second jaws can be adjusted. 
     In some embodiments, the first and second jaws can be configured to drive at least one fastener through tissue positioned therebetween in the closed position. This can be done using, for example, the firing mechanisms discussed herein. 
     In other embodiments, the system can include a lead screw effective to slidably move at least a portion of the tissue acquisition member along a longitudinal axis extending substantially parallel to a longitudinal axis of at least one of the first and second jaws. The lead screw can be actuated by rotation of a cable extending through the elongate shaft. Further, at least a portion of the tissue acquisition member can be configured to move vertically relative to the end effector in response to longitudinal translation of the cable. 
     In still other embodiments, the end effector can include a lead screw effective to slidably move at least a portion of the tissue acquisition member and the linkage assembly along a longitudinal axis extending substantially parallel to a longitudinal axis of at least one of the first and second jaws. 
     In certain embodiments, the linkage assembly can include a gear rack and the end effector can include a pinion gear effective to slidably move the linkage assembly and tissue acquisition member along a longitudinal axis extending parallel to a longitudinal axis of at least one of the first and second jaws. 
     In some embodiments, the end effector can include a hinge pin and the linkage assembly can include a hinge base having a plurality of indexed grooves configured to seat the hinge pin. The system can further include a cable connected to the linkage assembly and configured to slidably move the hinge base relative to the hinge pin to seat the hinge pin in any one of the plurality of indexed grooves. 
     In another aspect of the invention, a tissue acquisition and fixation system is provided that includes an elongate shaft having a longitudinal axis, an end effector coupled to a distal end of the elongate shaft, and a tissue acquisition member coupled to the end effector. The end effector can have a fixed jaw and a movable jaw that pivots relative to the fixed jaw, and the tissue acquisition member can be limited to (1) movement along a longitudinal axis of the tissue acquisition member, and (2) movement perpendicular to a first plane extending through the first and second jaws. 
     In some embodiments, the system can include a lead screw coupled to the tissue acquisition member to allow at least a portion of the tissue acquisition member to translate along the longitudinal axis of the tissue acquisition member. The lead screw can be driven by rotation of a cable extending through the elongate shaft. 
     In other embodiments, the system can include a hinge assembly connecting the tissue acquisition member to the end effector. And, in some embodiments, the lead screw can be coupled to the hinge assembly to allow at least a portion of the hinge assembly and the tissue acquisition member to translate along a longitudinal axis of the tissue acquisition member. 
     In certain other embodiments, the system can instead include a rack gear coupled to the tissue acquisition member and a pinion gear coupled to the end effector to allow the tissue acquisition member to translate along a longitudinal axis of the tissue acquisition member. 
     In one aspect of the invention, a tissue acquisition and fixation system is provided including a stapling member having first and second jaws, a tissue acquisition member coupled to at least one of the first and second jaws, and a secondary tissue acquirer coupled to the tissue acquisition member. The first and second jaws can be configured to move between an open position for receiving tissue and a closed position for engaging tissue. The first and second jaws can also be effective to apply at least one staple to tissue engaged between the first and second jaws. The tissue acquisition member can be configured to engage tissue and to position the tissue between the first and second jaws. Finally, the secondary tissue acquirer can be configured to engage tissue and maintain the tissue in position relative to the tissue acquisition member. 
     In some embodiments, the secondary tissue acquirer can include at least one hook configured to grasp tissue drawn against the tissue acquisition member. The at least one hook can be coupled to a rotatable shaft extending parallel to a longitudinal axis of the tissue acquisition member such that rotation of the shaft is effective to engage the at least one hook with tissue drawn against the tissue acquisition member. The secondary tissue acquirer can also include an actuating cable coupled to the rotatable shaft such that rotation of the actuating cable is effective to rotate the shaft and thereby engage the at least one hook with the tissue. 
     In other embodiments, the tissue acquisition member can include a surface configured to engage tissue, and the at least one hook can be pivotally coupled to the tissue acquisition member such that the at least one hook pivots in a plane parallel to a plane defined by the surface. Pivoting of the at least one hook can be effected by translation of at least one suture or thin actuating cable attached to an end of each of the at least one hook. The at least one hook can include a spring attached to each of the at least one hook and configured to bias the at least one hook to a first position, such as a retracted position. 
     In certain embodiments, the secondary tissue acquirer can include at least one hinged grasper configured to engage tissue drawn against the tissue acquisition member. Further, the secondary tissue acquirer can include a cable coupled to the at least one grasper and configured to move the at least one grasper from an open position for receiving tissue to a closed position for engaging tissue. In some embodiments, the at least one grasper can be disposed on a distal end of the tissue acquisition member. 
     In still other embodiments, the secondary tissue acquirer can include at least one clamp configured to engage tissue drawn against the tissue acquisition member. In some embodiments, the secondary tissue acquirer includes at least two clamps that are pivotally coupled to opposing surfaces of the tissue acquisition member. The system can further include a wedge member slidably mounted to a top surface of the tissue acquisition member and configured to engage the at least two clamps such that the at least two clamps engage tissue drawn against the tissue acquisition member. A cable can be coupled to the wedge member and configured to slidably move the wedge member, thereby controlling the clamps. 
     In another aspect of the invention, a tissue acquisition and fixation system is provided that includes an elongate shaft having proximal and distal ends, a staple applying assembly having a proximal end coupled to the distal end of the elongate shaft and having first and second jaws, and a tissue acquisition member coupled to the staple applying assembly by a linkage mechanism. At least one of the jaws can be movable such that the first and second jaws have an open position for receiving tissue and a closed position for engaging tissue. The first and second jaws can be effective to apply at least one staple to tissue engaged between the first and second jaws. The tissue acquisition member can be effective to engage tissue and to position the engaged tissue between the first and second jaws. Further, the linkage mechanism can be configured to move the tissue acquisition member between a first position that is longitudinally offset and proximal to the staple applying assembly, and a second position that is longitudinally adjacent to the staple applying assembly. 
     In some embodiments, a distal end of the tissue acquisition member can be disposed proximal to the proximal end of the staple applying assembly in the first position. Further, the distal end of the tissue acquisition member can be disposed longitudinally adjacent to a distal end of the staple applying assembly in the second position. 
     In some embodiments, the first jaw can include an anvil for forming a staple, and the second jaw can include a staple cartridge configured to house two or more rows of staples. The staple applying assembly can further include at least one firing wedge in each staple row that is configured to selectively eject at least one staple from the staple row. Each of the at least one firing wedges can be selectively controllable by a user, and each of the at least one firing wedges can be controlled by translation of an actuating cable. 
     In some other embodiments, the tissue acquisition member can include a vacuum pod configured to couple to a vacuum source and apply a vacuum force to draw surrounding tissue against at least one surface of the tissue acquisition member. The tissue acquisition member can also include a secondary acquirer coupled to the tissue acquisition member and configured to engage tissue and maintain the tissue in position relative to the tissue acquisition member. The secondary acquirer can be selected from the group consisting of hooks, graspers, or clamps coupled to the tissue acquisition member. 
     In certain embodiments, at least a portion of the tissue acquisition member can be movable across a plane defined by a superior surface of the first and second jaws in the second position. Furthermore, in some other embodiments, the linkage mechanism can be further configured to move the tissue acquisition member to a third position in which the tissue acquisition member is vertically offset from the first and second jaws such that tissue engaged by the tissue acquisition member can be disposed between the first and second jaws. 
     The present invention also provides methods of using the devices disclosed herein to create one or more folds to, for example, reduce gastric cavity volume. In one aspect, a method of acquiring and fixating tissue is provided that includes inserting a surgical device having first and second jaws and a tissue acquisition member into a hollow body lumen, positioning the surgical device in a first position, drawing tissue through the jaws and against the tissue acquisition member, and actuating the surgical device. In the first position the first and second jaws can extend substantially parallel to a tissue surface and the tissue acquisition member can be positioned on an opposite side of the jaws from the tissue. Actuating the surgical device can include moving the tissue acquisition member away from the first and second jaws to draw the tissue through the first and second jaws, closing the first and second jaws, and driving at least one fastener through the tissue disposed between the first and second jaws. 
     In some embodiments, positioning the surgical device in the first position can further include positioning the surgical device such that the first and second jaws are substantially parallel to the tissue. In addition, the tissue acquisition member can be connected to any of the first and second jaws by a hinge assembly and positioning the surgical device in the second position can further include actuating a positioning cable connected to the hinge assembly to cause the tissue acquisition member to move relative to the first and second jaws. 
     In other embodiments, driving at least one fastener through the tissue can include actuating a firing linkage to drive a fastener out of the second jaw, through the tissue disposed between the first and second jaws, and against the first jaw. Furthermore, drawing tissue against the tissue acquisition member can include actuating a vacuum source to suction the tissue against the tissue acquisition member. 
     In another aspect of the invention, a method of acquiring and fixating tissue is provided that includes positioning a stapling member having first and second jaws adjacent to a tissue surface, engaging the tissue surface with a tissue acquirer, moving the tissue acquirer to draw tissue up through the first and second jaws, moving the first and second jaws to a closed position to engage the tissue therebetween, and applying at least a first staple. Positioning the stapling member can include ensuring that a longitudinal axis of at least one of the first and second jaws is parallel to the tissue surface. Applying at least a first staple can include firing a staple from at least one of the first and second jaws through the tissue disposed between the first and second jaws. 
     In some embodiments, the method can further include moving the first and second jaws to an open position, moving the tissue acquirer to reposition the tissue disposed between the first and second jaws, moving the first and second jaws to the closed position, and applying at least a second staple from at least one of the first and second jaws. In other embodiments, the method can include, prior to moving the tissue acquirer, actuating a secondary tissue acquirer that can be effective to engage tissue to retain the position of the tissue surface relative to the tissue acquirer. 
     In certain embodiments, moving the tissue acquirer to draw tissue up through the first and second jaws can include translating a positioning cable coupled to the tissue acquirer. Furthermore, the step of engaging the tissue surface can include activating a vacuum source to draw the tissue surface against the tissue acquirer. 
     In another aspect of the invention, a method of acquiring and fixating tissue includes positioning a surgical device having first and second jaws and a tissue acquisition member such that a longitudinal axis of the device is parallel to a tissue surface and the tissue acquisition member is on an opposite side of the first and second jaws from the tissue surface. The method can further include applying a vacuum force to draw the tissue surface through the jaws and against the tissue acquisition member, and moving the tissue acquisition member in a direction away from the tissue surface to further draw tissue through the first and second jaws to create a tissue fold. 
     In some embodiments, the tissue acquisition member can be connected to any of the first and second jaws by a hinge assembly, and positioning the surgical device can include actuating a positioning cable connected to the hinge assembly to cause the tissue acquisition member to move relative to the first and second jaws. 
     In other embodiments, the method can further include driving at least one fastener through the tissue fold disposed between the first and second jaws. In certain embodiments, driving at least one fastener through the tissue can include actuating a firing linkage to drive a fastener out of the second jaw, through the tissue fold disposed between the first and second jaws, and against the first jaw. 
     In some other embodiments, the method can include, prior to moving the tissue acquisition member, actuating a secondary tissue acquirer effective to engage tissue to retain the position of the tissue surface relative to the tissue acquisition member. 
     In still another aspect of the invention, a method of acquiring and fixating tissue using a plurality of fasteners includes positioning a surgical device having a stapling member and a tissue acquisition member adjacent to tissue such that a longitudinal axis of any of a first and a second jaw of the stapling member is parallel to a surface of tissue. The method further includes drawing tissue to the tissue acquisition member and moving the tissue acquisition member vertically away from the first and second jaws. The method also includes moving the first and second jaws of the stapling member to a closed position and driving at least one fastener through the tissue disposed between the first and second jaws. Further, the method includes moving the first and second jaws of the stapling member to the open position and translating the tissue acquisition member along a longitudinal axis of the tissue acquisition member that is substantially parallel to a longitudinal axis of at least one of the first and second jaws. Finally, the method also includes moving the first and second jaws of the stapling member to the closed position such that at least one fastener is driven through the tissue disposed between the first and second jaws. 
     In some embodiments, the step of translating the tissue acquisition member can include rotating a cable to drive a lead screw coupled to the tissue acquisition member. In certain other embodiments, the tissue acquisition member can include a rack gear connected to a pinion gear on the stapling member, and the step of translating the tissue acquisition member can include actuating a cable to drive the pinion gear. In still other embodiments, the method can further include moving the tissue acquisition member any of vertically away from the first and second jaws of the stapling member and longitudinally with respect to the first and second jaws to further draw tissue through the first and second jaws. 
     In one aspect of the invention, a method of acquiring and fixating tissue includes positioning a surgical device having a stapling member with first and second jaws and a tissue acquisition unit adjacent to a tissue surface such that a longitudinal axis of the stapling member is parallel to the tissue surface. The method can further include moving the stapling member to an open position such that the first and second jaws are separated, and moving the tissue acquisition member between the first and second jaws adjacent to the tissue surface. The method can also include drawing tissue against the tissue acquisition member, and engaging the tissue drawn against the tissue acquisition member with a secondary acquirer coupled to the tissue acquisition member. Still further, the method can include moving the tissue acquisition member to a position offset from the first and second jaws, moving the stapling member to a closed position such that the first and second jaws are drawn together, and applying a staple through the tissue disposed between the first and second jaws. 
     In some embodiments, the step of engaging the tissue drawn against the tissue acquisition member with the secondary acquirer can include engaging at least one hook coupled to the tissue acquisition member with the tissue. In other embodiments, this step can include engaging at least one grasper coupled to the tissue acquisition member with the tissue. Engaging the at least one grasper can include tensioning a cable connected to the at least one grasper via at least one linkage. In still other embodiments, the step of engaging the tissue drawn against the tissue acquisition member with a secondary acquirer can instead include engaging at least one clamp pivotally coupled to the tissue acquisition member with the tissue. Engaging the at least one clamp coupled to the tissue acquisition member can include slidably moving a wedge member along a track formed in the tissue acquisition member to engage the wedge member with the at least one clamp pivotally coupled to the tissue acquisition member. 
     In another aspect of the invention, a method of acquiring and fixating tissue is provided that includes pivoting a tissue acquisition member from a position longitudinally proximal to an end effector to a position longitudinally aligned with the end effector. The method can further include engaging tissue with the tissue acquisition member and moving the tissue acquisition member to draw tissue through first and second jaws on the end effector. Still further, the method can include moving the first and second jaws to a closed position to engage the tissue therebetween, and actuating the jaws to apply at least one staple through the tissue engaged therebetween. 
     In some embodiments, pivoting the tissue acquisition member can further include advancing at least a portion of the tissue acquisition member across a plane defined by a superior surface of the first and second jaws. Further, in some embodiments, moving the tissue acquisition member to draw tissue through the first and second jaws can further include moving the tissue acquisition member to a position vertically offset from the first and second jaws. 
     In certain embodiments, the method can also include, prior to moving the tissue acquisition member to draw the tissue through the first and second jaws, engaging a secondary tissue acquirer to secure the tissue to the tissue acquisition member. The secondary tissue acquirer can be selected from the group consisting of hooks, graspers, or clamps coupled to the tissue acquisition member. 
     In certain other embodiments, actuating the jaws can include selectively advancing at least one firing wedge configured to eject at least one staple from at least one of the first and second jaws. Selectively advancing the at least one firing wedge can include advancing the at least one firing wedge along a row of staples to drive at least one staple from the row. Selectively advancing the at least one firing wedge can also include translating at least one actuator cable coupled to the at least one firing wedge. 
     The present invention also provides general methods for locating and forming patterns of gastric folds in order to reduce the size of a gastric cavity. In one aspect of the invention, a method for gastric volume reduction is provided that includes advancing a tissue acquisition and fixation device endoscopically through an esophagus and into a stomach, and manipulating the tissue acquisition and fixation device within the stomach to form a first fold of tissue on an interior surface of an anterior wall of the stomach. In some embodiments, the first fold of tissue can consist of a plurality of multiple smaller folds of tissue. The method can further include manipulating the tissue acquisition and fixation device within the stomach to form a second fold of tissue on an interior surface of a posterior wall of the stomach, where the second fold is not attached to the first fold. In some embodiments, the second fold of tissue can consist of a plurality of multiple smaller folds of tissue. 
     In some embodiments, a first fastener can secure the first fold and a second fastener can secure the second fold. In fact, the method can further include inserting at least one fastener through the first fold of tissue, and inserting at least one fastener through the second fold of tissue. In other embodiments, the method can include securing the first fold with at least one row of fasteners and securing the second fold with at least one row of fasteners. 
     In certain embodiments, manipulating the tissue acquisition and fixation device can include positioning first and second jaws of the tissue acquisition and fixation device to extend substantially parallel to the anterior wall of the stomach, and acquiring tissue to form the first and second folds. Acquiring tissue can include activating a vacuum source to draw tissue to a tissue acquisition member of the tissue acquisition and fixation device, and manipulating the tissue acquisition member to draw the tissue through the first and second jaws of the tissue acquisition and fixation device. Acquiring tissue can further include engaging a secondary acquirer coupled to the tissue acquisition member to retain the tissue in position relative to the tissue acquisition member. 
     In certain other embodiments, manipulating the tissue acquisition and fixation device can include moving a tissue acquisition member from a first position to a second position. In the first position, a distance between a longitudinal axis of the tissue acquisition member and a longitudinal axis of the device can be minimized. In the second position, the tissue acquisition member can be offset from the device such that the distance between the longitudinal axes of the tissue acquisition member and the device can be greater than in the first position. 
     In another aspect of the invention, a method of gastric volume reduction is provided that includes advancing a tissue acquisition and fixation device endoscopically into a stomach of a patient, and applying a vacuum to a tissue acquisition member to engage tissue. The method further includes manipulating the device to cause the tissue acquisition member to position the engaged tissue between opposed jaws coupled to the tissue acquisition member, and actuating the device to move the opposed jaws to a closed position in which the opposed jaws engage the tissue. The method also includes actuating the device to cause the opposed jaws to deliver at least one fastener through the engaged tissue. 
     In some embodiments, the method can include, prior to applying a vacuum to the tissue acquisition member, positioning the tissue acquisition and fixation device such that a longitudinal axis of the device is substantially parallel to the tissue surface. 
     In certain other embodiments, manipulating the device to position the engaged tissue between opposed jaws further can include actuating a hinge linkage coupling the tissue acquisition member to at least one of the jaws in order to move the tissue acquisition member relative to at least one of the jaws. Actuating the hinge linkage can also include translating an actuating cable coupled to the hinge linkage. 
     In still other embodiments, the method can include moving the opposed jaws to an open position, any of translating and vertically moving the tissue acquisition member to re-position the tissue between the opposed jaws, and re-actuating the device to move the opposed jaws to a closed position and to cause the opposed jaws to deliver at least a second fastener through the tissue. Translating the tissue acquisition member can include rotating a lead screw to cause the tissue acquisition member to translate with respect to the opposed jaws. The method can, in some embodiments, also include repeating the steps of moving the tissue acquisition member and re-actuating the device to create a row of fasteners. 
     In some embodiments, the method can include, prior to manipulating the device, engaging a secondary acquirer coupled to the tissue acquisition member to retain the tissue in position relative to the tissue acquisition member. 
     In another aspect of the invention, a method for gastric volume reduction is provided that includes manipulating a surgical device to form at least one plication on at least one of an anterior and a posterior inner surface of the fundus region of a patient&#39;s stomach. The method further includes, after forming the at least one plication, advancing the surgical device distally from the fundus toward the antrum region of the stomach and manipulating the surgical device to form a plurality of plications on at least one of an anterior and a posterior inner surface of the stomach. 
     In some embodiments, an end effector of the surgical device is articulated in a retroflexed position when the at least one plication is formed in the fundus. In other embodiments, advancing the surgical device distally from the fundus can include un-articulating the end effector to return the end effector to a position in which the end effector is substantially aligned with at least a distal portion of an insertion shaft having the end effector mated thereto. In some other embodiments, forming a plurality of plications in the stomach can also include articulating the end effector of the surgical device to access portions of the stomach. In still other embodiments, the plurality of plications can be formed in a distal-to-proximal direction. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The aspects and embodiments of the invention described above will be more fully understood from the following detailed description taken in conjunction with the accompanying drawings, in which: 
         FIG. 1  is a diagram of the six degrees of freedom of a rigid body; 
         FIG. 2  is a front perspective view of one embodiment of a staple applying assembly; 
         FIG. 3  is a top perspective view of the staple applying assembly of  FIG. 2 ; 
         FIG. 4  is a front perspective view of the staple applying assembly of  FIG. 2 ; 
         FIG. 5  is an alternative front perspective view of the staple applying assembly of  FIG. 2 ; 
         FIG. 6  is a front perspective view of a first jaw of the staple applying assembly of  FIG. 2 ; 
         FIG. 7  is a rear view of the staple applying assembly of  FIG. 2 ; 
         FIG. 8  is a front perspective view of one embodiment of a second jaw of a staple applying assembly; 
         FIG. 9  is an alternative transparent front perspective view of the second jaw of  FIG. 8 ; 
         FIG. 10  is a front perspective view of the stapler portion and staple former of the second jaw of  FIG. 8 ; 
         FIG. 11A  is a top view of a staple firing mechanism disposed on an outer surface of the second jaw of  FIG. 2 , shown in a first position; 
         FIG. 11B  is a top view of the staple firing mechanism of  FIG. 11A  shown in a second position; 
         FIG. 11C  is a top view of the staple firing mechanism of  FIG. 11A  shown in a third position; 
         FIG. 12A  is a front perspective view of the staple firing mechanism of  FIG. 11A  shown in the first position; 
         FIG. 12B  is a front perspective view of the staple firing mechanism of  FIG. 12A  shown in the second position; 
         FIG. 12C  is a front perspective view of the staple firing mechanism of  FIG. 12A  shown in the third position; 
         FIG. 13  is a perspective view of one embodiment of a surgical device including a staple applying assembly; 
         FIG. 14  is a side perspective view of one embodiment of a control handle of the surgical device of  FIG. 13 ; 
         FIG. 15  is a side perspective cutaway view of the control handle of  FIG. 14 ; 
         FIG. 16  is a side perspective transparent view of one embodiment of an elongate shaft of the surgical device of  FIG. 13 ; 
         FIG. 17  is a perspective view of one embodiment of an articulating section of the surgical device of  FIG. 13 ; 
         FIG. 18  is a side perspective view of one embodiment of a staple applying end effector of the surgical device of  FIG. 13 ; 
         FIG. 19  is a bottom perspective view of one embodiment of a tissue acquisition member of the surgical device of  FIG. 13 ; 
         FIG. 20  is a top perspective view of the tissue acquisition member of  FIG. 19 ; 
         FIG. 21A  is a front perspective view of one embodiment of a staple applying assembly including a longitudinally translating tissue acquisition member in a first position; 
         FIG. 21B  is a front perspective view of the staple applying assembly of  FIG. 21A  with the tissue acquisition member in a second position; 
         FIG. 21C  is a front perspective view of the staple applying assembly of  FIG. 21A  with the tissue acquisition member in a third position; 
         FIG. 22  is a side perspective view of another embodiment of a staple applying assembly including a translating hinge base; 
         FIG. 23A  is a side view of another embodiment of a translating hinge base; 
         FIG. 23B  is a top view of one embodiment of a staple applying assembly including the translating hinge base of  FIG. 23A ; 
         FIG. 24  is a side view of another embodiment of a translating hinge base; 
         FIG. 25  is a front perspective view of a tissue acquisition member including a secondary tissue acquirer that includes one or more graspers; 
         FIG. 26  is a front perspective view of another embodiment of a secondary tissue acquirer that includes one or more clamps; 
         FIG. 27A  is a front perspective view of another embodiment of a secondary tissue acquirer that includes one or more hooks; 
         FIG. 27B  is an alternative front perspective view of the tissue acquisition member of  FIG. 27A  showing the one or more hooks in a second position; 
         FIG. 28A  is a bottom perspective view of another embodiment of a secondary tissue acquirer that includes a rotating hook; 
         FIG. 28B  is a bottom perspective view of the rotating hook of  FIG. 28A  in a second position; 
         FIG. 28C  is a bottom perspective view of the rotating hook of  FIG. 28A  in a third position; 
         FIG. 29  is a front perspective view of one embodiment of a staple applying assembly including a 4-bar hinge linkage and multi-line staple cartridge; 
         FIG. 30  is a side perspective view of the staple applying assembly of  FIG. 29  showing the tissue acquisition member in a proximal storage position; 
         FIG. 31A  is a top view of one embodiment of a multi-line staple cartridge; 
         FIG. 31B  is a side view of the multi-line staple cartridge of  FIG. 31A ; 
         FIG. 32A  is a side view of another embodiment of a multi-line staple cartridge; 
         FIG. 32B  is a side view of the multi-line staple cartridge of  FIG. 32A  showing an actuating member in a second position; 
         FIG. 32C  is a side view of the multi-line staple cartridge of  FIG. 32A  showing an actuating member in a third position; 
         FIG. 33A  is a side view of one embodiment of a staple firing mechanism for use in a staple applying assembly; 
         FIG. 33B  is a side view of the staple firing mechanism of  FIG. 33A  showing the mechanism in a second position; 
         FIG. 34  is a side view of another embodiment of a staple firing mechanism for use in a staple applying assembly; 
         FIG. 35  is a side view of still another embodiment of a staple firing mechanism for use in a staple applying assembly; 
         FIG. 36  is a side perspective view of another embodiment of a staple firing mechanism for use in a staple applying assembly; 
         FIG. 37  illustrates a staple applying end effector approaching a tissue wall; 
         FIG. 38  illustrates the staple applying end effector of  FIG. 37  in an open position; 
         FIG. 39  illustrates the staple applying end effector of  FIG. 37  receiving tissue between open first and second jaws; 
         FIG. 40  illustrates the staple applying end effector of  FIG. 37  securing a gastric fold with a fastener; 
         FIG. 41  illustrates the staple applying end effector of  FIG. 37  translating a gastric fold to a first position; 
         FIG. 42  illustrates the staple applying end effector of  FIG. 37  applying a second fastener to a gastric fold; 
         FIG. 43  illustrates the staple applying end effector of  FIG. 37  translating a gastric fold to a second position; 
         FIG. 44  illustrates the staple applying end effector of  FIG. 37  translating a gastric fold to a third position; 
         FIG. 45  illustrates a gastric fold secured by a line of staples; 
         FIG. 46A  illustrates an exemplary method of positioning of a staple applying assembly within a gastric cavity; 
         FIG. 46B  illustrates articulation of the staple applying assembly to access the upper region of the gastric cavity; 
         FIG. 46C  illustrates an exemplary plication created in the upper region of the gastric cavity; 
         FIG. 47A  illustrates an exemplary method of forming multiple plications by fanning out from the position of the plication shown in  FIG. 46C ; 
         FIG. 47B  illustrates the fan-shaped articulation of the staple applying assembly to create multiple plications; 
         FIG. 47C  illustrates an embodiment of a fan-shaped pattern of plications; 
         FIG. 48A  illustrates another exemplary method of positioning of a staple applying assembly within a gastric cavity; 
         FIG. 48B  illustrates an exemplary plication created in the lower region of the gastric cavity; 
         FIG. 49A  illustrates an exemplary method of forming a second plication by extending from an end point of the plication shown in  FIG. 48B ; 
         FIG. 49B  illustrates a linear pattern formed from two plications; 
         FIG. 50A  illustrates an exemplary method of forming a third plication off the plications shown in  FIG. 49A ; 
         FIG. 50B  illustrates a linear pattern formed from three plications; 
         FIG. 50C  illustrates an exemplary combination of the various plication patters shown in  FIGS. 46A-50B   
         FIG. 51A  is a side view of an embodiment of a reciprocating tissue feeder; 
         FIG. 51B  is a front perspective view of an embodiment of a staple applying assembly including one or more reciprocating tissue feeders; 
         FIG. 51C  is a bottom view of another embodiment of a staple applying assembly including one or more reciprocating tissue feeders; 
         FIG. 52A  is a side view of one embodiment of a staple applying assembly including a mechanical grasper as a tissue acquisition member; 
         FIG. 52B  is a side view of the staple applying assembly of  FIG. 52A  in a second position; 
         FIG. 53A  is a side view of another embodiment of a staple applying assembly including a mechanical grasper as a tissue acquisition member; 
         FIG. 53B  is a side view of the staple applying assembly of  FIG. 53A  in a second position; 
         FIG. 54A  is a top view of one embodiment of a tissue acquisition member including a deflecting member. 
         FIG. 54B  is a side view of the tissue acquisition member of  FIG. 54A  in a first position; 
         FIG. 54C  is a side view of the tissue acquisition member of  FIG. 54A  in a second position; 
         FIG. 55A  is a side view of one embodiment of a staple applying assembly including a tissue acquisition member rotatably coupled to stapling jaws; 
         FIG. 55B  is a side view of the staple applying assembly of  FIG. 55A  in a second position; 
         FIG. 55C  is a side view of the staple applying assembly of  FIG. 55A  in a third position; 
         FIG. 56A  is front view of one embodiment of a staple applying assembly including articulating stapling jaws; 
         FIG. 56B  is a front view of the staple applying assembly of  FIG. 56A  in a second position; 
         FIG. 56C  is a front view of the staple applying assembly of  FIG. 56A  in a third position; 
         FIG. 56D  is a front view of the staple applying assembly of  FIG. 56A  in a fourth position; 
         FIG. 57A  is a side view of one embodiment of a staple applying assembly including extendable elongate members and an articulating shaft; 
         FIG. 57B  is a side view of the staple applying assembly of  FIG. 57A  in a second position; and 
         FIG. 57C  is a top view of the staple applying assembly of  FIG. 57A  in a third position. 
     
    
    
     DETAILED DESCRIPTION 
     Certain exemplary embodiments will now be described to provide an overall understanding of the principles of the devices and methods disclosed herein. One or more examples of these embodiments are illustrated in the accompanying drawings. Those skilled in the art will understand that the devices and methods specifically described herein and illustrated in the accompanying drawings are non-limiting exemplary embodiments and that the scope of the present invention is defined solely by the claims. The features illustrated or described in connection with one exemplary embodiment may be combined with the features of other embodiments. Such modifications and variations are intended to be included within the scope of the present invention. 
     The present invention generally provides devices and methods for apposing, forming, and securing tissue plications. These generally involve the creation of tissue plications for the reduction of cavity capacity, but may include the closure or repair of intentional (gastrotomy, colostomy, or enterotomy closure from Natural Orifice Translumenal Endoscopic Surgery (NOTES™), etc.) or unintentional (fistula, gastrointestinal leaks, etc.) tissue defects as well as the creation valves or restrictions to alter (e.g., enhance or impede) the flow of substances (e.g., Nissen fundoplication). In general, devices are provided having an end effector with a set of stapling jaws and a tissue acquisition member. The end effector can be coupled to the distal end of an elongate shaft or other surgical instrument that can be configured, for example, to be inserted into a patient&#39;s stomach through the esophagus. The surgical device can also include an articulating section to allow the end effector to articulate and thereby access a range of locations on, for example, both the anterior and posterior inner walls of the stomach. In use, the end effector can be positioned such that the stapling jaws are parallel to an inner tissue surface of the stomach. The tissue acquisition member can be disposed on an opposite side of the jaws from the tissue surface, and can be used to draw tissue through the jaws in a direction away from the tissue surface. This movement of the tissue acquisition member can create a tissue plication, or fold, disposed between the stapling jaws. The plication can be secured by driving a fastener out of the jaws and through the tissue. 
     By forming and fastening one or more of these plications, the volume or capacity of a cavity, such as the gastric cavity, can be reduced without the need for more invasive surgical procedures. The devices and methods of the present invention can be used to treat a wide variety of complications that develop as a result of metabolic disease. One common example of such a complication is obesity. However, non-obese individuals suffering from other metabolic disease complications, such as patients with low-Body Mass Index (BMI) type 2 diabetes, can also be treated using the teachings of the present invention. 
     As noted above, the devices disclosed herein can be at least partially positioned inside a patient&#39;s body cavity through an orifice for minimally invasive surgical procedures. Typically, the devices are inserted through a patient&#39;s mouth and extended down their esophagus into the stomach. However, it will be appreciated by those skilled in the art that any of the surgical device components disclosed herein can also be adapted for use in other surgical procedures, whether minimally invasive or open. 
     The various components of the devices disclosed herein can be formed from any of a variety of materials known in the art and suitable for use in surgical devices. For example, the various components can be formed from metal (e.g., stainless steel, titanium, or other biocompatible metals), plastic (e.g., polyetheretherketone (PEEK), or other biocompatible polymers), and/or combinations thereof. 
     Terminology 
     There are a number of ways in which to describe the position and orientation of an object in space. For example, the position and orientation of an object can be characterized in terms of the degrees of freedom of the object. The degrees of freedom of an object are the set of independent variables that completely identify the position and orientation of the object. As shown in  FIG. 1 , the six degrees of freedom of a rigid body with respect to a particular Cartesian reference frame can be represented by three translational (position) variables (e.g., horizontal position, vertical position, and lateral position) and by three rotational (orientation) variables (e.g., roll, pitch, and yaw). 
     For convenience of description, horizontal position is sometimes described herein as translational movement in an “in” direction or an “out” direction, or as longitudinal movement in a proximal or distal direction (e.g., where a longitudinal axis of a device is co-linear, or parallel to, the axis of horizontal position shown in  FIG. 1 ). Vertical position is sometimes described as translational movement in an “up” direction or a “down” direction, or as vertical movement that is perpendicular to the longitudinal movement described above. Lateral movement is sometimes described as translational movement in a “left” direction or a “right” direction, or as lateral movement that is perpendicular to both the longitudinal and vertical movements discussed above. Likewise, roll is sometimes described herein as rotation about a longitudinal axis, pitch is sometimes described as pivoting in the up direction or the down direction, and yaw is sometimes described as pivoting in the left direction or the right direction. An exemplary mapping of the in, out, up, down, left, and right directions to a surgical device is shown in  FIG. 1 . This terminology and the illustrated mapping are not intended to limit the invention, and a person having ordinary skill in the art will appreciate that these directional terms can be mapped to the device, or any component thereof, in any of a variety of ways. 
     The terms “a” and “an” can be used interchangeably, and are equivalent to the phrase “one or more” as utilized in the present application. The terms “comprising,” “having,” “including,” and “containing” are to be construed as open-ended terms (i.e., meaning “including, but not limited to,”) unless otherwise noted. Components described herein as being coupled may be directly coupled, or they may be indirectly coupled via one or more intermediate components. The recitation of any ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range, unless otherwise indicated herein, and each separate value is incorporated into the specification as if it were individually recited. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g., “such as”), provided herein is intended merely to better illuminate the invention and does not impose a limitation on the scope of the invention unless otherwise claimed. No language in the specification should be construed as indicating any non-claimed element as essential to the practice of the invention. 
     Stapling Jaws 
     One embodiment of a device of the present invention is a stapling member or staple applying assembly configured to approach a cavity wall such that a longitudinal axis of the device is parallel to the surface of the cavity wall. This is in contrast to the prior art devices described above, in which a device having a set of jaws is configured to approach a cavity wall such that a longitudinal axis of the device is perpendicular to the surface of the cavity wall. 
       FIGS. 2-5  illustrate such a device in several configurations.  FIG. 2  illustrates a staple applying assembly  200  in a collapsed or closed configuration that can be used to minimize the cross-sectional area of the assembly for introduction into, for example, a patient&#39;s gastric cavity through the esophagus. The assembly  200  is a generally elongate device (e.g., to facilitate entry into a narrow lumen such as the esophagus) that includes a first jaw  202 , a second jaw  204 , and a tissue acquisition member  206 . In some embodiments, the length of the first jaw  202  and the second jaw  204 , and therefore the staple applying assembly  200  as a whole, is in the range of about 25 millimeters to about 80 millimeters in length and fits within a circular diameter of about 14 mm to 20 mm to facilitate endoscopic entry of the device into a patient&#39;s gastric cavity. Although not shown in the attached figures, the exterior components of assembly  200  may be covered, coated, or contain additional features or geometry that minimize the risk of unintentional tissue damage during insertion, operation, or removal. Exemplary features include blunt surfaces, tapered tips, fillets, chamfers, elastomeric coatings/coverings, or any other similar feature known to one skilled in the art. 
     The first jaw  202  and the second jaw  204  can work in conjunction to apply at least one fastener through tissue engaged between the first jaw  202  and the second jaw  204 . In order to facilitate the engagement of tissue between the jaws, at least one of the first jaw  202  and the second jaw  204  can be movable to allow the assembly  200  to move between an open position for receiving tissue and a closed position for engaging tissue.  FIGS. 2 and 5  illustrate the first jaw  202  and the second jaw  204  in a closed position, while  FIGS. 3 and 4  illustrate the first jaw  202  and the second jaw  204  in an open position. In the particular embodiment illustrated in  FIGS. 2-5 , the first jaw  202  is pivotally connected to the second jaw  204  by pin  208 . 
     Referring to  FIG. 3 , the first jaw  202  can also include a slot  300  formed therein and aligned at an angle to a longitudinal axis of the first jaw  202 . The slot  300  can receive a sliding pin  302  to control movement of the first jaw  202  between the open and closed positions. In particular, the pin  302  can be seated in a slot  304  formed in the second jaw  204  that is in alignment with a longitudinal axis of the second jaw  204 . The pin  302  can also be connected to a positioning cable  306  or other actuation mechanism known in the art. As the pin  302  is moved along the path of the slot  304  in response to actuation by the positioning cable  306  (e.g., if the positioning cable  306  is pulled in a proximal direction), the first jaw  202  will pivot around the pin  208  as the pin  302  moves along the slot  300  of the first jaw  202 . As illustrated in  FIGS. 2-5 , when the pin  302  is in its distal-most position in the slots  300  and  304 , the first jaw  202  will move to the open position for receiving tissue shown in  FIGS. 3 and 4 . Conversely, when the pin  302  is retracted to its proximal-most position in the slots  300  and  304 , the first jaw  202  will move to the closed position for engaging tissue that is shown in  FIGS. 2 and 5 . In the embodiments disclosed herein, actuating the positioning cable  306  is sufficient to move the first jaw  202  to the open position for receiving tissue shown in  FIGS. 3 and 4 . It should be noted, however, that in some embodiments a biasing member, such as a spring, can be configured to assist transition between an open and a closed position. 
     In the embodiments disclosed herein, only the first jaw  202  moves to transition between the open and closed positions. It should be noted, however, that in some embodiments both the first and second jaws can be configured to move (e.g., similar to the operation of scissors) when transitioning between an open position and a closed position. 
     In some embodiments, the distal ends of the first jaw  202  and the second jaw  204  are configured to separate  10  mm or less when in the open position. Limiting the separation of the first jaw  202  and the second jaw  204  in the open position can prevent undesired surrounding tissue from being unintentionally drawn between the jaws by the tissue acquisition member. It can be undesirable for some surrounding tissue, such as small bowel, omentum, adjacent organs such as the liver, and blood vessels, to be included in a gastric plication, as it can cause complications such as gastric obstruction, tissue necrosis, and undetected bleeding. 
     The first jaw  202 , which is illustrated in isolation in  FIG. 6 , can also include an anvil portion  600  configured to form a staple or other fastener ejected from the second jaw  204 . As shown in the figure, the first jaw  202  features an anvil portion  600  having only one staple-forming receptacle  602 . However, in some embodiments, and as discussed in detail below, the staple applying assembly  200  may be configured to apply a plurality of staples sequentially or simultaneously. In these embodiments, the first jaw  202  may include a plurality of staple-forming receptacles formed along the elongate inner surface  604  of the first jaw  202 . 
     The proximal end of the first jaw  202  can include a mating portion  606  configured to movably connect the first jaw  202  to the second jaw  204 . The mating portion can include two symmetrical sidewalls  608  configured to receive the second jaw  204  in a recess  610  defined by the sidewalls  608 . Furthermore, each of the sidewalls  608  can include symmetrical slots  300  for receiving the pin  302 , as well as through-holes  612  for receiving the pivot pin  208 , as discussed above. It should be noted that, in some embodiments, the first jaw  202  can include only a single sidewall  608 , rather than two symmetrical sidewalls. 
       FIG. 7  illustrates a rear view of the staple applying assembly  200  and shows an additional feature of the first jaw  202 . In particular, the first jaw  202  can include a fillet  700  in the mating portion  606  to allow an endoscopic viewing scope to directly view any tissue disposed between the first jaw  202  and the second jaw  204 . This can be used to, for example, examine the depth of a plication being formed or the alignment of a plurality of staples or other fasteners being used to secure the plication. 
     An embodiment of the second jaw  204  is shown in isolation in  FIG. 8 . The second jaw  204  can be a generally elongate member having an attachment portion  800  that can be used to couple the second jaw  204 , and therefore the entire staple applying assembly  200 , to a surgical device, as discussed in more detail below. The attachment portion  800  can include any number of configurations known in the art and, in some embodiments, can comprise one or more tabs  802  having through-holes  804  configured to receive bolts or other fasteners for use in securing the attachment portion  800  to a surgical device. 
     The second jaw  204  can be formed from two symmetric outer walls  806  arranged parallel to each other and offset by a distance to create a recess  808  between the outer walls  806 . The outer walls  806  can be two separate walls held in position by, for example, elements such as a pin  208  or a connecting element coupled to the attachment portion  800 . Alternatively, the outer walls  806  can be formed from a single wall featuring a bend at the distal end, thus forming an elongated “U” shape. The recess  808  formed between the outer walls  806  can accommodate passage of one or more actuating cables, such as a positioning cable  306 . Referring to the rear view of  FIG. 7 , two actuating cables are shown in the recess  808  between the outer walls  806  of the second jaw  204 . The positioning cable  306  can be used, for example, to control the opening and closing of the first jaw  202  relative to the second jaw  204 , as discussed above. The second actuating cable  702  can be used, for example, to control the firing mechanism for delivering staples to tissue disposed between the jaws, as discussed in more detail below. 
     The recess  808  of the second jaw  204  can also house a stapler portion  900 , shown in the transparent view of the second jaw  204  in  FIG. 9 . The stapler portion  900  can be configured to retain a plurality of staples and urge them towards a staple former  902  that is configured to eject a staple or other fastener from the second jaw  204  toward the anvil portion  600  of the first jaw  202 .  FIG. 10  illustrates the stapler portion  900  and staple former  902  in isolation. 
     The stapler portion  900  includes an inverted “U” shaped housing  1002  that can be complementary in shape to the staple  1004  or other fastener being used. One or more staples  1004  can be loaded into the stapler portion  900  by sliding the staples  1004  over the housing  1002 , similar to loading a common office desktop stapler. In some embodiments, the stapler can hold up to  100  staples, but the total capacity can depend on the length of the stapler portion  900 , the diameter of the staple applying assembly  200  (and the subsequent size constraints that imposes on all components of the assembly), etc. In addition, a number of different staple types can be used with the devices of the present invention. The stapler portion  900  and anvil portion  600  can be configured to accommodate various staples  1004 , including staples that form into a box shape, a B-shape, or staples that form into three-dimensional or out-of-plane shapes. 
     The housing  1002  can feature a guide shaft  1006  connected thereto at a proximal end and a distal end of the housing  1002  and running parallel to the housing. In the embodiment illustrated in  FIG. 10 , the guide shaft  1006  is located above the housing  1002 , but could also be located to either side or below the housing. 
     The stapler portion  900  also includes a staple pusher  1008  that is connected to the guide shaft  1006 . The staple pusher  1008  can also have an inverted “U” shape similar in dimension to the staples  1004 . The illustrated staple pusher  1008  sits on top of the housing  1002  proximal to the staples  1004  and is connected to the guide shaft  1006  by a receiving eye  1010  protruding above the upper surface of the staple pusher  1008 . The staple pusher  1008  is configured to push the plurality of staples  1004  toward the distal end of the stapler portion  900 . This can be accomplished by a coil spring  1012 , or other urging member, that is disposed over the guide shaft  1006  such that it acts on the housing  1002  and the staple pusher  1008 , as illustrated in  FIG. 10 . 
     At the distal end of the stapler portion  900 , the staple former  902  is disposed in a slot  901  created by the stapler portion  900  and the outer walls  806  of the second jaw  204  (see FIGS.  12 A- 12 C for more detail of the outer walls  806  retaining the staple former  902 ). In other embodiments, either the outer walls  806  of the second jaw  204  or the stapler portion  900  can include a fully enclosed slot in which the staple former  902  can be disposed. The staple former  902  can have any shape suitable to translate along an axis offset from a longitudinal axis of the second jaw  204  to push a staple or other fastener from the stapler portion  900  of the second jaw  204  into the anvil portion  600  of the first jaw  202 . In the illustrated embodiment, the staple former  902  is a thin, rectangular element positioned such that a longitudinal axis thereof is perpendicular to a longitudinal axis of the second jaw  204 . The staple former  902  can also include a protrusion  1014  having a fillet  1016  that is configured to receive a portion of the fastener delivery mechanism, as discussed in detail below. 
     Fastener Delivery Mechanism 
     There are a variety of fastener delivery mechanisms that can be used to actuate the staple former  902  to eject a staple  1004  from the second jaw  204  into the first jaw  202 .  FIGS. 11A-11C  illustrate one embodiment of a staple-firing linkage disposed on an outer surface of the outer walls  806  of the second jaw  204 . 
     The staple-firing linkage includes a forming link  1100  that is pivotally connected to the second jaw  204  via a pin  1102 . At its distal end, the forming link  1100  includes a second pin  1104  that is seated in the fillet  1016  of the protrusion  1014  on the staple former  902 . As stated above and shown in  FIG. 11A , the staple former  902  is able to slide perpendicular to a longitudinal axis of the second jaw  204  within the slot  901  formed by the outer walls  806  and the stapler portion  900  of the second jaw  204 . In this arrangement, as the forming link pivots about pin  1102 , the staple former  902  is forced to slide up or down. It should be noted that, similar to the discussion of the first jaw  202  above, the staple-firing linkage can be formed on a single side of the second jaw  204 , or can be symmetrically disposed on opposing sides of the second jaw  204 . The use of symmetrical components on either side of the second jaw  204  can be seen in  FIGS. 2-5, 8, and 12A-12C , for example. 
     At its proximal end, the forming link can be pivotally and slidably connected to a distal end of a firing link  1106  using a pin  1108 . The firing link  1106  can be pivotally connected to the second jaw  204  by the pin  208 , which, as discussed above, can also serve to pivotally connect the first jaw  202  to the second jaw  204 . The firing link  1106  can include a slot  1110  formed therein and disposed at an angle to a longitudinal axis of the firing link  1106 . The slot  1110  can receive a pin  1112  that is configured to control the firing of a staple or other fastener from the second jaw  204 . Similar to controlling the movement of the first jaw  204  discussed above, the pin  1112  is also seated within a slot  810  (shown in  FIG. 8 ) formed in the outer walls  806  of the second jaw  204 . The slot  810 , like slot  304 , is disposed substantially parallel to a longitudinal axis of the second jaw  204 . As a result, when the actuating cable  702  (shown in  FIG. 7 ) is, for example, pulled, the pin  1112  will move proximally within the slot  810  of the second jaw  204 . This also causes movement of the pin  1112  within the slot  1110  of the firing link  1106 , which causes the firing link  1106  to rotate about pin  208 . The rotation of the firing link  1106  causes an opposing rotation of the forming link  1100  about the pin  1102 , which results in the translation of the staple former  902 . In the embodiments disclosed herein, actuating the actuating cable  702  is sufficient to cause movement of the pin  1112  within the slot  1110  of the firing link  1106 , which causes the firing link  1106  to rotate about the pin  208 . It should be noted, however, that in some embodiments a biasing member, such as a spring, can be configured to assist movement of the firing link  1106 . 
       FIGS. 11A-11C  illustrate the operation of the above-described linkage. In  FIG. 11A , the pin  1112  is disposed at a distal-most point in the slot  1110  of the firing link  1106 . As a result, the firing link  1106  is rotated in a counter-clockwise direction, which, in turn, causes the forming link  1100  to rotate in a clockwise direction to slide the staple former  902  to the bottom of the figure. In this orientation, the staple former  902  is sufficiently clear of the stapler portion  900  to allow the spring  1012  to urge the next staple  1004  into the slot  901  formerly occupied by the staple former  902 . 
     In  FIG. 11B , the actuating cable  702  has begun to move proximally, pulling pin  1112  with it along slot  810  formed in the second jaw  204 . The movement of the pin  1112  within the slot  1110  of the firing link  1106  causes the firing link  1106  to rotate about the pin  208  in a clockwise direction. This rotation causes the forming link  1100  to undergo an opposing, counter-clockwise rotation about the pin  1102 , and the staple former  902  correspondingly begins sliding toward the top of the figure. As the staple former  902  passes back across the second jaw  204 , it will encounter the staple  1004 , which was previously pushed into the slot  901 . The staple former  902  will exert a force on the staple  1004  to begin ejecting it out of the second jaw  204 . Note that, in some embodiments, the staple former  902  may have a curved or textured face on the end that interfaces with staple  1004  in order to prevent the staple from slipping off the staple former  902 . 
       FIG. 11C  illustrates the finished firing position, in which the actuating cable  702  has pulled the pin  1112  to its proximal-most position in the slot  1110 , thereby fully rotating the firing link  1106  in the clockwise direction. This rotation has caused the forming link  1100  to fully rotate in the counter-clockwise direction and pass the staple former  902  through its range of motion to fully eject the staple  1004  or other fastener from within the second jaw  204 . 
       FIGS. 12A-12C  illustrate in more detail the sliding of the staple former  902  within the second jaw  204 . In these figures, the first jaw  202  and the second jaw  204  are shown in the closed position that is effective to engage tissue disposed between the two jaws. The staple former  902  begins in the position shown in  FIG. 12A , raised above the inner stapler portion  900  enough such that a staple  1004  can be urged forward into the slot  901  in which the staple former  902  travels. As the movement of the actuating cable  702  rotates the firing link  1106 , the forming link  1100  pivots around the pin  1102  and the pin  1104  drives the staple former  902  toward the first jaw  202 . The staple former  902  interfaces with the staple  1004  and begins urging it toward the first jaw  202 . The range of motion is complete when the staple former  902  has driven the staple  1004  completely out of the second jaw  204  such that it passes through any tissue disposed between the two jaws and deforms itself against the anvil portion  600  of the first jaw  202 . 
     There are a variety of mechanical linkages known in the art suitable to move the staple former  902  such that it interfaces with and ejects a staple or other fastener from the second jaw  204  into the first jaw  202 . These various linkages are considered to be within the scope of the present invention. 
     Tissue Acquisition Member 
     The above discussion focuses on the interaction of the first and second jaws to engage and secure tissue drawn between the jaws (i.e., securing the gastric fold or plication that is created by drawing tissue between the jaws). A tissue acquisition member or primary tissue acquirer, various embodiments of which are described in detail below, can be utilized to position tissue between the first and second jaws prior to delivering a fastener. In general, the tissue acquisition member can use a variety of techniques for engaging tissue, such as through vacuum, tissue penetration, pressure clamping, etc. The tissue acquisition member preferably extends substantially parallel to the jaws, and is positioned on one side of the jaws and is effective to capture tissue adjacent to an opposite side of the jaws and to pull the captured tissue through the jaws. In an exemplary embodiment, the tissue acquisition member is positioned in a first plane that extends substantially parallel to a second plane extending through each of the first and second jaws. 
     Referring back to  FIG. 2 , one embodiment of a tissue acquisition member  206  is shown in a configuration used for entry into a patient&#39;s body through a restricted lumen, such as the esophagus. In the position illustrated in  FIG. 2 , the tissue acquisition member  206  rests with an inferior, tissue-engaging surface  308  contacting a superior surface  309  of the second jaw  204 . This minimizes the cross-sectional area of the staple applying assembly  200  during insertion into a patient&#39;s body. 
     The tissue acquisition member  206 , much like the first and second jaws  202 ,  204 , can be a generally elongate member. The elongate body of the tissue acquisition member  206  can define an inner lumen that connects to one or more vacuum ports disposed on the tissue engaging surface  308  of the tissue acquisition member  206  that are effective to engage and draw tissue against the tissue acquisition member. The tissue acquisition member  206  can also include a connection port  310  to connect to a vacuum source. The connection port  310  can be in communication with the inner lumen and the one or more vacuum ports of the tissue acquisition member  206 . 
     The tissue acquisition member  206  can be connected to the staple applying assembly  200  by a hinge assembly or linkage  312 . The linkage  312 , which can include one or more hinge mechanisms, can allow the tissue acquisition member  206  to move vertically toward and away from the first and second jaws  202 ,  204  while maintaining its tissue engaging surface  308  in a plane that is substantially parallel to a second plane that extends through each of the first jaw  202  and the second jaw  204 . There can also be some associated proximal/distal longitudinal motion because the linkage  312  swings the tissue acquisition member  206  through an arcuate path. In particular, a hinge linkage  312  having more than one hinge mechanism (e.g., as shown in  FIGS. 2 and 5 ) can allow the tissue acquisition member  206  to move from the position shown in  FIG. 2  to that shown in  FIG. 5  without changing its rotational orientation with respect to the first and second jaws  202 ,  204 . 
     In the embodiment illustrated in  FIG. 2 , the hinge linkage  312  includes a first connecting arm  210  that is pivotally connected at one end to a proximal end of an upper base plate  212  and pivotally connected at the other end to a proximal end of a lower base plate  214 . The pivotal connection between the first connecting arm  210  and the upper or lower base plates  212 ,  214  can be accomplished using, for example, hinge pins  216 . The hinge linkage  312  also includes a second connecting arm  218  that is pivotally connected at one end to a distal end of the upper base plate  212  and pivotally connected at the other end to a distal end of the lower base plate  214 . The upper base plate  212  can be coupled to the tissue acquisition member  206  and the lower base plate  214  can be coupled to a superior surface of the first jaw  202 . As a result, the first and second connecting arms  210 ,  218  form a 2-bar linkage that allows the tissue acquisition member  206  to swing through an arcuate path between, for example, a lower position shown in  FIG. 2  to an upper position shown in  FIG. 5   
     As mentioned above and shown in  FIG. 3 , the tissue acquisition member  206  can be coupled to the first jaw  202  alone such that the tissue acquisition member  206  moves in conjunction with the first jaw  202 . In other words, as the first jaw opens and closes, the tissue acquisition member  206  moves with and remains parallel to the first jaw. The first jaw  202  can have a shape complementary to the shape of the tissue acquisition member  206  to allow the tissue acquisition member to pass into the space created between the first and second jaws  202 ,  204  when in the open position. For example, the tissue acquisition member  206  can be positioned vertically as shown in  FIG. 2  (e.g., with a bottom surface  308  of the tissue acquisition member  206  being substantially coplanar with a top surface  309  of the second jaw  204 ), but with the first and second jaws  202 ,  204  in the open position. In such a configuration, the tissue acquisition member  206  can be disposed just above the space between the jaws, as shown in FIG.  3 . In such a position, the tissue acquisition member  206  can be separated from the tissue on the opposite side of jaws by a distance roughly equal to the thickness of the jaws. The vacuum source can be activated, thereby causing the tissue acquisition member  206  to draw tissue against, for example, the inferior surface  308 . A positioning cable connected to the hinge linkage  312  or to the tissue acquisition member  206  itself (e.g., in some embodiments, the positioning cable can also connect to the vacuum connection port  308  to deliver suction to the tissue acquisition member  206 ) can be used to raise the tissue acquisition member  206  away from the first and second jaws  202 ,  204 , as shown in  FIG. 5 . Any tissue drawn against the inferior surface  308  would be drawn through the space between the first and second jaws  202 ,  204 , thereby creating a gastric fold. The first and second jaws  202 ,  204  can then be moved to the closed position and one or more staples can be fired to secure the plication. 
     Still further, the tissue acquisition member  206  can be configured to pass between the open first and second jaws  202 ,  204  to better engage with tissue disposed on an opposing side of the jaws. For example, and as shown in  FIG. 5 , the connecting arms  210 ,  218  of the hinge linkage  312  can include one or more “S” bends  502 . When in a raised orientation in which the tissue acquisition member  206  is vertically offset from the first and second jaws  202 ,  204  (as shown in  FIG. 5 ), the S bends  502  provide a longitudinal offset that maintains the tissue acquisition member  206  in a location above the first and second jaws  202 ,  204  and longitudinally aligned with the jaws. Further, when the tissue acquisition member  206  is lowered into the space between the open first and second jaws  202 ,  204 , the S bends  502  can allow the inferior, tissue engaging surface  308  to pass between the first and second jaws  202 ,  204  toward the tissue on the opposite side of the jaws. In particular, the tissue acquisition member  206  can be positioned such that the inferior, tissue engaging surface  308  is disposed below the superior surface  309  of the second jaw  204 . 
     Endoscopic Controls 
     The staple applying assembly  200  disclosed above can be included as an end effector on a number of surgical devices. One exemplary device  1300  is illustrated in  FIG. 13 . The device includes a handle  1302  at its proximal end, a shaft or extension section  1304 , and a staple applying assembly  1306  coupled to the distal end of the extension section  1304 . 
     The handle  1302  can include any of a variety of actuation mechanisms to facilitate remote manipulation of the end effector staple applying assembly  1306 . As shown in  FIG. 14 , the handle  1302  can include one or more levers, including a trigger lever  1400  and a palm lever  1402 .  FIG. 15   shows  the handle  1302  without a cover, and illustrates that the levers  1400 ,  1402  can be used to tension one or more wires, such as the positioning cable  306  and actuating cable  702  discussed above. 
     The handle  1302  can also include one or more actuators  1406  configured to allow for rotation, as well as translation, of a cable extending to the end effector. In addition, the handle  1302  can include a central lumen  1500  to allow an operator to pass a visualizing (or other type of) scope through the handle and extension section to view or otherwise aid in the use of the end effector. 
     The extension section  1304  can be a generally elongate shaft that includes a hollow outer tube  1600  having one or more inner passages defined therethrough. For example, the outer tube  1600  can include an opening  1602  in a sidewall thereof near a distal end of the tube. A hollow inner tube  1604  can be disposed inside the outer tube  1600  and it can include an angled section  1606  that interfaces with the opening  1602  in the outer tube. In such a configuration, for example, a visualizing scope can be passed through the lumen  1500  in the handle  1302  and the inner tube  1604  of the extension section  1304  such that the scope extends from the opening  1602  in the sidewall of the outer tube and can visualize the end effector from a position just proximal of the surgical site. In further exemplary configurations, the opening  1602  can be configured in various geometries or contain additional components that effect the exit angle of the visualizing scope. Exemplary designs include ramps, levers, and elevators, all of which are considered within the scope of this invention. In addition to the inner tube  1604 , the outer tube  1600  can carry one or more actuating cables that connect between the end effector and the handle  1302 . These can include, for example, the positioning cable  306  and the actuating cable  702  discussed above. 
     The staple applying assembly  1306  can be coupled directly to the distal end of the extension section  1304 . However, in some embodiments, it can be beneficial to provide for articulation of the end effector. Accordingly, one or more articulating joints  1700  can be coupled between the distal end of the extension section  1304  and to the staple applying assembly  1306 . A set of exemplary articulating joints is shown in  FIG. 17 . The set can include an end cap  1702  that couples directly to the distal end of the extension section  1304 . Each articulating joint  1700 ,  1700 ′ can connect to its neighboring joints via pivoting pins  1704 ,  1704 ′. Each articulating joint  1700  can include an inner lumen to allow passage of one or more actuating cables, endoscopes, etc. The articulating joints can be controlled using, for example, one or more actuating cables running down opposing sides of the articulating joint through, for example, passages  1706 ,  1708 . As one actuating cable is tensioned at the handle  1302 , the articulating joints will pivot toward the side carrying the tensioned cable. Selectively releasing and tensioning the one or more actuating cables can control the orientation of the articulating joints  1700 ,  1700 ′. Furthermore, additional joints may be disposed on the surgical device  1300  in the handle  1302 , the extension section  1304 , and/or the staple applying assembly  200 . The articulating joint  1700  is an exemplary joint. Such joints may be configured to provide additional motion, in either or any of the up, down, left, right, in, or out directions, as shown in  FIG. 1 . In some embodiments, the staple applying assembly  1306  can be coupled to the extension section  1304  by four articulating joints. 
       FIG. 18  illustrates an embodiment of the staple applying assembly  1306  disposed on the surgical device  1300 . As shown in the Figure, the articulating joints  1700  can, in some embodiments, provide for large ranges of articulating movement. This can be beneficial when forming a plurality of gastric plications, as discussed in more detail below. 
     Translating Tissue Acquirer 
     When forming a gastric plication, it is often necessary to secure the plication with more than one staple or fastener. In many cases, it can be desirable to form one or more lines of staples to secure a plication. As mentioned above, the hinge linkage  312  that connects the tissue acquisition member  206  to the first jaw  202  swings the tissue acquisition member through an arcuate path that involves both vertical movement toward and away from the first and second jaws  202 ,  204  (i.e., movement up and down above the jaws) and proximal or distal longitudinal translation (i.e., translation along a longitudinal axis of the jaws). This longitudinal motion can be effective to place the distal end of the jaws (that ejects the staples or other fasteners) forward or behind a previously placed staple, but the range of motion can be limiting. Further, the longitudinal and vertical movements occur together, meaning an uneven or arc-shaped line may be formed. 
     In some embodiments, it can thus be beneficial to include an indexing mechanism for translating the tissue acquisition member  206  longitudinally after it has been raised to a position that is vertically offset from the first and second jaws  202 ,  204 . Such a mechanism can allow the tissue to be translated longitudinally through the jaws, thereby allowing a row of staples to be applied to the tissue without the need to release and recapture the tissue at multiple locations. The staple applying assembly illustrated in  FIG. 18  includes an indexing mechanism in the form of a lead screw  1800  that can rotate to longitudinally adjust the position of the tissue acquisition member above the first and second jaws. 
       FIGS. 19 and 20  illustrate one embodiment of a tissue acquisition member  1902  and hinge linkage  312  in isolation. As shown in the figures, the assembly is similar to those described above. The hinge linkage  312  can include a hinge base  214  configured to couple with the first jaw  202 , and two connecting arms  210 ,  218  with “S” bends  502  that connect to a second hinge base  212  coupled to the tissue acquisition member  1902 . The tissue acquisition member  1902  includes an inferior, tissue engaging surface  308  having, in this embodiment, a single large vacuum port  1906 . The vacuum port is in communication with a vacuum supply through a connecting tube  2002 . 
     The illustrated tissue acquisition member  1902  includes an additional component, namely a tissue acquisition member base  1908 . The base  1908  is coupled to the second hinge base  212  and seats a threaded rotating lead screw  1910 . The rotating lead screw  1910  extends distally from the base  1908  in a direction parallel to a longitudinal axis of the tissue acquisition member  1902 . The lead screw  1910  can be configured to rotate without translating with respect to the base  1908 , as explained below. 
     The tissue acquisition member  1902  can be narrower than the embodiments described above so as to accommodate a protrusion  1912  on one side thereof that has a threaded bore formed therethrough in a direction parallel to a longitudinal axis of the tissue acquisition member. The threaded protrusion can receive the threaded lead screw  1910  such that the tissue acquisition member translates proximally and distally along the lead screw  1910  as the lead screw is rotated. 
     On an opposing side of the tissue acquisition member  1902  from the protrusion  1912 , a guide pin  2004  extends from the tissue acquisition member through a bore formed in the base  1908 . The guide pin  2004  slides freely through the bore in the base  1908 , and serves to prevent the tissue acquisition member  1902  from rotating as the lead screw  1910  is rotated. 
     Any of several actuating cable configurations are possible with the lead screw  1910 . For example, as illustrated in  FIGS. 19 and 20 , a positioning cable  2006  can be attached to the base  1908  so as to control the vertical offset of the tissue acquisition member  1902  from the first and second jaws  202 ,  204 . A second, rotating actuating cable can then be coupled to the lead screw  1910  to actuate its rotation and thereby control the longitudinal translation of the tissue acquisition member  1902 . Alternatively, a single actuating cable can be employed that connects to the lead screw  1910  in the base  1908 . Applying a tensioning force to the actuating cable can be effective to control the vertical offset of the tissue acquisition member  1902 , while rotation of the cable can be effective to control the longitudinal translation of the tissue acquisition member. 
       FIGS. 21A-C  illustrate an exemplary embodiment of this single control wire configuration. For example, the tissue acquisition member base  2102  does not include an extension on its top surface to receive a positioning cable, in contrast to the base  1908  illustrated in  FIGS. 19 and 20 . Rather, the single actuating cable  2102  extending into the lead screw  1910  serves both purposes.  FIG. 21A  illustrates the tissue acquisition member  2104  in its proximal-most position on the lead screw  1910 .  FIG. 21B  illustrates the tissue acquisition member  2104  in an intermediate position, and  FIG. 21C  illustrates the tissue acquisition member  2104  in its distal-most position on the lead screw  1910 . 
     There are a variety of alternative ways to longitudinally translate the tissue acquisition member with respect to the first and second jaws  202 ,  204 . For example, in an exemplary embodiment illustrated in  FIG. 22 , the lead screw has been moved from the tissue acquisition member  2201  to the base of the hinge linkage  2202 . In particular, a hinge base  2203  can be mounted to a platform having a protrusion  2204  on one side thereof with a threaded bore formed therein. In addition, a baseplate (not shown) can be mounted to the first jaw  202  and configured to hold the lead screw  1910  just above the surface of the first jaw  202  and parallel to a longitudinal axis of the first jaw. The protrusion  2204  can receive the lead screw  1910  such that, as the lead screw is rotated, the hinge base  2203  (along with the rest of the hinge linkage  2202  and the tissue acquisition member  2201 ) translates proximally or distally along the lead screw  1910 . An additional guide pin or other stabilizing member can also be included, similar to the guide pin  2004  of  FIG. 20 , to prevent rotation of the hinge base  2203  and tissue acquisition member  2201 . 
     Locating the lead screw  1910  on the first jaw  202  can eliminate the “S” bend that can form in the lead screw actuating cable when the tissue acquisition member is raised above the first and second jaws  202 ,  204  by a significant amount. However, this can require use of a separate cable to rotate the lead screw, as well as offset positioning of the tissue acquisition member  2201  from the first and second jaws  202 ,  204  because the lead screw is located on the first jaw and does not vertically offset from the jaw. 
     In other embodiments, a lead screw can be replaced with an alternative indexing mechanism, such as a rack and pinion gear set.  FIG. 23A  illustrates an exemplary embodiment of a hinge base  2302  that has a rack gear set formed therein. The gear set can be slidably disposed in a track formed on, for example, the first jaw  202 . The first jaw  202  can also be configured to rotatably retain a pinion gear  2304  a distance above the track such that it interfaces with the rack gear set of the hinge base  2302 . The pinion gear  2304  can be controlled by a control wire pulley system  2306 , thereby allowing an operator to turn the pinion gear  2304  in either direction. By turning the pinion gear  2304  (which is mounted on the first jaw  202 ), the hinge base  2302  will translate proximally or distally within the track formed in the first jaw  202 . As a result, the entire hinge linkage  2308  and tissue acquisition member will also longitudinally translate. 
       FIG. 23B  illustrates the rack and pinion gear set embodiment from a top view. The figure shows the first jaw  202 , the second jaw  204 , the tissue acquisition member  206 , the hinge linkage  2308 , the hinge base  2302  with rack gear set, and the pinion gear  2304 . Note that the illustration is not shown to scale for ease of viewing. 
     Another alternative indexing mechanism involves the use of a hinge base with a plurality of indexed grooves that can seat a hinge pin.  FIG. 24  illustrates an exemplary embodiment in which a hinge base  2402  is slidably disposed on a surface of the first jaw  202 . The hinge base forms part of the hinge linkage  2403  connected to the tissue acquisition member  206 , but also includes a portion having a plurality of indexed grooves  2404  formed therein. The plurality of indexed grooves  2404  can be spaced apart at a variety of distances. In an exemplary embodiment, the plurality of grooves  2404  can be separated by about 2 centimeters. The first jaw  202  can have a hinge pin  2406  rigidly attached thereto and configured to be seated in one of the plurality of indexed grooves  2404 . The hinge pin  2406  can have an asymmetric profile such as a flat bottom surface and a curved top surface. This profile can match the shape of the plurality of indexed grooves  2404 , and can prevent undesired motion of the hinge base  2402 . 
     A control wire or rigid pusher element  2408  can also be attached to the hinge base  2402 . Further, the hinge base  2402 , or at least a portion thereof containing the plurality of indexed grooves  2404 , can be formed from a material strong enough to retain the hinge pin  2406  within an indexed groove  2404  during normal use of the tissue acquisition device, but flexible enough to allow the hinge pin  2406  to move from one indexed groove to another upon application of tension or thrust from an operator. As a result, the operator can, for example, pull the hinge base  2402  in a proximal direction to seat or snap the hinge pin  2406  into the next-most distal indexed groove  2404 , thereby translating the hinge base  2402 , hinge linkage  2403 , and tissue acquisition member  206 . 
     Secondary Tissue Acquirer 
     In some embodiments, the tissue acquisition member alone may not be sufficiently strong (e.g., may not have sufficient vacuum strength) to maintain its hold on tissue drawn against the tissue engaging surface as the tissue acquisition member is raised away from the first and second jaws. As a result, a secondary tissue acquirer can be employed to help retain the position of tissue drawn against the tissue acquisition member. A person skilled in the art will appreciate that any secondary tissue acquisition member can be using with any primary tissue acquisition member disclosed herein, or alternatively the secondary tissue acquisition member can be used instead of the primary tissue acquisition members disclosed herein. 
     The secondary tissue acquirer can have a variety of configurations. Generally, the secondary tissue acquirer is coupled to the tissue acquisition member and configured to engage and retain tissue in a particular position relative to the tissue acquisition member. The secondary tissue acquirer can include any of one or more hooks, graspers, and clamps pivotally or otherwise connected to the tissue acquisition member. 
     In one exemplary embodiment illustrated in  FIG. 25 , a tissue acquisition member  2500  includes a secondary tissue acquirer  2502  connected to its distal end. The secondary tissue acquirer  2502  includes opposing graspers  2504 ,  2506  that are pivotally connected to a pin  2508  that extends from the distal end of the tissue acquisition member  2500 . The proximal end of the grasper  2504  is pivotally connected to a linkage  2510 , and the proximal end of the grasper  2506  is pivotally connected to a linkage  2512 . The linkages  2510 ,  2512  are, in turn, connected to each other pivotally at point P. 
     To operate the secondary tissue acquirer  2502 , an actuating cable can be attached to point P to pull it upward, thereby causing the graspers  2504 ,  2506  to pivot around the pin  2508  toward each other. This is similar to the operation of an ice block pick. When the graspers  2504 ,  2506  pivot toward each other, they can engage any tissue disposed therebetween. Further, the graspers  2504 ,  2506  can be formed with either sharp or dull distal ends to aid in tissue engagement. 
     An actuating cable connected to the secondary tissue acquirer  2502  can be routed, for example, over the top of the tissue acquisition member  2500 . In some embodiments, the tissue acquisition member  2500  may have a track, depression, or other guide formed on its upper surface to accommodate the actuating cable extending to the secondary tissue acquirer  2502  on the distal end of the tissue acquisition member  2500 . 
     An exemplary track formed on an upper surface of a tissue acquisition member is illustrated in  FIG. 26 , which shows another embodiment of a secondary tissue acquirer. In this embodiment, the tissue acquisition member  2600  includes a track  2602  formed on an upper surface thereof and configured to slidably receive one or more triangular wedge members  2604 . The wedge member  2604  (or, if there are more than one, each wedge member) can, in turn, be connected to one or more actuating cables seated within, along, or adjacent to the track  2604 . The tissue acquisition member  2600  also features two or more clamps  2606 ,  2608  pivotally connected to the tissue acquisition member  2600 . The clamp  2606  includes a tissue-engaging distal end  2610  that can be blunt or sharp, and a proximal end  2612  configured to engage with the wedge member  2604 . Though not shown clearly in the figure, the opposing clamp  2608  can include similar features. In the embodiments disclosed herein, a biasing member, such as a spring, can be configured to assist movement of the clamps  2606 ,  2608 . 
     To operate the secondary tissue acquirer, an operator can slide wedge member  2604  in a proximal direction within track  2602  by, for example, pulling on an actuating cable connected to the wedge member  2604 . As the wedge member  2604  moves proximally, its sides will interface with the proximal ends of the clamps  2606 ,  2608 . The triangular shape of the wedge member  2604  will progressively push the proximal ends of the clamps  2606 ,  2608  laterally away from a longitudinal axis of the tissue acquisition member  2600  as the wedge member  2604  is advanced proximally. Due to the pivotal connection of the clamps  2606 ,  2608  to the tissue acquisition member  2600 , the distal ends of the clamps  2606 ,  2608  will move inward toward each other, thereby engaging any tissue drawn against the lower surface of the tissue acquisition member. 
     While  FIG. 26  illustrates one exemplary configuration for the clamps and wedge member, it should be noted that a variety of alternative configurations are also possible. For example, multiple sets of clamps can be used with multiple wedge members. In addition, alternative actuation technologies can be used to drive the movement of the wedge member within the track on the tissue acquisition member. For example, the wedge member can be slidably driven along the track using pneumatic force, rather than one or more actuating cables. 
       FIGS. 27A and 27B  illustrate a third embodiment of a secondary tissue acquirer that utilizes one or more grasping hooks to engage and retain tissue drawn against the tissue acquisition member. In this embodiment, a tissue acquisition member  2700  includes a rotatable shaft  2702  extending through a portion of the body of the tissue acquisition member. One or more tissue-engaging hooks  2704  that are coupled to the rotatable shaft such that, as the shaft rotates, they swing in a plane that is angularly offset from (i.e., not parallel to) a longitudinal axis of the tissue acquisition member  2700 . 
     The rotatable shaft  2702  can be controlled by an actuating cable coupled to the shaft at the proximal end of the tissue acquisition member  2700 . The shaft  2702  and actuating cable can be coupled such that rotation of the actuating cable creates a corresponding rotation of the shaft. 
       FIG. 27B  illustrates the tissue acquisition member  2700  with the hooks  2704  in a retracted position. In order to prevent the hooks from engaging tissue in the retracted position, the tissue acquisition member can include one or more protruding sections  2800  that extend beyond the length of the hooks  2704  and prevent their distal ends from engaging with surrounding tissue. 
       FIGS. 28A-28C  illustrate yet another embodiment of a secondary tissue acquirer coupled to the tissue acquisition member. The secondary tissue acquirer includes a hook mounted on a rotatable shaft such that the hook can swing into tissue drawn against the lower surface of the tissue acquisition member.  FIGS. 28A-C  illustrate the hook in three positions: a retracted position in  FIG. 28A , an intermediary position in  FIG. 28B , and a fully engaged position in  FIG. 28C . 
     As shown in  FIG. 28A , a tissue acquisition member  2800  can have a slot  2802  formed in a sidewall  2804  thereof parallel to a longitudinal axis of the tissue acquisition member. The tissue acquisition member  2800  can also include a protrusion  2806  from the sidewall  2804  that is located above the slot  2802 , and a short rotatable shaft  2808  can extend from a lower surface of the protrusion. A hook  2810  can be coupled to the shaft such that, as the shaft rotates, the hook moves in a plane that is parallel to the lower surface of the tissue acquisition member and the slot  2802 . Further, a distal end  2812  of the hook  2810  can swing through the slot  2802  such that it crosses a plane defined by the sidewall  2804  of the tissue acquisition member  2800 . 
     To control the rotation of the hook  2810 , a suture  2814  or thin actuating cable can be attached to a proximal end  2816  of the hook. The proximal end  2816  of the hook can be offset from the rotatable shaft  2808  such that tensioning the suture  2814  can cause the shaft, and therefore the hook  2810 , to rotate. The suture  2814  can, in turn, be connected to, for example, a linear actuator housed in a second protrusion  2818  on the sidewall  2804  of the tissue acquisition member  2800 . Accordingly, rotation of the hook  2810  can be controlled by actuation of the linear actuator to tension the suture  2814 . The rotatable shaft  2808  can also include a spring member to bias the shaft and return the hook  2810  to the retracted position shown in  FIG. 28A  upon release of the tension on the suture  2814 . 
     A number of variations on this secondary tissue acquirer configuration are also possible. For example, the hook  2810  can be configured to be disposed just below the lower surface of the tissue acquisition member  2800 , thereby eliminating the need for a slot  2802 . Furthermore, the tissue acquisition member  2800  can include more than one hook and actuator pair, or could include a single actuator connected to a series of hooks for simultaneously rotating multiple hooks so as to engage tissue drawn against the tissue acquisition member  2800 . 
     Low Profile Insertion Position 
     In certain situations, it can be desirable to create larger plications, or plications that are secured by multiple lines of staples or other fasteners. However, devices configured to apply multiple fasteners, or sets of fasteners, can often be larger in size, which is a concern for endoscopic procedures. There is a general inverse relationship between the rigid length and the diameter of a surgical device that can be introduced endoscopically. This means that as a device increases in diameter, its rigid length must decrease in order to permit endoscopic entry and manipulation within a patient. Conversely, a device having a large rigid length will need to have a smaller diameter to allow it to be endoscopically inserted into a patient. To address this problem, the devices disclosed below utilize a low profile insertion position that reduces the diameter of the staple applying assembly such that it can be inserted into a patient endoscopically despite the use of, for example, larger jaws or a large staple cartridge. 
       FIG. 29  illustrates another embodiment of a staple applying assembly or stapling member  2900 . Similar to the staple applying assembly  200  discussed above, staple applying assembly  2900  includes a first jaw  2902 , a second jaw  2904 , and a tissue acquisition member  2906 . In the illustrated embodiment, however, the second jaw  2904  includes a multi-line staple cartridge  2908  rather than the stapler portion  900  discussed above. The operation of the multi-line staple cartridge  2908  is discussed in more detail below. 
     The staple applying assembly  2900  also includes a 4-bar hinge linkage  2910  connecting the tissue acquisition member  2906  to the first jaw  2902 . The hinge linkage  2910  can include a base member  2912  and four linkage arms  2914 ,  2916 ,  2918 ,  2920 . Each of the linkage arms  2914 ,  2916 ,  2918 ,  2920  can be pivotally connected at one end to opposing sides of the base member  2912  and pivotally connected at the other end to opposing sides of the tissue acquisition member  2906 . As a result, there is no connection between the top surface of the first or second jaws and the bottom surface of the tissue acquisition member, as shown in other embodiments. 
     This particular configuration of the hinge linkage  2910  allows the tissue acquisition member  2906  to move through an increased range of motion. In particular, the tissue acquisition member  2906  can move from a first position adjacent to, and substantially between, the first and second jaws  2902 ,  2904  to a second position that is offset above the first and second jaws, similar to the embodiments discussed above. However, the tissue acquisition member  2910  can continue to move to a third position in which the tissue acquisition member is disposed proximal to the first and second jaws  2902 ,  2904 , as shown in  FIG. 30 . Further, the tissue acquisition member  2906  can be in contact with a shaft of a surgical device (e.g., extension section  1304  discussed above) extending proximally from the staple applying assembly  2900 . 
     As shown in  FIG. 30 , this proximal storage position can provide a reduced overall diameter of the surgical tool for introduction into a patient endoscopically. For example, in an exemplary embodiment, the rigid length of the staple applying assembly  2900  can be about 25 millimeters to about 80 millimeters in length, with a diameter of about 14 mm to about 20 mm. 
     The linkage  2910  can provide additional benefits as well. For example, the linkage  2910  can utilize linkage arms having bends and other shape features that allow the tissue acquisition member  2906  to be lowered beyond a plane defined by a superior surface of the first and second jaws  2902 ,  2904  or a shaft extending proximally from the staple applying assembly  2900 . This can, for example, allow the tissue acquisition member  2906  to be lowered between the first and second jaws  2902 ,  2904  toward tissue when the jaws are in an open position. In addition, a shaft extending proximally from the staple applying assembly  2900  can include a feature, such as a recess, to seat the tissue acquisition member  2906  and thereby reduce the total diameter of the staple applying assembly  2900  as much as possible. 
     Another benefit of the linkage  2910  is that the increased range of motion can be utilized to form larger plications. For example, when the tissue acquisition member  2906  is raised above the first and second jaws to a maximum height, the linkage  2910  will be approximately halfway through its range of motion (i.e., roughly halfway between the orientations shown in  FIGS. 29 and 30 ). If an operator desires to form an even larger plication, the tissue acquisition member  2906  can simply be retracted further, as if moving it toward the proximal low-profile insertion position. Because tissue is still attached to the tissue acquisition member via vacuum suction, a secondary tissue acquirer, or both, the tissue will continue to be drawn further through the first and second jaws  2902 ,  2904 , thereby creating a larger plication. 
     Alternative Fastening Mechanisms 
     The stapler portion  900  described above is just one of a variety of fastening mechanisms that can be used to secure plications formed by a tissue acquisition member. The multi-line staple cartridge  2908  illustrated in  FIGS. 29 and 30  is another embodiment of a fastener delivery mechanism of the present invention. 
     The multi-line staple cartridge  2908  has a generally rectangular body with four rows of staples that are aligned end-to-end parallel to a longitudinal axis of the cartridge. While four rows of staples are illustrated, the staple cartridge  2908  can include a different number of rows. The staple cartridge  2908  can also include a mechanism for ejecting the staples from the cartridge selectively. 
       FIG. 31A  depicts a top view of the staple cartridge  2908  showing each of the four rows of staples  3102 ,  3104 ,  3106 ,  3108 . Each staple row  3102 ,  3104 ,  3106 ,  3108  includes a wedge  3110 ,  3112 ,  3114 ,  3116  slidably disposed in the row. Each wedge  3110 ,  3112 ,  3114 ,  3116  can be configured to interface with and eject a staple from the row as the wedge slides along the row. 
     The ejection mechanism is illustrated in  FIG. 31B , which depicts the staple cartridge  2908  from the side view. As the figure illustrates, the wedge  3110  can be seated in the row  3102  that contains a plurality of staples. The wedge  3110  can also be connected to an actuating cable  3118  to control its position along the row of staples  3102 . For example, an operator can tension the actuating cable  3118  to slide the wedge  3110  to the left in  FIG. 31B  (i.e., in the direction of the arrow L). The wedge  3110  can have a slanted surface  3120  that engages a first staple  3122  and ejects it from the staple cartridge  2908  toward, for example, the anvil jaw of the stapler  2902  (i.e., in the direction of the arrow U). After the first staple  3122  is ejected from the staple cartridge  2908 , the operator can stop tensioning the actuating cable  3118  to cease ejecting staples, or continue to slide the wedge  3110  proximally (i.e., to the left in  FIG. 31B ) to subsequently eject one or more of the other staples in the row  3102 . 
     Each staple row  3102 ,  3104 ,  3106 ,  3108  can have a similar configuration with its own wedge and actuating cable. Accordingly, the staple cartridge  2908  can provide four rows of staples wherein each row is selectively controllable using a control wire or actuating cable connected to the wedge slidably disposed in the row. 
       FIGS. 32A-C  illustrate an alternative embodiment for sequentially ejecting fasteners from a row, such as the rows  3102 ,  3104 ,  3106 ,  3108  of the staple cartridge  2908 . In this embodiment, a fastener cartridge  3200  includes one or more rows of fasteners  3202 , where each fastener is disposed in a silo  3204  within the cartridge. Collapsible T-tags are illustrated in the figure, but it is possible to use staples or a variety of other fasteners as well. Each silo  3204  connects to a central row passage  3206  at its bottom end. Further, the row passage  3206  includes a swinging trap door  3208  mounted on the distal end of each silo  3204 . In a loaded cartridge, as shown in  FIG. 32A , each trap door is held in an open position by an actuating member  3210 , which also forms the bottom surface of each silo  3204 . 
     To eject a fastener, the actuating member  3210  can be drawn proximally (i.e., in the direction of arrow P) past a first silo  3204 . Once the actuating member  3210  moves beyond the trap door  3208  of the silo, the door will swing shut to the position shown in  FIG. 32B  as a result of its biasing via, for example, a spring. The actuating member  3210  can then be advanced distally to eject the fastener. In particular, the actuating member  3210  will abut against the sloped surface of the trap door  3208  and be deflected upward into the silo  3204 . The actuating member  3210  can then push the fastener out of the silo  3204  and into surrounding tissue, as shown in  FIG. 32C . In order to function properly, the actuating member  3210  can be formed from a material that is flexible enough to permit deflection into a silo  3204  and also sufficiently incompressible to apply an ejection force to the fastener  3202 . 
     To selectively deliver an additional fastener from a row of fasteners in a cartridge  3200 , the actuating member  3210  can be retracted past the next-most proximal silo, and subsequently advanced distally to eject the fastener. Similar to the staple cartridge  2900 , the cartridge  3200  can feature multiple rows of fasteners, each having their own actuating member  3210  so as to make each row of fasteners selectively controllable. 
     A number of variations on this fastener cartridge are possible. For example, the collapsible T-tag fasteners  3202  shown may be disposed within the central row passage  3206  or within the actuating member  3210 . 
     In other embodiments, devices are provided that are capable of simultaneously ejecting a plurality of staples from a stapling member.  FIGS. 33A and 33B  illustrate one embodiment of such a device. The figures depict one staple ejecting module  3300  that includes components similar to the stapler portion  900  and the staple former  902  discussed above. In particular, the module  3300  can be integrated into, for example, the second jaw  204  and can include a plurality of staples  3302 , a staple pusher  3304 , and a biasing element  3306  configured to press the staple pusher into the plurality of staples and urge them toward a slot  3308 . A longitudinal axis of the slot  3308  can be offset at an angle from a longitudinal axis of the second jaw  204  and, in some embodiments, can be perpendicular to the longitudinal axis of the second jaw. 
     A firing linkage of the module  3300  can include a staple former  3310  slidably disposed in the slot  3308 . The staple former  3310  can be pivotally connected to a forming link  3312 . The forming link  3312  can be pivotally connected to, for example, the second jaw  204  at pin P. The forming link  3312  can also be pivotally connected to a firing link  3314  between pin P and staple former  3310 . The firing link  3314  can, in turn, be pivotally connected to a firing pin T that can be slidably disposed within a slot  3316  that extends parallel to a longitudinal axis of the second jaw  204 . The firing pin T can be connected to an actuating cable such that, as the actuating cable is pulled, the firing pin T translates within the slot  3316 . 
     In particular, the pin T can move from a first position illustrated in  FIG. 33A  to a second position illustrated in  FIG. 33B . As the pin T moves, its horizontal translation is converted into a vertical movement of the staple former  3310  by the firing link  3314  and the forming link  3312 . As the staple former  3310  moves upward from the bottom of the slot  3308 , it ejects a staple  3302  that was pushed into the slot  3308  by the staple pusher  3304 . 
       FIGS. 33A and 33B  illustrate only a single staple ejecting module  3300 , however, a staple applying assembly may include more than one module  3300  along the length of, for example, the second jaw  204 . By including a plurality of these modules along the length of a device and connecting each firing pin T to an actuating cable, a single actuation of the cable can be effective to eject a plurality of staples simultaneously. 
       FIG. 34  illustrates another embodiment of a staple ejecting module  3400 . Most of the components are similar, but there is only a single firing link  3402 . The firing link  3402  is coupled at a first end to a pin A seated in a slot  3404  and coupled at a second end to the firing pin T that is seated in the slot  3316 . As the pin T is translated in the slot  3316 , the firing link  3402  causes a related motion of the pin A along the path of the slot  3304 . The slot  3304  begins below the plurality of staples  3302  and curves upward toward the opening of the slot  3308 . As the pin A travels toward the opening of the slot  3308 , the firing link  3402  comes in contact with a staple  3302  in the slot  3308  and ejects the staple  3302  from the second jaw  204 . In order to prevent the firing link  3402  from slipping on the staple  3302  or picking up multiple staples, the face of the firing link that interfaces with the staple can include one or more features to prevent such a slippage. These features can include, for example, a concave shape and a textured surface to aid in gripping the staple. As can be seen in the right-hand side of  FIG. 34 , a plurality of the described staple ejecting modules  3400  can be disposed along the length of, for example, the second jaw  204  of a staple applying assembly. 
       FIG. 35  illustrates yet another embodiment of a staple ejecting module that can be replicated along the length of, for example, the second jaw  204  in order to simultaneously eject multiple staples. In this embodiment, the pivoting or sliding linkages of  FIGS. 33A-34  are replaced by a rigid cam member  3502  that translates in a direction parallel to a longitudinal axis of the second jaw  204 . The cam member  3502  includes a cam surface  3504  that interfaces with a staple former  3506 . The staple former  3506  is slidably disposed in the slot  3308  and ejects a staple  3302  in a similar manner to staple former  3310  as the cam member  3502  urges the staple former farther upward. 
     In still another embodiment shown in  FIG. 36 , a pivoting staple former  3602  is used to simultaneously eject each of the staples located on opposing sides of a pivot point  3604 . The second jaw  3606  in this embodiment includes a plurality of slots  3608  housing staples  3610 . An elongate staple former that extends substantially the entire length of the second jaw  3606  is pivotally attached to the second jaw  3606  by the pin  3604 . At a proximal end of the second jaw  3606 , the staple former  3602  is pivotally coupled to a pulley wheel  3612  by a link  3614 . An actuating cable  3616  can be used to rotate the pulley wheel  3612  clockwise or counterclockwise by tensioning opposing ends of the actuating cable. 
     To eject staples from each of the slots  3608  located distal to the pivot point  3604 , the operator can rotate the pulley wheel  3612  in a clockwise direction. This action lowers the proximal end of the staple former  3602  and raises the distal end of the staple former, thereby ejecting the staples from the distal end slots  3608 . Conversely, to eject staples from the slots  3608  located proximally to the pivot point  3604 , the operator can rotate the pulley wheel  3612  in a counterclockwise direction, thereby raising the proximal end of the staple pusher  3602  and ejecting staples. 
     The above-disclosed embodiments are examples of mechanisms capable of firing multiple staples or other fasteners sequentially or simultaneously. It should be noted that there are a variety of other mechanisms for accomplishing this goal as well. These include, for example, the incorporation of a continuous feed linear stapler into the staple applying assembly to avoid having to remove the device for re-loading. All of these variations are considered within the scope of the present invention. 
     Methods of Use 
     The present invention also provides methods for creating and securing gastric plications. The methods of the present invention are generally, though not exclusively, characterized by positioning jaws of a stapling device parallel to a tissue surface, rather than perpendicular to it. A tissue acquisition member can then be used to draw tissue through the jaws to create a gastric plication. 
     Several stages of an embodiment of a method of the present invention are illustrated in 
       FIGS. 37-45 . As shown in  FIG. 37 , a surgical device  3700  can be inserted into a patient&#39;s gastric cavity through the esophagus, and subsequently positioned along the stomach wall such that a longitudinal axis of the end effector is substantially parallel to an inner surface of the stomach wall. The surgical device  3700  can include a staple applying assembly  3702  according to any of the various embodiments discussed above. 
     Once in the gastric cavity, a viewing scope  3802  can be extended from an elongate shaft  3803  extending proximally from the staple applying assembly  3702 , as shown in  FIG. 38 . After any necessary positional adjustment using the visual aid of the scope  3802 , the first and second jaws  3804 ,  3806  can be moved to an open position in which they are configured to receive tissue. In addition, the tissue acquisition member  3808  can be further lowered, e.g., moved closer toward the jaws and the tissue on the opposite side of the jaws. In some embodiments, the tissue acquisition member can be moved into the space between the first and second jaws  3804 ,  3806 , if so desired. 
     As shown in  FIG. 39 , a vacuum source can be activated such that one or more vacuum ports on a lower surface of the tissue acquisition member  3808  draw tissue against the surface. Because the tissue acquisition member  3808  is located substantially between the first and second jaws  3804 ,  3806 , the tissue drawn against the tissue acquisition member passes through the first and second jaws and begins to form a gastric plication, or fold. As mentioned above, in some embodiments the first and second jaws are configured to separate by 10 mm or less to prevent any undesired surrounding tissue from also being drawn through the first and second jaws. Alternatively, the jaws can be opened sufficiently to allow the vacuum pod to pass between and directly contact tissue. In such a circumstance, the jaws can be manually or automatically closed to a distance less than 10 mm once the vacuum pod is free of the region between the jaws. 
     After drawing tissue against the tissue acquisition member  3702  by suction, any secondary tissue acquirer can be actuated to engage the tissue and help maintain its position as the tissue acquisition member is moved away from the first and second jaws  3804 ,  3806 . The tissue acquisition member  3702  can then be actuated by, for example, tensioning a cable connected to the tissue acquisition member. This tensioning can cause the tissue acquisition member to both raise above (i.e., move farther away from) and translate longitudinally with respect to the first and second jaws  3804 ,  3806  via hinge linkage  4000 , as shown in  FIG. 40 . This action causes additional tissue to be drawn through the first and second jaws  3804 ,  3806 , thereby enlarging the size of the plication being formed. 
     Once the size of the plication has been properly set (which may be at a partially elevated position in the event multiple rows are intended), the first and second jaws can be moved to a closed position effective to engage the tissue disposed therebetween, as shown in  FIG. 40 . A firing mechanism can then be actuated by, for example, tensioning an actuating cable connected to the firing linkage of the second jaw  3806 . The firing mechanism can be effective to eject a staple or other fastener from the second jaw  3806 , through the tissue disposed between the first and second jaws, and into an anvil portion of the first jaw  3804 . 
     The first and second jaws  3804 ,  3806  can then be moved back to the open position, revealing a first fastener  4100  securely holding the tissue layers of the plication together, as shown in  FIG. 41 . To secure additional fasteners in the plication, the tissue acquisition member  3702  can be translated longitudinally along its axis using, for example, a lead screw  4102  attached to the tissue acquisition member, as described above.  FIG. 42  shows the tissue acquisition member  3702  translated distally from the position shown in  FIG. 41 . In some embodiments, the distance between successive fasteners is less than 2 cm. In other embodiments, the distance between successive fasteners is about 1 cm. 
     The process above can be repeated to secure the plication with a second fastener  4300 , as shown in  FIG. 43 , and can be further repeated until the tissue acquisition member reaches the distal end of the lead screw  4102 , as shown in  FIG. 44 . At this point, if a second, parallel line of staples is necessary, the jaws can be moved to the open position, the tissue acquisition member can be translated back to its original proximal position on the lead screw  4100 , and the height of the tissue acquisition member over the first and second jaws can be adjusted via the hinge linkage to position the tissue for the delivery of a second line of staples. 
     If a second line of staples is not desired (suggesting, but not requiring, that the fold height was maximally created), the tissue acquisition member can release the tissue by disengaging any secondary tissue acquirers and deactivating the vacuum source connected to the tissue acquisition member. The end result can be a gastric fold secured by an even line of staples  4500 , as shown in  FIG. 45 . To create an additional fold, the tissue acquisition member can be repositioned and the process started anew. 
     The methods disclosed above demonstrate how to use a device of the present invention to create and secure a gastric plication. However, the present invention also contemplates other methods of plication placement within the gastric cavity. For example, some data has shown that reduction of gastric volume through invagination of the greater curvature of the stomach has yielded significantly larger excess weight loss percentage than invagination of the lesser curvature. 
     Accordingly, in another exemplary method, one or more gastric plications can be formed on an anterior or posterior wall of the greater curvature of the stomach. An exemplary method for forming a plication is illustrated in  FIGS. 46A-C . As shown in  FIG. 46A , a device, such as device  4600  according to the present invention, can be inserted through a patient&#39;s esophagus  4602  and into the stomach cavity  4604 . The device can then be articulated using, for example, the articulating joints described above, to access the anterior or posterior wall of the stomach near or within the fundus, as shown in  FIG. 46B . Finally, a plication can be created and secured using, for example, the method described above. This leaves a secured gastric plication, as shown externally in  FIG. 46C . 
     To create additional plications, the end effector staple applying assembly can be articulated from the position of “Fold A” shown in  FIG. 47A  to a second position labeled “Fold B.” The above process can then be repeated to create and secure a second plication. If necessary, the end effector can again be articulated from the position of “Fold B” to a third position labeled “Fold C.” Additional folds can be made as necessary, forming a fan-shaped pattern. After forming and securing all plications, the end effector can be retracted back out of the gastric cavity through the esophagus, leaving secured plications such as those shown in  FIG. 47C . 
     The multiple plications discussed above can be formed in a clockwise or counterclockwise direction (i.e., moving from Fold A to Fold C, or Fold C to Fold A). In addition, plications can be formed on both the anterior and posterior walls of the greater curvature of the stomach. In forming plications on both walls, the methods of the present invention can include forming all plications on one wall before the other, or alternating between the two. In addition, plications can be formed on both walls in a particular section of the stomach before alternately or otherwise forming plications in other sections of the stomach. Further, plications can be formed in any of a proximal or a distal direction. For example, plications can be formed on both the posterior and anterior walls in or near the fundus before forming plications on alternate walls in a distal to proximal direction in other areas of the stomach. Still further, the respective folds created on the anterior and posterior walls of the stomach are not attached to each other. These methods can provide the benefit of limiting the impact of a decreasing working space as the multiple plications are formed and secured. 
     In another embodiment, multiple plications can be formed in an end-to-end fashion to create a single extended plication, rather than the fan-shaped pattern described above. To do so, a staple applying assembly  4800  according to the teachings of the invention can be inserted into a patient&#39;s stomach through the esophagus. Once in the stomach, the staple applying assembly  4800  can be positioned along the anterior wall of the stomach near or within the antrum, as shown in  FIG. 48A . The staple applying assembly can be actuated according to any of the methods described above to form and secure a first gastric plication (labeled “Fold A”), shown externally in  FIG. 48B . 
     Following formation of the first plication, the staple applying assembly  4800  can be retracted toward the esophagus as shown in  FIG. 49A . Once the staple applying assembly is in a position to create a gastric plication that extends from the first gastric plication (labeled “Fold A”), the assembly  4800  can be actuated to create a second gastric plication (labeled “Fold B”), which is shown externally in  FIG. 49B . 
     The above process can be repeated again to create a third gastric plication (labeled “Fold C”), as shown in  FIGS. 50A and 50B . Depending on the size (e.g., length) of the stapling jaws of the staple applying assembly  4800 , the process may be repeated more or fewer times in order to create a desired number of gastric plications. 
     Similarly to the methods of forming plications in a fan-shaped pattern described above, the above methods contemplate forming all plications on an anterior wall of the stomach followed by forming all plications on a posterior wall, or alternately forming plications on the anterior wall and the posterior wall. Further, plications may be formed in both walls of one section of a cavity before forming plications alternately or in another manner in another section of the cavity. In addition, the plications formed on the anterior wall are not attached to those on the posterior wall of the stomach. Still further, the plications can be formed in a distal to proximal order, as shown in the figures, or in a proximal to distal order (i.e., moving from Fold C to Fold A). Following the formation of the final plication, the staple applying assembly can be removed from the stomach via the esophagus. One skilled in the art will appreciate that a combination of the embodiments described above may be used (e.g., first forming a plication in or near the fundus, and then forming a plication in a distal to proximal order, or first forming at least one plication in the form of a fan and then forming at least one plication in the form of a line), as shown in  FIG. 50C . 
     In one exemplary method for gastric volume reduction, a surgical device of the present invention can be inserted into the gastric cavity via a patient&#39;s esophagus. An end effector of the gastric device can be retroflexed or articulated using, for example, articulating joints, to access the fundus region of the stomach (as shown in  FIG. 50A ). The end effector can then be utilized to create and secure a plication on at least one of the anterior and posterior inner surfaces of the fundus (e.g., Fold C of  FIG. 50A ). In an exemplary embodiment, folds are formed in both the anterior and posterior inner surfaces. 
     The formation of one or more folds in the fundus can significantly reduce the capacity of that region of the stomach, making it difficult to un-articulate the end effector, i.e., return the end effector to its original position in which it is substantially longitudinally aligned with at least a distal portion of the insertion shaft to which the end effector is attached. Accordingly, in some embodiments, it can be desirable to form folds in the fundus prior to forming any folds in the antrum so as to allow the surgical device to be extended distally toward the antrum of the stomach and to be un-articulated once the end effector is clear of the constricted fundus. In some embodiments, the end effector can then be extended into the antrum of the stomach without articulation (or with a lesser amount of articulation) and utilized to form a plurality of plications on at least one of the anterior and posterior inner surfaces of the stomach (e.g., Folds A and B of  FIG. 50A ). In an exemplary embodiment, the end effector is un-articulated and a series of folds are formed along each of the anterior and posterior walls. 
     Forming a plurality of plications in the stomach can be accomplished in a variety of manners. For example, all plications can be formed on one of the anterior or posterior surfaces of the stomach before forming plications on the other surface. In other embodiments, plications can be formed alternately on the anterior and posterior surfaces. In addition, plications can be formed in any of a proximal and a distal direction along the surfaces. For example, after forming plications in the fundus and extending the end effector into the antrum of the stomach, the plurality of plications can be formed in a distal-to-proximal direction along at least one of the anterior and posterior surfaces of the stomach (e.g., forming Fold A and then Fold B of  FIG. 50A ). In other embodiments, folds can be created in a proximal-to-distal direction on one surface (e.g., the anterior surface) and a distal-to-proximal direction on the other surface (e.g., the posterior surface), or vice versa. There are a number of variations in the order and direction in which plications can be formed in the cavity, all of which are considered within the scope of the present invention. 
     The above methods can be utilized to avoid complications resulting from the reductions in cavity capacity that occur as plications are formed. For example, in certain embodiments, forming all plications in the fundus region first can be advantageous because the unrestricted volume in the remainder of the stomach cavity can be used to accommodate movement of the end effector as any articulation necessary to reach the fundus is released. After releasing the articulation of the end effector, plications can be formed in the remainder of the stomach cavity in a distal-to-proximal direction (i.e., from the lower antrum region toward the esophagus). This pattern effectively retracts the end effector out of the stomach as the plications are formed. 
     Other Embodiments 
     Disclosed below are still additional embodiments of the present invention that provide variations over the embodiments discussed above. These embodiments, as well as others that may be apparent to one of ordinary skill in the art, are considered to be within the scope of the present invention. 
     Reciprocating Tissue Feeders 
       FIGS. 51A-C  illustrate one embodiment of a reciprocating tissue feeder that can be used in conjunction with the devices described above to aid in drawing tissue through, for example, a set of stapling jaws. As shown in  FIG. 51A , the reciprocating tissue feeder can include an elongate member  5100  having one or more unidirectional protrusions  5102  that are configured to engage tissue when moved in one direction and slip past tissue when moved in an opposing direction. The elongate member  5100  can also feature a through-bore  5104  or other attachment feature that allows the elongate member  5100  to be coupled to an actuator. 
     An embodiment of a stapling member having one or more reciprocating tissue feeders is shown in  FIG. 51B . As shown in the figure, the stapling member includes first and second jaws  5106 ,  5108 . The surface of the second jaw  5106  that opposes the first jaw  5108  can include one or more of the reciprocating tissue feeders  5100 . Each feeder  5100  can be coupled to an actuator, such as a small linear actuator, configured to alternately translate the feeder  5100  along its longitudinal axis. Provided the feeder  5100  is oriented such that the tissue engaging portions of its unidirectional protrusions  5102  face in the direction of desired motion (e.g., the upward direction illustrated by arrow A), the alternating motion of the feeders  5100  can aid a tissue acquisition member (not shown) in drawing tissue through the jaws. It should be noted that the surface of the first jaw  5108  that opposes the second jaw  5106  can have one or more tissue feeders  5100  disposed thereon as well, though these are blocked from view in the figure. 
     One or more of the reciprocating tissue feeders  5100  can also be placed on a bottom surface of the stapling jaws  5106 ,  5108 , as shown in  FIG. 51C . In this embodiment, the reciprocating tissue feeders  5100  can aid in gathering tissue surrounding the stapling jaws and bringing it toward the jaws to assist a tissue acquisition member (not shown) in drawing tissue through the jaws. The feeders  5100  on the second jaw  5106  can be configured such that reciprocal motion drives tissue in the direction of arrow B (i.e., the tissue engaging faces of protrusions  5102  on feeders  5100  face in the direction of arrow B). Tissue feeders  5100  disposed on the bottom surface of the first jaw  5108  can be configured to drive tissue in an opposing direction illustrated by arrow C. This converging motion helps gather surrounding tissue such that a tissue acquisition member can more easily draw the tissue through the jaws  5106 ,  5108 . 
     It should be noted that other embodiments of the reciprocating tissue feeder  5100  are also possible. For example, a reciprocating belt (e.g., similar to a conveyer belt) having affixed thereto one or more unidirectional protrusions similar to protrusions  5102  can be incorporated into one or more surfaces of stapling jaws to aid in drawing tissue between the jaws. For example, a reciprocating belt could be configured to run substantially the entire length of a stapling jaw, or one or more belts could be located at particular locations along a surface of the jaw. Such a belt could be configured to move forward and back alternately, or to run in a continuous loop such that any protrusions are prevented from engaging tissue (e.g., by being contained within the body of a stapling jaw) during the return stroke. 
     Alternative Tissue Acquisition Members 
     There are a variety of mechanisms suitable for grasping a tissue wall and drawing a portion of the tissue wall in a direction so as to create a fold in the tissue wall. Several exemplary embodiments are discussed below. These embodiments can be utilized in conjunction with, or in place of, the tissue acquisition members discussed above. 
     Mechanical Grasper 
     In certain embodiments, a mechanical grasper can be utilized in place of vacuum suction in a tissue acquisition member.  FIG. 52A  illustrates a side view of a stapling member that includes a set of stapling jaws  5200  and a tissue acquisition member  5202  coupled thereto and disposed to one side of another of the jaws  5200 . At the distal tip of the tissue acquisition member  5202  is a mechanical grasper  5204  that is configured to extend beyond a distal end of the jaws  5200 . The mechanical grasper can have a variety of shapes and features and, in some embodiments, can be a corkscrew-shaped member configured to engage a tissue wall. At its proximal end, the tissue acquisition member  5202  can be coupled to the jaws  5200  via, for example, a two bar hinge linkage  5206 , similar to the hinge linkages discussed above. 
     In operation, the device can be advanced to a tissue wall  5208  and grasper  5204  can be used to engage the tissue wall. This can be done, for example, by rotating the grasper  5204  to drive it into tissue. Next, an actuating cable  5210  can be tensioned to raise the tissue acquisition member  5202  above the jaws  5200  such that tissue is drawn into a space between the jaws  5200 , as shown in  FIG. 52B . The jaws  5200  can then be actuated according to the teachings of the invention to secure a plication using a staple or other fastener. Multiple fasteners could be used by, for example, opening the jaws and raising the tissue acquisition member  5202  more in order to further draw tissue through the jaws  5200 . 
     In another embodiment illustrated in  FIGS. 53A and 53B , an articulating tissue acquisition member  5300  can be used in place of the hinge linkage  5206  to draw tissue through a set of stapling jaws  5302 . The articulating member  5300  can be located between the two stapling jaws, to the side of the two jaws, or adjacent to an upper surface of the jaws  5302 . 
     The jaws  5302  can be positioned near a tissue wall surface such that a longitudinal axis of the device is either perpendicular, parallel, or at another intermediary angle to the tissue wall surface. The tissue acquisition member  5300  can then be articulated to allow a mechanical grasper  5304  at a distal end thereof to engage tissue. Tensioning of internal control wires can cause the articulation of the tissue acquisition member  5300 , similar to the articulating joints described above. 
     After the mechanical grasper  5304  has engaged tissue, the articulating tissue acquisition member  5300  can be moved into the position shown in  FIG. 53B , thereby drawing tissue into the space between jaws  5302 . Jaws  5302  can then be actuated according to the teachings of the invention to secure the plication created by the articulating tissue acquisition member  5300 . 
     Deflecting Member 
     In still another embodiment, the deflection of a member under compression can be used to draw tissue away from a tissue wall surface to form a gastric plication. As shown in the top view of  FIG. 54A , a tissue acquisition member  5400  can include a proximal base  5402  that can be fixedly attached to, for example, an upper surface of a first jaw of a set of stapling jaws (not shown). Coupled to the proximal base  5402  can be a rigid rail  5404  extending distally parallel to a longitudinal axis of, for example, a set of stapling jaws. A distal base  5406  can be located distal to the proximal base  5402  and slidably coupled to the rail  5404 . An actuating cable  5408  can extend from the distal base  5406  to allow an operator to draw the distal base  5406  toward the proximal base  5402  along the rigid rail  5404 . Finally, a resilient flexible member  5410  can be coupled to and disposed between the proximal base  5402  and the distal base  5406 . In some embodiments, the coupling can be permit pivoting between the member  5410  and each of the bases  5402 ,  5406 . 
     In use, the tissue acquisition member  5400  can be positioned parallel to a tissue wall surface  5412  as shown in  FIG. 54B . A grasper element  5414  can extend from an inner lumen in the member  5410  through an opening in an outer sidewall thereof. The grasper can include any number of mechanical elements configured to engage tissue, such as a corkscrew or a small set of grasping jaws, as shown in the figure. The grasper element  5414  can engage tissue and draw it against the member  5410  as the grasper element  5414  is retracted back into the inner lumen of the member. 
     Once tissue has been drawn against the member  5410 , the actuating cable  5408  can be tensioned such that the distal base  5406  slides proximally along the rail  5404 . The movement of the distal base  5406  can cause the resilient flexible member  5410  to deflect as shown in  FIG. 54C . As a result of the fact that tissue has been drawn against the member  5410  by the grasper  5414 , the tissue can be pulled away from the tissue wall surface  5412  as the member deflects further. If, for example, the tissue acquisition member  5400  is mounted on an upper surface of a set of stapling jaws, the tissue can be drawn up through the jaws as it rises, forming a gastric plication that can be secured using the stapling jaws, as described above. 
     Dual Supporting Arms 
       FIGS. 55A-C  illustrate another embodiment of a tissue acquisition member in which stapling jaws rotate into position and draw the tissue acquisition member away from the tissue wall surface. As shown in  FIG. 55A , a tissue acquisition member  5500  can include a mechanical grasper  5502  or other tissue engagement element disposed on a distal end thereof In addition, the tissue acquisition member  5500  can be pivotally coupled to an end of a first and a second stapling jaw  5504 ,  5506 . The first and second jaws  5504 ,  5506  can be configured to rotate at least 180 degrees about the tissue acquisition member  5500 . 
     In use, the tissue acquisition member  5500  can approach a tissue wall surface  5508  with the first and second jaws  5504 ,  5506  in a position such that they do not extend beyond a distal end of the tissue acquisition member  5500 , as shown in  FIG. 55A . After the grasper  5502  engages tissue, the first and second jaws  5504 ,  5506  can be rotated as shown in  FIG. 55B  to a position in which they extend beyond a distal end of the tissue acquisition member  5500 . As the first and second jaws  5504 ,  5506  rotate in the direction of arrow A, the tissue acquisition member  5500  will be drawn away from the tissue wall surface  5508 , and tissue will be drawn into the space between the first and second jaws, as shown in  FIG. 55C . The first and second jaws  5504 ,  5506  can then be actuated to secure the plication. 
     Articulating Grasper 
     In the embodiment shown in  FIGS. 56A-D , an articulating set of stapling jaws  5600  can be used to secure a gastric plication. To begin, an endoscopic device having an articulating set of stapling jaws  5600  and a tissue grasper  5602  is inserted into a patient&#39;s stomach through the esophagus, as shown in  FIG. 56A . The device can be positioned over a desired plication site, and can be articulated if necessary to align and engage the tissue grasper  5602  with the stomach wall, as shown in  FIG. 56B . 
     Once engaged with the tissue of the stomach wall, an actuating cable  5604  connected to the tissue grasper  5602  can be tensioned to draw tissue away from the stomach wall surface, forming a plication. In addition, the actuating cable  5604 , which can initially be constrained along the entire length of the device, can be released from a distal portion of the device such that the tissue is drawn in a direction offset from the stapling jaws  5600 , as shown in  FIG. 56C . 
     Finally, and as shown in  FIG. 56D , the stapling jaws  5600  can be articulated further such that tissue is drawn through the jaws as it is pulled away from the stomach wall surface by the grasper  5602 . The stapling jaws can then be actuated to secure the plication with one or more staples or other fasteners. 
     Articulating Loops 
       FIGS. 57A-C  illustrate another articulating plication device that utilizes flexible resilient loops to form a gastric plication. As shown in  FIG. 57A , the device  5700  can include a shaft  5702  and two elongate members  5704 ,  5706  formed of a resilient flexible material coupled to the shaft at a first terminal end  5708  and a second terminal end  5710  (note that only one member  5704  is visible in the side view of  FIG. 57A  because the second member  5706  is directly behind the visible member  5704 ). The device  5700  can also include a tissue engagement element  5712  (e.g., a corkscrew, a small set of grasping jaws, etc.) located at a distal end of the shaft  5702 . 
     In use, the shaft  5702  can approach a tissue wall surface  5714  such that a longitudinal axis of the device  5700  is perpendicular to the tissue wall surface. The tissue engagement element  5712  can be actuated to engage tissue, and then one or more of the first terminal end  5708  and the second terminal end  5710  can be actuated to advance the elongate members  5704 ,  5706  toward the tissue wall surface  5714 . This can be accomplished, for example, by slidably disposing the first and second terminal ends  5708 ,  5710  in a track formed on the shaft  5702 . Note that only one of the first and second terminal ends must be movable and the other can be fixedly attached to the shaft, as shown in  FIG. 57B . Alternatively, both terminal ends can be configured to translate along the shaft  5702 . 
     As the two elongate members  5704 ,  5706  advance toward the tissue wall surface  5714 , they will deform into a loop shape. The tissue engagement element  5712  will also be drawn away from the tissue wall surface, thereby drawing tissue into a space between the two elongate members  5704 ,  5706  and forming a fold of stomach tissue. To secure the plication formed between the two elongate members  5704 ,  5706 , the shaft  5702  can feature two or more articulating joints  5716 ,  5718  that allow a fastener element  5720  to approach the plication by passing a fastener through the two loops formed by the resilient flexible members  5704 ,  5706 . The fastener element can extend from the shaft  5702  to pierce the plication and prevent it from flattening after the resilient flexible members  5704 ,  5706  are removed.  FIG. 57C  illustrates such articulation from a side view, where each of the elongate members  5704 ,  5706  are visible. 
     Assembly &amp; Reconditioning 
     The devices disclosed herein can be designed to be disposed after a single use, or they can be designed for multiple uses. In either case, however, the device can be reconditioned for reuse after at least one use. Reconditioning can include any combination of the steps of disassembly of the device, followed by cleaning or replacement of particular pieces, and subsequent reassembly. In particular, the device can be disassembled, and any number of the particular pieces or parts of the device can be selectively replaced or removed in any combination. Upon cleaning and/or replacement of particular parts, the device can be reassembled for subsequent use either at a reconditioning facility or by a surgical team immediately prior to a surgical procedure. Those skilled in the art will appreciate that reconditioning of a device can utilize a variety of techniques for disassembly, cleaning/replacement, and reassembly. Use of such techniques, and the resulting reconditioned device, are all within the scope of the present invention. 
     For example, the surgical devices disclosed herein may be disassembled partially or completely. In particular, the stapler portion  900  can be removable from the second jaw  204  to facilitate loading or re-loading of staples. In addition, each of the components of the firing mechanism can be separated from the stapling jaws to facilitate cleaning or repair. Similarly, each of the first jaw, the second jaw, and the tissue acquisition member can be separated from each other, and the entire end effector can be separated from any attached surgical device, such as device  1300  shown in  FIG. 13 . 
     Preferably, the devices described herein will be processed before surgery. First, a new or used instrument can be obtained and, if necessary, cleaned. The instrument can then be sterilized. In one sterilization technique, the instrument is placed in a closed and sealed container, such as a plastic or TYVEK bag. The container and its contents can then be placed in a field of radiation that can penetrate the container, such as gamma radiation, x-rays, or high-energy electrons. The radiation can kill bacteria on the instrument and in the container. The sterilized instrument can then be stored in the sterile container. The sealed container can keep the instrument sterile until it is opened in the medical facility. 
     It is preferred that device is sterilized. This can be done by any number of ways known to those skilled in the art including beta or gamma radiation, ethylene oxide, steam, and a liquid bath (e.g., cold soak). 
     All papers and publications cited herein are hereby incorporated by reference in their entirety. One skilled in the art will appreciate further features and advantages of the invention based on the above-described embodiments. Accordingly, the invention is not to be limited by what has been particularly shown and described, except as indicated by the appended claims.