Patent Publication Number: US-2023157699-A1

Title: Hook and loop for hemostasis clip release

Description:
PRIORITY CLAIM 
     The present disclosure claims priority to U.S. Provisional Pat. Application Serial No. 63/264,490 filed Nov. 23, 2021; the disclosure of which is incorporated herewith by reference. 
    
    
     FIELD 
     The present disclosure relates to endoscopic devices and, in particular, relates to endoscopic clipping devices for treating tissue along the gastrointestinal tract. 
     BACKGROUND 
     Physicians have become more willing to perform aggressive interventional and therapeutic endoscopic gastrointestinal (GI) procedures, which may increase the risk of perforating the wall of the GI tract or may require closure of the GI tract wall as part of the procedure. Such procedures may include, for example, the removal of large lesions, tunneling under the mucosal layer of the GI tract to treat issues below the mucosa, full thickness removal of tissue, treatment of issues involving organs outside the GI tract by passing through a wall of the GI tract, and endoscopic treatment/repair of post-surgical issues (e.g., post-surgical leaks, breakdown of surgical staple lines, and anastomotic leaks). 
     Currently, tissue may be treated via endoscopic closure devices including through-the scope clips or over-the-scope clips. Over-the-scope clips may be particularly useful for achieving closure of larger tissue defects. These endoscopic closure devices can save costs for the hospital as well as providing benefits for the patient. In some cases, however, current endoscopic closure devices may be difficult to use, time consuming to position, or insufficient for certain perforations, conditions and anatomies. For example, current over-the-scope clips may require launching of the clip from a position in which the clip itself is not visible to the operator. That is, prior to clipping the operator may view the target tissue to be clipped and, based on this visualization of the target tissue and an understanding of the positioning of the unseen clip relative to the field of view may determine that the distal end of the device and the clip are in a desired position relative to the target tissue. Based on the observation of the target tissue, the operator then deploys the clip without being able to see the clip itself until it is deployed. Once deployed, such current over-the scope clips are generally incapable of being repositioned. 
     SUMMARY 
     The present disclosure relates to a clipping system for treating tissue. The system includes an adapter extending longitudinally from a proximal end configured to be mounted over a distal end of an insertion device to a distal end; a clip; and a first extending member. The clip includes first and second jaws connected to one another so that the first and second jaws are movable between an insertion configuration, in which the first and second jaws are separated from one another to receive tissue therebetween and an initial deployed configuration in which the first and second jaws are drawn toward one another to grip tissue therebetween. The clip is biased toward the initial deployed configuration. The first jaw includes a first jaw connection element. The first extending member is configured to be releasably coupled to the clip. The first extending member extends from a proximal end accessible to a user at a proximal end of the insertion device to a first extending member connection device configured to releasably couple to the first jaw connection element. The first extending member is configured to permit movement of the adapter relative to the clip while the first extending member remains coupled to the clip to place the system in a review configuration in which the clip is physically spaced from the adapter to enhance visual observation of the clip. The first extending member is operable to retract the clip proximally over the adapter so that the clip is forced open as the clip is retracted over the adapter freeing the clip from tissue on which it had been clipped. 
     In an embodiment, the jaw connection element includes a slot extending through each of the jaws and wherein the first extending member connection device includes a hook, the slot being sized and shaped to releasably receive the hook. 
     In an embodiment, a width of the slot is smaller than a diameter of a curvature of the hook. 
     In an embodiment, a width the slot is larger than a width of the distal end of the first extending member so that the distal end of the first extending member is releasable from the first jaw connection element. 
     In an embodiment, the first jaw connection element includes a wire extending from the first jaw and wherein the first extending member connection device includes a hook-shaped curvature at the distal end of the first extending member, the wire including a loop configured to engage the hook-shaped curvature of the first extending member. 
     In an embodiment, a first end of the wire is attached to the first jaw and a second end of the wire includes the loop sized, shaped and configured to be hooked via the distal end of the first extending member. 
     In an embodiment, the wire is looped through a hole extending through the first jaw to form a closed loop configured to be hooked via the distal end of the first extending member. 
     In an embodiment, the wire extends from a first end to a second end, each of the first and second ends attached to a surface of the first jaw so that the wire defines a loop configured to be hooked via the hook-shaped curvature of the first extending member. 
     In an embodiment, the system further includes a second extending member releasably coupled to a second jaw connection element of the second jaw. The second extending member connection device includes a hook-shaped curvature at the distal end of the second extending member for engaging the second jaw connecting element. 
     The present disclosure also includes a clipping system for treating tissue. The system includes an endoscope extending longitudinally from a proximal end to a distal end; an adapter, a clip, and first and second extending members. The adapter extends longitudinally from a proximal end configured to be mounted over the distal end of the endoscope so that a channel of the adapter is aligned with a channel of the endoscope. The clip includes first and second jaws connected to one another so that the first and second jaws are movable between an insertion configuration, in which the first and second jaws are separated from one another to receive tissue therebetween and an initial deployed configuration in which the first and second jaws are drawn toward one another to grip tissue therebetween. The clip is biased toward the initial deployed configuration. The first jaw includes a first jaw connection element. The first and second extending members are configured to be releasably coupled to the clip and movably connected to the adapter. The first and second extending members extends from proximal ends accessible to a user at a proximal end of the endoscope. A distal end of the first extending member includes a first extending member connection device configured to be releasably connected to the first jaw connection element so that longitudinal movement of the first extending member relative to the endoscope moves the clip between the insertion configuration, the initial deployed configuration and a review configuration in which the clip is physically separated from the adapter to enhance visual observation of the clip. 
     In an embodiment, the first jaw connection element includes a slot extending therethrough and wherein the first extending member connection device includes a hook at a distal end of the first extending member, the slot defining an engaging section of the first jaw between the slot and an exterior edge of the first jaw, the engaging section configured to be received within the hook-shaped curvature of the first extending member. 
     In an embodiment, the first jaw includes a wire coupled thereto, the wire including a loop configured to engage the hook-shaped curvature of the first extending member. 
     In an embodiment, a first end of the wire is attached to the first jaw and a second end of the wire includes the loop that is sized, shaped and configured to be hooked via the distal end of the first extending member. 
     In an embodiment, the wire extends from a first end to a second end, each of the first and second ends being attached to a surface of the first jaw so that the wire defines a loop configured to be hooked via the hook-shaped curvature of the first extending member. 
     In addition, the present disclosure relates to a method for treating tissue. The method includes inserting a clip to a target area in a body lumen via an endoscope, the clip mounted over a distal end of the endoscope, via an adapter, in an insertion configuration in which jaws of the clip are separated from one another; applying a suction force through a working channel of the endoscope so that tissue is drawn into a channel of the adapter and between the jaws of the clip; moving the clip from the insertion configuration toward an initial deployed configuration by releasing tension along extending members coupled to the clip so that the jaws revert under a spring bias to a closed configuration in which the jaws move toward one another to grip tissue received therebetween, the extending members releasably coupled to the clip; and moving the endoscope relative to the clip while the extending members remain coupled to the clip to a review configuration in which a visualization of the clip via the endoscope is enhanced. 
     In an embodiment, when it is determined that the clip requires repositioning, moving the extending members proximally relative to the endoscope until the clip is drawn proximally over the adapter to the insertion configuration and repositioning the clip over the target area. 
     In an embodiment, the method further includes moving the extending members distally relative to the clip while in the review configuration, to disengage the extending members from the clip and release the clip to a final deployed configuration. 
     In an embodiment, the extending members are biased one of toward and away from one another so that, upon disengagement of the extending members from the clip, the endoscope and the extending members may be withdrawn proximally from the body. 
     In an embodiment, each of the extending members is independently released from the clip by moving the distal end of the endoscope laterally with respect to the clip so that each of the extending members is independently movable relative to the clip and proximally withdrawable therefrom. 
    
    
     
       BRIEF DESCRIPTION 
         FIG.  1    shows a longitudinal side view of a system according to an exemplary embodiment of the present disclosure; 
         FIG.  2    shows a perspective view of a clip according to the system of  FIG.  1   ; 
         FIG.  3    shows a plan view of the clip according to the system of  FIG.  1   ; 
         FIG.  4    shows a side view of the clip according to the system of  FIG.  1   , in a review configuration; 
         FIG.  5    shows a side view of a distal portion of an extending member according to the system of  FIG.  1   ; 
         FIG.  6    shows a partial plan view of the clip according to the system of  FIG.  1   ; 
         FIG.  7    shows a plan view of a clip according to another exemplary embodiment of the present disclosure; 
         FIG.  8    shows a plan view of a clip according to another exemplary embodiment of the present disclosure; 
         FIG.  9    shows a partial plan view of a clip according to yet another exemplary embodiment of the present disclosure; 
         FIG.  10    shows a perspective view of a clip according to another exemplary embodiment; and 
         FIG.  11    shows a perspective view of a clip according to a further exemplary embodiment. 
     
    
    
     DETAILED DESCRIPTION 
     The present disclosure may be further understood with reference to the following description and the appended drawings, wherein like elements are referred to with the same reference numerals. The present disclosure relates to a clipping system and, in particular, relates to an over-the-scope endoscopic clipping system, in which an initial placement of a clip may be viewed and adjusted prior to a final deployment thereof. Exemplary embodiments of the present disclosure comprise a clip mountable over a distal end of an endoscope via an adapter and releasably coupled to extending members so that the clip may be moved between an insertion configuration, an initial deployed configuration and a review configuration in which the clip can be viewed prior to being finally deployed. 
     In particular, each of the extending members includes a hook at a distal end thereof configured to be looped over a portion of a corresponding one of the jaws to releasably couple the extending members to the clip so that the clip is movable relative to the endoscope between the insertion configuration, the initial deployed configuration and review configuration via the extending members. In the insertion configuration, the clip is mounted over the adapter in a proximal position maintained in the insertion configuration ready to receive tissue between jaws thereof while the clip’s position minimizes its occlusion of the field of view of the endoscopic vision system. The insertion configuration is configured to facilitate insertion of the endoscope to a target site adjacent to tissue to be clipped while the system allows the clip to be deployed and clipped over tissue in an initial deployed configuration. The device permits the endoscope to be withdrawn proximally away from the clip and the tissue over which it is clipped while the clip remains coupled to the device in a review configuration. 
     As the endoscope is withdrawn proximally while the clip remains in place over the target tissue, the field of view of the vision system of the endoscope widens to show the clip and the tissue clipped thereby so that the operator can determine whether the position of the clip is desirable or in need of adjustment. If the operator determines that the clip is positioned as desired, the clip is deployed by releasing the clip from the hooked distal ends of the extending members and left in place clipped over the target tissue. If the operator determines that the position of the clip needs adjustment, the endoscope and the adapter coupled thereto are moved distally to a position adjacent to the clip. The clip is then drawn proximally over the adapter to reopen the clip which is drawn proximally over the distal end of the adapter forcing the clip to open against its natural bias as the clip slides proximally back over the adapter toward the insertion configuration. 
     After the clip has been removed from the tissue and returned to the insertion configuration, the operator can re-position the endoscope and device as desired, draw target tissue into the adapter (e.g., under suction or a grasper applied via a working channel of the endoscope) and once more deploy the clip from the adapter over the target tissue in the initial deployed position. The endoscope is then withdrawn proximally once again as the clip remains coupled to the device so that the device moves again into the review configuration. The position of the clip and the clipped tissue are again observed and, this process may be repeated until the clip is positioned as desired. When the operator sees that the tissue over which the clip is closed is the desired portion of tissue, the clip may be deployed and released from the device and endoscope as described below. It will be understood by those of skill in the art that terms proximal and distal, as used herein, are intended to refer to a direction toward and away from, respectively, a user of the device. 
     As shown in  FIGS.  1  -  7   , a clipping system  100  for treating tissue defects and/or perforations according to an exemplary embodiment comprises a clip  102  configured to be inserted through, for example, a body lumen to a target area to clip a target tissue thereof. The clip  102  is insertable to the target area via an insertion device  104  including, for example, an endoscope  106 . The clip  102  is mountable to a distal end  108  of the endoscope  106  via an adapter  110  mounted to a distal end  108  of an endoscope  106  and is movable relative to the endoscope  106  via extending members  112 , to which the clip  102  is releasably coupled. 
     Each of the extending members  112  includes a hook-shaped distal end  116  configured to be releasably looped over a portion of a corresponding jaw  114  of the clip  102  to facilitate movement of the clip  102  relative to the endoscope  106  between an insertion configuration, an initial deployed configuration, a review configuration, and a final deployed configuration. In the insertion configuration, the clip  102  is mounted over the adapter  110  with jaws  114  separated from one another to receive tissue therebetween. To move the clip  102  from the insertion configuration toward the initial deployed configuration, the extending members  112  are moved distally relative to the endoscope  106 , permitting the clip  102  to be moved distally off the adapter  110  toward a closed configuration in which the jaw  114  are moved toward one another to grip tissue that has been drawn into the adapter  110 . 
     Upon clipping of the tissue via the jaws  114  in the initial deployed configuration, the clip  102  may be moved toward the review configuration by moving the extending members  112  distally away from the endoscope  106  (or drawing the endoscope  106  proximally relative to the extending members  112 ) so that the clip  102  is distanced from the adapter  110 , while remaining tethered to the insertion device  104  via the extending members  112 . This widens the field of view of the endoscope vision system relative to the clip  102  and the target tissue and allows for some movement of the endoscope  106  relative to the clip  102  to enable more extensive observation of the placement and/or position of the clip  102  relative to the target tissue. 
     As described below, if the user determines the position of the clip  102  is incorrect or sub-optimal, the user may move the endoscope  106  distally to a position adjacent to the clip  102  and then retract the clip  102  proximally by withdrawing the extending members  112  proximally relative to the adapter  110  so that the clip  102  is drawn back over the distal end of the adapter  108  forcing the clip  102  open as it is slid proximally back over the adapter  110  to return to the insertion configuration. The user may then reposition the endoscope  106  and the clip  102  and repeat these steps so that the placement and/or position of the clip  102  relative to a target tissue may be adjusted prior to a final deployment of the clip  102 . That is, if the operator sees in the review configuration that the clip  102  is not positioned as desired, the clip  102  may be re-opened and removed from the tissue so that the device can be re-positioned until the clip  102  is closed over the desired portion of tissue. 
     Once it is determined that the clip  102  has been clipped over the desired tissue, the extending members  112  are moved distally relative to the clip  102  so that the hook-shaped distal ends  116  disengage from the corresponding portions of the jaws  114 , thereby separating the clip  102  from the insertion device  104  and deploying the clip  102  in the body. Although not shown, it will be understood by those of skill in the art that the movement of the clip  102  between the insertion configuration, the initial deployed configuration, the review configuration and the final deployed configuration may be controlled via a user interface which, in one embodiment, is coupled to a proximal end of the endoscope  106  and, in particular, includes an actuator coupled to proximal ends of the extending members  112  to impart proximal and distal movement to the proximal ends of the extending members  112  to achieve the desired corresponding movements of the distal ends of the extending members  112  as would be understood by those skilled in the art. Those skilled in the art will understand that although two extending members  112  are shown in this embodiment, any desired number of extending members  112  may be employed without departing from the scope of the disclosed embodiments. 
     As discussed above, the insertion device  104 , as shown in  FIG.  1   , may include, for example, any standard endoscope  106 . The clip  102  may be mounted to the endoscope  106  via the adapter  110  sized, shaped and configured to be mounted over the distal end  108  of the endoscope  106 . As will be understood by those of skill in the art, the endoscope  106  is configured to be inserted through a body lumen to a target area within the lumen and thus, must be sufficiently flexible to navigate through even tortuous paths of the body lumen. 
     The adapter  110  extends from a proximal end  140  configured to be mounted to the distal end  108  of the endoscope  106  to a distal end  142  and includes a channel  144  extending therethrough. The adapter  110  may be mounted to the endoscope  106  via, for example, a friction fit, so that the channel  144  is substantially longitudinally aligned with a channel  146  of the endoscope  106 . Thus, tissue is viewable through the channel  146  via an optical system of the endoscope  106 . In another embodiment, the adapter  110  may also be formed of a transparent material to enhance the visibility of the tissue. 
     In one embodiment, the adapter  110  includes a pair of holes  130  extending longitudinally therethrough a wall thereof. The holes  130  are configured to slidably receive the extending members  112  therethrough. An outer diameter of the adapter  110  is sized, shaped and configured to receive the clip  102  thereover, in the insertion configuration. In one exemplary embodiment, the adapter  110  tapers from the proximal end  140  toward the distal end  142  so that the clip  102  is biased toward the initial deployed configuration. 
     The clip  102 , however, may remain mounted over the adapter  110  in the open insertion configuration, with the jaws  114  separated from one another, so long as a sufficient proximally directed tension is applied to the extending members  112  so that the extending member  112  hold the clip  102  in place. If this tension is removed from the extending members  112 , a natural bias of the clip  102  draws the jaws  114  toward one another pushing the clip  102  distally over the tapered surface of the adapter  110  until the clip  102  slides distally off of the adapter  110  as the extending members  112  are moved distally with the clip  102 . 
     The insertion device  104 , in one embodiment, includes a pair of extending members  112 , each extending member  112  extending longitudinally along or within the endoscope  106  and the adapter  110  so that the extending members  112  are longitudinally movable relative to the endoscope  106 . In one embodiment, each of the extending members  112  is independently movable relative to the other(s). In another embodiment, the extending members  112  may be move simultaneously relative to the endoscope  106 . Each of the extending members  112  extend from a proximal end accessible to the user via, for example, an actuator, to the hook-shaped distal end  116 , which extends distally of the endoscope  106  to be coupled to the clip  102 . 
     As described above, the extending members  112  may extend through and/or along the endoscope  106  to be received within the holes  130  of the adapter  110  so that the distal ends  106  extend distally from the holes  130  to engage the clip  102 . The extending members  112  may be moved longitudinally relative to the endoscope  106  to move the clip  102 , which is coupled thereto, toward and away from the distal end  108  of the endoscope  106  between the insertion configuration, the initial deployed configuration and the review configuration. 
     According to an exemplary embodiment, each of the hook-shaped distal ends  116  extends along a J-shaped curve  138 . In particular, each of the hook-shaped distal ends  116  extends along the curve  138  so that a hook tip  132  thereof extends in a proximal direction (e.g., toward the proximal end of the extending member  112 ). Thus, as will be described in further detail below, when the hook-shaped distal ends  116  are looped through corresponding portions of the clip  102 , and tension is maintained along the extending members  112  relative to the clip  102 , the distal ends  116  remain engaged with the clip  102 . 
     In one embodiment, the distal ends  116  of the extending members  112  are biased toward or away from one another, depending on a configuration of each of the extending members  112 . For example, when the distal tips  132  are positioned in a radially outward position relative to a remaining longitudinal length (e.g., a portion of the extending members  112  extending along a length of the endoscope  106 ) of the extending members  112 , as shown in  FIGS.  1  and  4   , the distal ends  116  may be biased toward one another. 
     If, however, the distal tips  132  are positioned in a radially inward position relative to the remaining longitudinal length of the extending members  112 , the distal ends  116  may be biased away from one another. In either case, when the hook-shaped distal ends  116  are coupled to the clip  102 , however, the distal ends  116  are constrained toward an engaged configuration. As will be described in further detail below, each of the distal ends  116  is looped over a portion of a corresponding one of the jaws  114  of the clip  102  so that the extending members  112  remain engaged with the clip  102  until it is desired to release the clip  102  in the final deployed configuration. Once the clip  102  has been clipped over a target tissue and moved toward the review configuration, however, moving the extending members  112  distally relative to the clip  102 , causes the distal ends  116  to disengage from the clip  102  so that the distal ends  116  are permitted to revert to their biased configuration, in which the distal ends  116  move radially inward or outward relative to one another. Thus, since the distal ends  116  are moved out of engagement with the clip  102 , the insertion device  104  may be drawn proximally away from the clip  102  and removed from the body so that just the clip  102  remains deployed in the body. 
     In another embodiment, however, the distal ends  116  are not required to be biased relative to one another. Rather, to disengage the clip  102  from the distal ends  116  of the extending members  112  toward the final deployed configuration, as will be described in further detail below, each of the extending members  112  is moved independently relative to the others and longitudinally relative to the clip  102  so that when the distal end  108  of the endoscope  106  is moved laterally to correspondingly move a desired one of the extending member  112  out of engagement with the clip  102 . 
     As shown in  FIGS.  2 - 3   , the clip  102  includes a pair of jaws  114  and, in this embodiment, each of the jaws  114  includes gripping features  118  such as, for example, teeth, for gripping target tissue. The jaws  114  of the clip  102  of this embodiment are connected to one another via hinges  120 . In one embodiment, each of the jaws  114  extends along a curve from a first end  122   to a second end  124  so that a first one of the hinges  120  connects the first ends  122  of each of the jaws  114  to one another, while a second one of the hinges  120  connects the second ends  124  of each of the jaws  114  to one another. 
     In one embodiment, the hinges  120  are spring biased, biasing the jaws  114  toward the initial deployed configuration in which the jaws  114  are closed so that the gripping features  118  of one of the jaws  114  contact tissue located therebetween. In particular, in the initial deployed configuration, the jaws  118  extend toward one another so that target tissue may be gripped between the jaws  114  via, for example, the gripping features  118 . However, when the clip  102  is mounted over the adapter  110  in the insertion configuration, the jaws  114  are stretched over opposing portions of the adapter  110  so that an exterior surface of the adapter  110  maintains the clip  102  open with the jaws  114  separated from one another so that the target tissue drawn into the adapter  110  is positioned therebetween. 
     When the clip  102  is moved distally off the adapter  110 , the clip  102  is freed to close under the natural bias of the hinges  120 . It will be understood by those of skill in the art that the hinges  120  and/or jaws  114  of the clips  102  may be formed of any of a variety of materials so long as the hinges  120  bias the jaws  114  toward the initial deployed configuration, as described above and so that the bias is sufficiently strong to maintain the clip  102  in position clipped over target tissue after the clip has been finally deployed. In one example, portions of the clip  102  (e.g., the hinges  120 ) are formed of a shape memory alloy such as, for example, Nitinol to provide and/or add to the bias toward the closed configuration. 
     In one embodiment, each of the jaws  114  also includes a slot  126  via which the extending members  112  releasably engage the clip  102 . The slot  126  of this embodiment extend through each of the jaws  114 , midway between the first and second ends  122 ,  124  thereof. The slot  126  may be sized and shaped to receive a hook tip  132  of each of the hook-shaped distal ends  116 . In particular, the hook tip  132  may be received within the slot  126  so that an engaging section  134 , which is defined via a portion of the slot  126  and an exterior edge  136  of each of the jaws  114  (i.e., an edge along a portion of the jaw  114  opposing the gipping features  118 ), is received within the curve  138  of the hook-shaped distal end  116  of each of the extending members  112 . In other words, the hook-shaped distal end  116  is looped over the engaging section  134  to be releasably coupled to the clip  102 . 
     According to an exemplary embodiment, the engaging section  134  may also be defined via a stiff, raised portion of the jaw  114  so that when the extending members  112  are engaged with the clip  102 , the distal ends  116  are not pushed against tissue gripped via the clip  102 , as shown in  FIG.  4   . In other words, the engaging section  134  protrudes away from a surface  128  of the clip  102  which, when the clip  102  is gripped over tissue, extends away from the tissue. Thus, there is sufficient room for the distal ends  116  to be moved out of engagement with the clip  102  when it is desired to disengage the clip  102  from the extending members  112 , toward the final deployed configuration. 
     As shown in  FIGS.  5 - 6   , so that the distal ends  116  of the extending members  112  may engage and disengage the clip  102  as desired, an interior width A1 of the curve  138  (e.g., a diameter of the curve  138 ) of each of the distal ends  116  should be greater than a width A2 of the engaging section  134  (e.g., a distance between the exterior edge  136  of the jaw  114  and an edge  148  of the slot  126  closest thereto). In addition, an overall width B1 of the distal end  116  should be less than a width B2 of the slot  126 . The width B2 of the slot  126  may defined as a distance between the edge  148  and a portion of an opposing edge  150  that is farthest away from of the edge  148 . It will be understood by those of skill in the art that the slot  126  and a cross-section of the distal ends  116  of the extending members  112  may have any of a variety of shapes and sizes so long as the distal ends  116  are configured to be hooked through the slots  126  of the jaws  114  and engaged/disengaged therewith, as described above. 
     According to an exemplary method for tissue closure utilizing the clipping system  100 , the clip  102  is inserted through a body lumen such as, for example, the GI tract, to a target area within the body lumen via an insertion device  104  (for example, an endoscope  106 ). As described above, in the insertion configuration, the clip  102  is mounted to the distal end  108  of the endoscope  106  via the adapter  110 , so that the jaws  114  are separated from one another in the open configuration. The clip  102  is guided to the target area via the visualization system of the endoscope and positioned over a target tissue. A grasping device or suction force is then applied through a working channel of the endoscope  104  so that the target tissue is drawn into the channel  144  of the adapter  110 . Thus, when the clip  102  is moved toward the initial deployed configuration by releasing a tension along the extending members  112  (e.g., moving the extending members  112  proximally relative to the endoscope  106 ), the clip  102  slides distally along the adapter  110  toward the biased closed configuration to grip the target tissue. 
     It will be understood by those of skill in the art that suctioning and/or gripping of the tissue in this initial deployed configuration may obstruct an imaging/optical lens of the endoscope  106  so that the user is unable to visualize and/or confirm whether a desired target tissue has been properly clipped. Thus, the clip  102  may be moved toward the review configuration by drawing the endoscope  106  distally relative to the clip  102 , while the clip  102  remained clipped on the tissue. A distance between the adapter  110  and the clip  102  widens a field of view of the endoscope  106  so that the clip  102 , and the tissue gripped thereby, may be viewed via the optical/visualization system of the endoscope  106 . 
     If, upon visualization, the user determines that the clip  102  requires an adjustment and/or a repositioning relative to the target tissue, the extending members  112  may be translated proximally relative to the endoscope  106  until the clip  102  is moved proximally over the adapter  110 , as described above, toward the open configuration. As the clip  102  is moved toward the open configuration, the tissue gripped thereby is released, permitting the clip  102  to be repositioned over the target tissue, as desired. The clip  102  may then once again moved toward the initial deployed configuration, and then toward the review configuration. This process may be repeated, as necessary, until the user is able to visually confirm that the clip  102  has been clipped over the target tissue, as desired. 
     Once the user confirms that the target tissue has been clipped, as desired, the clip  102  may be moved from the review configuration to the final deployed configuration, by releasing the clip  102  from the extending members  112 . As described above, in one embodiment, the extending members  102  may be moved distally relative to the clip  102 . As the extending members  112  are moved distally relative to the clip  102 , the hook-shaped distal ends  116  disengage the engaging sections  134  of the clip  102 . As the distal ends  116  are released, the distal ends  116  are oved toward their biased configuration, radially toward or away from one another depending on an orientation of each of the distal ends  116  relative to the clip  102 . 
     For example, where the curves  138  of the hook-shaped distal ends  116  curve radially outwardly to engage the clip  102 , as shown in the  FIG.  4   , the distal ends  116  may be biased radially inwardly relative to one another. Where the curves  138  of the hook-shaped distal ends  116  curve radially inwardly to engage the clip  102 , the distal ends  116  may be biased radially outwardly relative to one another. Thus, movement of the extending members  112  distally of the clip  102 , moves the distal ends  116  out of engagement with the clip  102  so that the distal ends  116 , allowing the distal ends to revert toward their biased configuration so that the extending members  112 , and the remaining portions of the insertion device  104 , may be moved proximally away from the clip  102  and withdrawn from the body. 
     In another embodiment in which the distal ends  116  are not biased relative to one another, the extending members  112  are moved independently relative to one another. For example, when it is desired to move the clip  102  from the review configuration to the final deployed configuration, a first one of the extending members  112  is moved distally relative to the clip  102  so that the distal end  116  thereof is disengaged from a corresponding one of the engaging sections  134 . The distal end  108  of the endoscope  106  is then moved laterally relative to a longitudinal axis of the insertion device  104  so that the first extending member  112  is correspondingly moved relative to the clip  102 . The distal end  108  of the endoscope  106  is moved until the distal end  106  is aligned with a corresponding one of the slots  126  so that the distal end  116  is removable therefrom by drawing the first extending member  112  proximally relative to the clip  102 . 
     Upon removal of the first extending member  112  from the clip  102 , a second one of the extending members  112  may be similarly moved distally relative to the clip  102  until the distal end  116  thereof disengages a corresponding one of the engaging sections  134  of the clip  102 . The distal end  108  of the endoscope  106  is then moved in a lateral direction relative to the longitudinal axis of the insertion device  104  until the distal end  116  of the second extending member  112  is aligned with a corresponding one of the slots  126  so that drawing the second extending member  112  proximally relative thereto removes the distal end  116  of the second extending member  112  therefrom. Thus, the extending members  112  are separated from the clip  102  and the insertion device  104  may be removed from the body so that just the clip  102  remains in the body, clipped over the target tissue, in the final deployed configuration. 
     Although the clip  102  of the system  100  is shown and described as including the slots  126  and the engaging sections  134  for engaging the hook-shaped distal ends  116  of the extending members  112 , it will be understood by those of skill in the art that the clip  102  may have any of a variety of engaging features configured to similarly engage the hook-shaped distal ends  116  of the insertion device  104 . The engaging features of the clip  102  may have any of a variety of configurations so long as the hook-shaped distal ends  116  may be hooked or looped to a corresponding portion of the jaws  114  to engage the clip  102  so that the clip  102  is movable between the insertion, initial deployed, review and final deployed configurations, as described above. 
     In one exemplary embodiment, as shown in  FIG.  7   , rather than a slot, each jaw  214  of a clip  202  may include a wire  252  extending from a first end  254  attached to the jaw  214  to a second end  256  including a loop  258  sized, shaped and configured to engage a corresponding one of the hook-shaped distal ends  116 . In another exemplary embodiment, as shown in  FIG.  8   , each jaw  314  of a clip  302  may include a hole  326  extending therethrough. A wire  352  is looped through each hole  326  to form a closed loop  358  that is configured to be engaged via a corresponding one of the hook-shaped distal ends  116 . In yet another embodiment, as shown in  FIG.  9   , each jaw  414  of a clip  402  may include a wire  452  attached to thereto to form a loop  458  configured to be engaged via a corresponding one of the hook-shaped distal ends  116 . First and second ends  454 ,  456  of the wire  452  are attached to a surface of the jaw  414  to form the loop  458 . 
     In a further exemplary embodiment, as shown in  FIG.  10   , rather than a slot, each jaw  514  of a clip  502  includes a hook  552  extending from each of the jaws  514 . In this embodiment, each of the extending members  112  includes a snare  554  extending from its distal end  116 . The hook  552  is sized, shaped and configured to engage the snare  554 . In the insertion configuration, the extending members  112  are positioned so that the snare  554  is looped around the hook  552 . As the extending members  112  are extended distally to move the clip  502  off of the adapter  110 , the snare  552  remains looped over the hook  552 . 
     When the clip  502  leaves the adapter  110  and clips over tissue, the user may move the clip to the final deployed configuration by manipulating the extending members  112  to remove the snares  552  from the hooks  552  (e.g., by moving the loops of the snares  554  off of the free ends of the hooks  552 ). If the user wishes to reposition the clip  502  after the snares  554  have been removed from the hooks  552 , the extending members  112  may be manipulated to loop the snares  554  back over the hooks  552 . The user may then pull the extending members  112  proximally to draw the clip  502  back over and onto the adapter  110  as described above in regard to the previous embodiments. 
     In another exemplary embodiment, as shown in  FIG.  11   , each jaw  614  of a clip  602  includes a post  652  extending distally from each of the jaws  614  to an enlarged head  656 . The post  652  is sized, shaped and configured to engage the snare  554 . Similar to the clip  502 , in the insertion configuration, the extending members  112  are positioned so that the snare  554  is looped around the post  652  with the enlarged head  656  assisting in maintaining the snare  554  looped around the post  652  as the clip  602  is moved between the insertion, initial deployed and review configurations. As the extending members  112  are extended distally to move the clip  602  off of the adapter  110 , the snare  554  remains looped over the post  652 . When the clip  602  leaves the adapter  110  and clips over tissue, the user may move the clip  602  to the final deployed configuration by manipulating the extending members  112  to remove the snares  554  from the post  652  (e.g., by moving the loop of the snare  552  over the enlarged head  656  and off of the free end of the post  652 ). If the user wishes to reposition the clip  602  after the snares  654  have been removed from the posts  652 , the extending members  112  may be manipulated to loop the snares  554  back over the posts  652 . The user may then pull the extending members  112  proximally to draw the clip  602  back over and onto the adapter  110  as described above in regard to the previous embodiments. 
     It will be understood by those of skill in the art that the clips  202 - 602 , as described above, may be utilized with the insertion device  104 , in a manner substantially similar to the method, as described above with respect to system  100 . In particular, upon engagement of the extending members  112  to the clips  202 - 402 , the clips  202 - 402  may be moved between the insertion, initial deployed, review and final deployed configuration via movement of the extending members  112  longitudinally relative to the endoscope  106 , as described above. 
     It will be apparent to those skilled in the art that various modifications may be made in the present disclosure, without departing from the scope of the disclosure. Furthermore, those skilled in the art will understand that the features of any of the various embodiments may be combined in any manner that is not inconsistent with the description and/or the functionality of the embodiments.