Patent Publication Number: US-2022233182-A1

Title: Endoscopic suturing device with circular needle

Description:
PRIORITY 
     This application is a continuation of U.S. application Ser. No. 16/433,710, which claims priority to U.S. Provisional Application No. 62/681,783, filed Jun. 7, 2018, both of which are incorporated herein by reference in their entirety. 
    
    
     BACKGROUND 
     Full-thickness gastrointestinal defects such as perforation, anastomotic leak, and fistula are severe conditions caused by various types of pathologies. Such conditions are more likely to require intensive care, involve long hospital stays, and have high rates of morbidity and mortality. The currently available advanced endoscopic closing techniques have a major role in the treatment of full-thickness gastrointestinal defects. Endoscopic clips are the most common treatment for the closure of small defects. However, endoscopic clips are less useful for larger defects because of the restricted opening distance between their jaws, low closure force, and inability to accomplish deep-tissue capture. 
     Innovative endoscopic devices to place full thickness sutures have been an area of interest for closure of large defects. However, most of the suturing devices developed in last two decades are cumbersome and expensive, leaving more and more physicians searching for simple suturing devices. Endoscopic suturing is a minimally invasive technique that can be used for a variety of gastrointestinal indications, such as stoma and gastric reductions, fistula repair, bariatric therapy, stent and graft fixation, and GI bleeds. 
     SUMMARY 
     For correct piercing, the tissue must be supported opposite the needle side. Some devices, however, employ a driving mechanism designed such that the needle pierces by moving first sideways, pivoting about 90 degree, and finishes longitudinally from the most distal position proximally to the receiver, which now serves as a support for the pierced tissue. As such, these devices provide no support for the tissue when the needle moves sideways, so the tissue could be pushed away from the needle path before it is completely pierced. Thus, to provide such side support with such devices, a tissue grabber (e.g. grasper, corkscrew), is often required, which is a major shortcoming. Provided herein are devices, apparatus, systems, and methods that actuate an arcuate needle (as used herein, an “arcuate needle” is synonymous with a “circular needle” and is an arced needle that is not fully circular, but travels in a circular path or a substantially circular path) through a c-shaped distal assembly that is non-perpendicularly angled relative to the major axis of the endoscope and having a non-aligned angle relative to the major axis of the endoscope. As such, a tissue grabber is not necessary when using the device to suture, as the device is easily manipulated to seat the tissue between the open ends of the “C” and into the gap formed by the “C” of the c-shaped distal assembly for suturing once in such position without separate support required. 
     Further, for such current devices, a separate working channel must be provided to bring the grabber into the suturing area. Since one channel is used for the anchor exchange catheter, the scope must have two working channels or one extra working channel by over-tube. The requirement of a special two-channeled scope is another significant shortcoming, which makes the procedure more expensive. To preserve the small overall diameter, the working channels for the grabber must have a small outer diameter. Some current devices employ a grabber that is a long shaft with a helical screw on the tip. This helix, however, often lacks sufficient torsional stiffness to work reliably because of its small diameter and long length. Further, without a screw-in depth limit, potential perforations pose another shortcoming. Additionally, such devices employ a straight needle, which when piercing the tissue travels in a circular motion. Such a motion exposes the needle body to a sideway tissue reaction force, which might cause the needle to deflect and miss the receiver of the exchange catheter. To prevent this, the entire distal mechanisms on such devices require extra bulk to enable additional stiffness. Finally, as a distal part of such devices is positioned such that the scope camera axis lays in the needle operation plane, the tissue in the needle path blocks the camera&#39;s view during suturing. Provided herein are devices, apparatus, systems, and methods that actuate an arcuate needle through a c-shaped distal assembly that is non-perpendicularly angled relative to the major axis of the endoscope and having a non-aligned angle relative to the major axis of the endoscope, which allow for ease of vision using the camera of the device. Such distal assemblies are coupled to the distal end of the endoscope without use of the working channel, and in plain view of the camera of the endoscope during use and suturing for ease of maneuvering the needle through the tissue, and for simplicity and accuracy of suturing. 
     Other currently available devices employ a circular needle that is translated over the gap from exit to entrance in a uniform circular motion. While such devices enable tissue support against the piercing needle, such a needle driving mechanism is too long to be used with a flexible shaft (i.e. a flexible endoscope) without impeding its flexibility and maneuverability. Further, such devices must be rigid to employ both its rack and pinion and crankshaft positioned in-line and longitudinally, and are thus unusable for endoscopic procedures, where flexibility of the scope must not be compromised. Further, as such devices employ a cassette for suture replacement having a needle permanently attached to the suture; such a device would not be suitable for endoscopic procedures. Provided herein are devices, apparatus, systems, and methods that actuate an arcuate needle through a c-shaped distal assembly that is coupled to the distal, non-flexing, end of the scope and use a simple set of wires and shuttle coupled to the wire to manipulate the arcuate needle through the suturing process without loss of scope flexibility. 
     One aspect provided herein is an endoscopic suturing system comprising: a distal assembly comprising: a first housing comprising an arcuate needle guide, a shuttle guide, and an endoscope fastener, wherein the endoscope fastener couples the first housing to an endoscope; an arcuate needle comprising a notch and a suture attachment, wherein the arcuate needle has a center axis, and wherein the arcuate needle is disposed within the arcuate needle guide; and a shuttle having a pawl, wherein the shuttle is conveyed within the shuttle guide; wherein the notch and the pawl engage when the shuttle translates in a first rotational direction about the center axis, and wherein the notch and the pawl disengage when the shuttle translates opposite the first rotational direction; a proximal assembly comprising: a second housing; an actuator connected to the second housing; and a cable connecting the actuator to the shuttle and configured to translate the shuttle in the first direction and in the second direction in response to an actuation of the actuator. 
     In some embodiments, the pawl comprises a spring, a flexure, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the pawl is engagement biased. In some embodiments, the notch is ramped in a direction opposite the first direction. In some embodiments, the endoscope fastener comprises a tie, a string, a band, a hook and loop fastener, a tape, a strap, a magnet, a cinch, a press fit, a set screw, an adhesive, or any combination thereof. 
     In some embodiments, the endoscope has a proximal outer diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope has a proximal outer diameter of about 5 mm to about 6 mm, about 5 mm to about 7 mm, about 5 mm to about 8 mm, about 5 mm to about 9 mm, about 5 mm to about 10 mm, about 5 mm to about 11 mm, about 5 mm to about 12 mm, about 5 mm to about 13 mm, about 5 mm to about 14 mm, about 5 mm to about 15 mm, about 5 mm to about 16 mm, about 6 mm to about 7 mm, about 6 mm to about 8 mm, about 6 mm to about 9 mm, about 6 mm to about 10 mm, about 6 mm to about 11 mm, about 6 mm to about 12 mm, about 6 mm to about 13 mm, about 6 mm to about 14 mm, about 6 mm to about 15 mm, about 6 mm to about 16 mm, about 7 mm to about 8 mm, about 7 mm to about 9 mm, about 7 mm to about 10 mm, about 7 mm to about 11 mm, about 7 mm to about 12 mm, about 7 mm to about 13 mm, about 7 mm to about 14 mm, about 7 mm to about 15 mm, about 7 mm to about 16 mm, about 8 mm to about 9 mm, about 8 mm to about 10 mm, about 8 mm to about 11 mm, about 8 mm to about 12 mm, about 8 mm to about 13 mm, about 8 mm to about 14 mm, about 8 mm to about 15 mm, about 8 mm to about 16 mm, about 9 mm to about 10 mm, about 9 mm to about 11 mm, about 9 mm to about 12 mm, about 9 mm to about 13 mm, about 9 mm to about 14 mm, about 9 mm to about 15 mm, about 9 mm to about 16 mm, about 10 mm to about 11 mm, about 10 mm to about 12 mm, about 10 mm to about 13 mm, about 10 mm to about 14 mm, about 10 mm to about 15 mm, about 10 mm to about 16 mm, about 11 mm to about 12 mm, about 11 mm to about 13 mm, about 11 mm to about 14 mm, about 11 mm to about 15 mm, about 11 mm to about 16 mm, about 12 mm to about 13 mm, about 12 mm to about 14 mm, about 12 mm to about 15 mm, about 12 mm to about 16 mm, about 13 mm to about 14 mm, about 13 mm to about 15 mm, about 13 mm to about 16 mm, about 14 mm to about 15 mm, about 14 mm to about 16 mm, or about 15 mm to about 16 mm. In some embodiments, the endoscope has a proximal outer diameter of about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. In some embodiments, the endoscope has a proximal outer diameter of at least about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, or about 15 mm. In some embodiments, the endoscope has a proximal outer diameter of at most about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. 
     In some embodiments, the endoscope fastener has an inner diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope fastener has an inner diameter of about 5 mm to about 6 mm, about 5 mm to about 7 mm, about 5 mm to about 8 mm, about 5 mm to about 9 mm, about 5 mm to about 10 mm, about 5 mm to about 11 mm, about 5 mm to about 12 mm, about 5 mm to about 13 mm, about 5 mm to about 14 mm, about 5 mm to about 15 mm, about 5 mm to about 16 mm, about 6 mm to about 7 mm, about 6 mm to about 8 mm, about 6 mm to about 9 mm, about 6 mm to about 10 mm, about 6 mm to about 11 mm, about 6 mm to about 12 mm, about 6 mm to about 13 mm, about 6 mm to about 14 mm, about 6 mm to about 15 mm, about 6 mm to about 16 mm, about 7 mm to about 8 mm, about 7 mm to about 9 mm, about 7 mm to about 10 mm, about 7 mm to about 11 mm, about 7 mm to about 12 mm, about 7 mm to about 13 mm, about 7 mm to about 14 mm, about 7 mm to about 15 mm, about 7 mm to about 16 mm, about 8 mm to about 9 mm, about 8 mm to about 10 mm, about 8 mm to about 11 mm, about 8 mm to about 12 mm, about 8 mm to about 13 mm, about 8 mm to about 14 mm, about 8 mm to about 15 mm, about 8 mm to about 16 mm, about 9 mm to about 10 mm, about 9 mm to about 11 mm, about 9 mm to about 12 mm, about 9 mm to about 13 mm, about 9 mm to about 14 mm, about 9 mm to about 15 mm, about 9 mm to about 16 mm, about 10 mm to about 11 mm, about 10 mm to about 12 mm, about 10 mm to about 13 mm, about 10 mm to about 14 mm, about 10 mm to about 15 mm, about 10 mm to about 16 mm, about 11 mm to about 12 mm, about 11 mm to about 13 mm, about 11 mm to about 14 mm, about 11 mm to about 15 mm, about 11 mm to about 16 mm, about 12 mm to about 13 mm, about 12 mm to about 14 mm, about 12 mm to about 15 mm, about 12 mm to about 16 mm, about 13 mm to about 14 mm, about 13 mm to about 15 mm, about 13 mm to about 16 mm, about 14 mm to about 15 mm, about 14 mm to about 16 mm, or about 15 mm to about 16 mm. In some embodiments, the endoscope fastener has an inner diameter of about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. In some embodiments, the endoscope fastener has an inner diameter of at least about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, or about 15 mm. In some embodiments, the endoscope fastener has an inner diameter of at most about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. 
     In some embodiments, the system further comprises a cable sheath surrounding at least a portion of the cable. In some embodiments, the system further comprises a cable fastener that removably couples at least a portion of the cable sheath to the endoscope. In some embodiments, the cable fastener comprises a tie, a string, a band, a hook and loop fastener, a tape, a strap, a magnet, a cinch, a press fit, a set screw, an adhesive, or any combination thereof. 
     In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is about 5 degrees to about 120 degrees. In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is about 5 degrees to about 10 degrees, about 5 degrees to about 20 degrees, about 5 degrees to about 30 degrees, about 5 degrees to about 40 degrees, about 5 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 70 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 90 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 70 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 90 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 70 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 90 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 70 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 90 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about 100 degrees, about 50 degrees to about 120 degrees, about 60 degrees to about 70 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 90 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 70 degrees to about 80 degrees, about 70 degrees to about 90 degrees, about 70 degrees to about 100 degrees, about 70 degrees to about 120 degrees, about 80 degrees to about 90 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 90 degrees to about 100 degrees, about 90 degrees to about 120 degrees, or about 100 degrees to about 120 degrees. In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is at least about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, or about 100 degrees. In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is at most about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. 
     In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within about 5 degrees to about 120 degrees. In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within about 5 degrees to about 10 degrees, about 5 degrees to about 20 degrees, about 5 degrees to about 30 degrees, about 5 degrees to about 40 degrees, about 5 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 70 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 90 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 70 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 90 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 70 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 90 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 70 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 90 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about 100 degrees, about 50 degrees to about 120 degrees, about 60 degrees to about 70 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 90 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 70 degrees to about 80 degrees, about 70 degrees to about 90 degrees, about 70 degrees to about 100 degrees, about 70 degrees to about 120 degrees, about 80 degrees to about 90 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 90 degrees to about 100 degrees, about 90 degrees to about 120 degrees, or about 100 degrees to about 120 degrees. In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within at least about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, or about 100 degrees. In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within at most about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. 
     In some embodiments, the arcuate needle comprises two or more notches. In some embodiments, at least one of the first housing, the second housing, the arcuate needle, the shuttle, or the actuator are composed of plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. In some embodiments, the first housing further comprises a cable pulley that guides the cable. In some embodiments, the arcuate needle further comprises a suture attachment fastener. In some embodiments, first housing further comprises a pulley, and wherein the cable is strung around the pulley. In some embodiments, the second housing couples to the endoscope. 
     Another aspect provided herein is an endoscopic suturing system comprising: a distal assembly comprising: a first housing comprising an arcuate needle guide and an endoscope fastener, wherein the endoscope fastener couples the first housing to an endoscope; an arcuate needle comprising a notch and a suture attachment, wherein the arcuate needle has a center axis, and wherein the arcuate needle is disposed within the arcuate needle guide; and a proximal assembly comprising: a second housing that removably attaches to an endoscope; an actuator connected to the second housing; and a cable having a pawl; wherein the notch and the pawl engage when the cable translates in a first rotational direction about the center axis, and wherein the notch and the pawl disengage when the cable translates opposite the first rotational direction. 
     In some embodiments, the pawl comprises a spring, a flexure, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the pawl is engagement biased. In some embodiments, the notch is ramped in a direction opposite the first direction. In some embodiments, the endoscope fastener comprises a press-fit fastener, a clamp, an adhesive, a tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof. 
     In some embodiments, the endoscope has a proximal outer diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope has a proximal outer diameter of about 5 mm to about 6 mm, about 5 mm to about 7 mm, about 5 mm to about 8 mm, about 5 mm to about 9 mm, about 5 mm to about 10 mm, about 5 mm to about 11 mm, about 5 mm to about 12 mm, about 5 mm to about 13 mm, about 5 mm to about 14 mm, about 5 mm to about 15 mm, about 5 mm to about 16 mm, about 6 mm to about 7 mm, about 6 mm to about 8 mm, about 6 mm to about 9 mm, about 6 mm to about 10 mm, about 6 mm to about 11 mm, about 6 mm to about 12 mm, about 6 mm to about 13 mm, about 6 mm to about 14 mm, about 6 mm to about 15 mm, about 6 mm to about 16 mm, about 7 mm to about 8 mm, about 7 mm to about 9 mm, about 7 mm to about 10 mm, about 7 mm to about 11 mm, about 7 mm to about 12 mm, about 7 mm to about 13 mm, about 7 mm to about 14 mm, about 7 mm to about 15 mm, about 7 mm to about 16 mm, about 8 mm to about 9 mm, about 8 mm to about 10 mm, about 8 mm to about 11 mm, about 8 mm to about 12 mm, about 8 mm to about 13 mm, about 8 mm to about 14 mm, about 8 mm to about 15 mm, about 8 mm to about 16 mm, about 9 mm to about 10 mm, about 9 mm to about 11 mm, about 9 mm to about 12 mm, about 9 mm to about 13 mm, about 9 mm to about 14 mm, about 9 mm to about 15 mm, about 9 mm to about 16 mm, about 10 mm to about 11 mm, about 10 mm to about 12 mm, about 10 mm to about 13 mm, about 10 mm to about 14 mm, about 10 mm to about 15 mm, about 10 mm to about 16 mm, about 11 mm to about 12 mm, about 11 mm to about 13 mm, about 11 mm to about 14 mm, about 11 mm to about 15 mm, about 11 mm to about 16 mm, about 12 mm to about 13 mm, about 12 mm to about 14 mm, about 12 mm to about 15 mm, about 12 mm to about 16 mm, about 13 mm to about 14 mm, about 13 mm to about 15 mm, about 13 mm to about 16 mm, about 14 mm to about 15 mm, about 14 mm to about 16 mm, or about 15 mm to about 16 mm. In some embodiments, the endoscope has a proximal outer diameter of about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. In some embodiments, the endoscope has a proximal outer diameter of at least about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, or about 15 mm. In some embodiments, the endoscope has a proximal outer diameter of at most about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. 
     In some embodiments, the endoscope fastener has an inner diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope fastener has an inner diameter of about 5 mm to about 6 mm, about 5 mm to about 7 mm, about 5 mm to about 8 mm, about 5 mm to about 9 mm, about 5 mm to about 10 mm, about 5 mm to about 11 mm, about 5 mm to about 12 mm, about 5 mm to about 13 mm, about 5 mm to about 14 mm, about 5 mm to about 15 mm, about 5 mm to about 16 mm, about 6 mm to about 7 mm, about 6 mm to about 8 mm, about 6 mm to about 9 mm, about 6 mm to about 10 mm, about 6 mm to about 11 mm, about 6 mm to about 12 mm, about 6 mm to about 13 mm, about 6 mm to about 14 mm, about 6 mm to about 15 mm, about 6 mm to about 16 mm, about 7 mm to about 8 mm, about 7 mm to about 9 mm, about 7 mm to about 10 mm, about 7 mm to about 11 mm, about 7 mm to about 12 mm, about 7 mm to about 13 mm, about 7 mm to about 14 mm, about 7 mm to about 15 mm, about 7 mm to about 16 mm, about 8 mm to about 9 mm, about 8 mm to about 10 mm, about 8 mm to about 11 mm, about 8 mm to about 12 mm, about 8 mm to about 13 mm, about 8 mm to about 14 mm, about 8 mm to about 15 mm, about 8 mm to about 16 mm, about 9 mm to about 10 mm, about 9 mm to about 11 mm, about 9 mm to about 12 mm, about 9 mm to about 13 mm, about 9 mm to about 14 mm, about 9 mm to about 15 mm, about 9 mm to about 16 mm, about 10 mm to about 11 mm, about 10 mm to about 12 mm, about 10 mm to about 13 mm, about 10 mm to about 14 mm, about 10 mm to about 15 mm, about 10 mm to about 16 mm, about 11 mm to about 12 mm, about 11 mm to about 13 mm, about 11 mm to about 14 mm, about 11 mm to about 15 mm, about 11 mm to about 16 mm, about 12 mm to about 13 mm, about 12 mm to about 14 mm, about 12 mm to about 15 mm, about 12 mm to about 16 mm, about 13 mm to about 14 mm, about 13 mm to about 15 mm, about 13 mm to about 16 mm, about 14 mm to about 15 mm, about 14 mm to about 16 mm, or about 15 mm to about 16 mm. In some embodiments, the endoscope fastener has an inner diameter of about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. In some embodiments, the endoscope fastener has an inner diameter of at least about 5 mm, about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, or about 15 mm. In some embodiments, the endoscope fastener has an inner diameter of at most about 6 mm, about 7 mm, about 8 mm, about 9 mm, about 10 mm, about 11 mm, about 12 mm, about 13 mm, about 14 mm, about 15 mm, or about 16 mm. 
     In some embodiments, the system further comprises a cable sheath surrounding at least a portion of the cable. In some embodiments, the system further comprises a cable fastener that removably couples at least a portion of the cable to the endoscope. In some embodiments, the cable fastener comprises a press-fit fastener, a clamp, an adhesive, a tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof. 
     In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is about 5 degrees to about 120 degrees. In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is about 5 degrees to about 10 degrees, about 5 degrees to about 20 degrees, about 5 degrees to about 30 degrees, about 5 degrees to about 40 degrees, about 5 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 70 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 90 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 70 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 90 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 70 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 90 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 70 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 90 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about 100 degrees, about 50 degrees to about 120 degrees, about 60 degrees to about 70 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 90 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 70 degrees to about 80 degrees, about 70 degrees to about 90 degrees, about 70 degrees to about 100 degrees, about 70 degrees to about 120 degrees, about 80 degrees to about 90 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 90 degrees to about 100 degrees, about 90 degrees to about 120 degrees, or about 100 degrees to about 120 degrees. In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is at least about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, or about 100 degrees. In some embodiments, an angle between a center axis of the arcuate needle guide and a proximal axis of the endoscope is at most about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. 
     In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within about 5 degrees to about 120 degrees. In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within about 5 degrees to about 10 degrees, about 5 degrees to about 20 degrees, about 5 degrees to about 30 degrees, about 5 degrees to about 40 degrees, about 5 degrees to about 50 degrees, about 5 degrees to about 60 degrees, about 5 degrees to about 70 degrees, about 5 degrees to about 80 degrees, about 5 degrees to about 90 degrees, about 5 degrees to about 100 degrees, about 5 degrees to about 120 degrees, about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 70 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 90 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 70 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 90 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 70 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 90 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 70 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 90 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 70 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 90 degrees, about 50 degrees to about 100 degrees, about 50 degrees to about 120 degrees, about 60 degrees to about 70 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 90 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 70 degrees to about 80 degrees, about 70 degrees to about 90 degrees, about 70 degrees to about 100 degrees, about 70 degrees to about 120 degrees, about 80 degrees to about 90 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 90 degrees to about 100 degrees, about 90 degrees to about 120 degrees, or about 100 degrees to about 120 degrees. In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within at least about 5 degrees, about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, or about 100 degrees. In some embodiments, an angle between a center axis adjustable within of the arcuate needle guide and a proximal axis adjustable within of the endoscope is adjustable within at most about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 70 degrees, about 80 degrees, about 90 degrees, about 100 degrees, or about 120 degrees. 
     In some embodiments, the arcuate needle comprises two or more notches. In some embodiments, at least one of the first housing, the second housing, the arcuate needle, or the actuator are composed of plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. In some embodiments, the first housing further comprises a cable pulley that guides the cable. In some embodiments, the arcuate needle further comprises a suture attachment fastener. In some embodiments, first housing further comprises a pulley, and wherein the cable is strung around the pulley. In some embodiments, the second housing couples to the endoscope. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The novel features of the disclosure are set forth with particularity in the appended claims. A better understanding of the features and advantages of the present disclosure will be obtained by reference to the following detailed description that sets forth illustrative embodiments, in which the principles of the disclosure are utilized, and the accompanying drawings of which: 
         FIG. 1  is an illustration of an exemplary endoscopic suturing system, per an embodiment herein; 
         FIG. 2  is an illustration of an exemplary first proximal assembly coupled to an endoscope, per an embodiment herein; 
         FIG. 3  is an illustration of a second exemplary proximal assembly, per an embodiment herein; 
         FIG. 4  is an illustration of a third exemplary distal assembly, per an embodiment herein; 
         FIG. 5  is an illustration of the exemplary first distal assembly on an endoscope, per an embodiment herein; 
         FIG. 6  is a detailed illustration of the exemplary first distal assembly, per an embodiment herein; 
         FIG. 7  is a detailed illustration of the exemplary first distal assembly in a first position with a portion of the shuttle guide removed, per an embodiment herein; 
         FIG. 8  is a detailed illustration of the exemplary first distal assembly in a second position with a portion of the shuttle guide removed, per an embodiment herein; 
         FIG. 9  is a detailed illustration of the exemplary first distal assembly in a third position with a portion of the shuttle guide removed, per an embodiment herein; 
         FIG. 10  is a detailed illustration of the exemplary first distal assembly in a fourth position with a portion of the shuttle guide opaque, per an embodiment herein; 
         FIG. 11  is a detailed illustration of the exemplary first distal assembly in a fifth position with a portion of the shuttle guide opaque, per an embodiment herein; 
         FIG. 12  is a detailed illustration of the exemplary first distal assembly in a sixth position with a portion of the shuttle guide opaque, per an embodiment herein; 
         FIG. 13  is a detailed illustration of the exemplary first distal assembly in a seventh position with a portion of the shuttle guide opaque, per an embodiment herein; 
         FIG. 14  is an illustration of an exemplary arcuate needle, per an embodiment herein; 
         FIG. 15  is an illustration of an exemplary arcuate needle having 2 notches, per an embodiment herein; 
         FIG. 16  is an illustration of an exemplary arcuate needle and suture, per an embodiment herein; 
         FIG. 17  is the exemplary first illustration of in-situ suture replacement by the exemplary first distal assembly, per an embodiment herein; 
         FIG. 18  is a second exemplary illustration of in-situ suture replacement by the exemplary first distal assembly, per an embodiment herein; 
         FIG. 19A  is an exemplary illustration of a shuttle, wherein the pawl is engaged, per an embodiment herein; 
         FIG. 19B  is an exemplary illustration of a shuttle, wherein the pawl is disengaged, per an embodiment herein; 
         FIG. 20  is a first illustration of an exemplary second proximal assembly coupled to an endoscope, per an embodiment herein; 
         FIG. 21  is a second illustration of the exemplary second proximal assembly coupled to an endoscope, per an embodiment herein; 
         FIG. 22  is a third illustration of the exemplary second proximal assembly coupled to an endoscope, per an embodiment herein; 
         FIG. 23  is a first bottom perspective illustration of the exemplary second proximal assembly without a bottom plate, per an embodiment herein; 
         FIG. 24  is a second bottom perspective illustration of the exemplary second proximal assembly without a bottom plate, per an embodiment herein; 
         FIG. 25  is an illustration of an exemplary first housing of the second proximal assembly, per an embodiment herein; 
         FIG. 26  is a cross-sectioned illustration of the exemplary second proximal assembly, per an embodiment herein; 
         FIG. 27A  is a bottom cross-sectioned illustration of the exemplary second proximal assembly in a first position, per an embodiment herein; 
         FIG. 27B  is a bottom cross-sectioned illustration of the exemplary second proximal assembly in a second position, per an embodiment herein; 
         FIG. 27C  is a bottom cross-sectioned illustration of the exemplary second proximal assembly in a third position, per an embodiment herein; 
         FIG. 27D  is a bottom cross-sectioned illustration of the exemplary second proximal assembly in a fourth position, per an embodiment herein; 
         FIG. 27E  is a bottom cross-sectioned illustration of the exemplary second proximal assembly in a fifth position, per an embodiment herein; 
         FIG. 27F  is a bottom cross-sectioned illustration of the exemplary second proximal assembly in a sixth position, per an embodiment herein; 
         FIG. 28  is a top perspective view illustration of an exemplary removable first housing bottom, per an embodiment herein; 
         FIG. 29  is a bottom perspective view illustration of an exemplary removable first housing bottom, per an embodiment herein; 
         FIG. 30A  is an illustration of an exemplary first cable and pawl combination, per an embodiment herein; 
         FIG. 30B  is an illustration of an exemplary second cable and pawl combination, per an embodiment herein; 
         FIG. 30C  is an illustration of an exemplary engaged cable and pawl combination, per an embodiment herein; 
         FIG. 31A  is an illustration of an exemplary third distal assembly in a first position, per an embodiment herein; 
         FIG. 31B  is an illustration of the exemplary third distal assembly in a second position, per an embodiment herein; 
         FIG. 32  is another illustration of the exemplary third distal assembly in a second position, per an embodiment herein; 
         FIG. 33  is another illustration of the exemplary third distal assembly in a second position, per an embodiment herein; 
         FIG. 34  is an illustration of an exemplary first portion of the first housing of the exemplary third distal assembly in a second position, per an embodiment herein; 
         FIG. 35  is a detailed view illustration of the exemplary first portion of the first housing of the exemplary third distal assembly, per an embodiment herein; and 
         FIG. 36  is a detailed view illustration of an exemplary second portion of the first housing of the exemplary third distal assembly, per an embodiment herein. 
     
    
    
     DETAILED DESCRIPTION 
     Provided herein are tissue suturing systems, devices, apparatuses, and methods for endoscopic suturing of tissue in the body. In some embodiments, the systems, devices, apparatuses, and methods herein are used in conjunction with a flexible endoscope to suture tissue. The suturing systems, devices, apparatuses and methods described herein are configured to perform full thickness endoscopic suturing for a variety of gastrointestinal indications including, for example, tissue closure, bariatric therapy, stent fixation, and graft fixation. Provided herein are devices, apparatus, and systems that actuate an arcuate needle (as used herein, an “arcuate needle” is synonymous with a “circular needle” and is an arced needle that is not fully circular, but travels in a circular path or a substantially circular path) through a c-shaped portion of a distal assembly, wherein such c-shaped portion of the distal assembly is non-perpendicularly angled relative to the major axis of the endoscope and has a non-aligned angle relative to the major axis of the endoscope (see needle axis  501 , elsewhere herein). As such, a tissue grabber is not necessary when suturing using the arcuate needle of the distal assembly, as the distal assembly is easily manipulated to seat the tissue between open ends of the c-shape portion of the distal assembly and into the gap formed by the “C” of the c-shaped portion of the distal assembly for suturing once in such position without separate support required. The alignment and angles of the devices, apparatus, and systems and methods relative to the scope allow for ease of vision using the camera of the device. Such distal assemblies are coupled to the distal end of the endoscope without use of the working channel, and in plain view of the camera of the endoscope during use and suturing for ease of maneuvering the needle through the tissue, and for simplicity and accuracy of suturing. Further, the devices, apparatus, and systems and methods described herein actuate the arcuate needle through a c-shaped distal assembly that is coupled to the distal, non-flexing, end of the scope and use a simple set of wires and shuttle coupled to the wire to manipulate the arcuate needle through the suturing process without loss of scope flexibility. 
     Endoscopic Suturing System 
       FIG. 1  is an illustration of an exemplary endoscopic suturing system  100  configured for use with an endoscope  140 . As shown the exemplary endoscopic suturing system  100  comprises a distal assembly  120 , a proximal assembly  110 , and a cable  130 . In some embodiments, the endoscopic suturing system  100  further comprises a cable fastener  150  which couples at least a portion of the cable  130  to the endoscope  140 . In some embodiments, the cable fastener  150  removably couples at least a portion of the cable  130  to the endoscope  140 . In some embodiments, the cable fastener  150  fastens the cable  130  to the endoscope  140  by wrapping around the cable  130  and the endoscope  140 . In some embodiments, the cable fastener  150  fastens the cable  130  to the endoscope  140  by clamping to the cable  130  and the endoscope  140 . In some embodiments, the cable fastener  150  fastens the cable  130  to the endoscope  140  by removably adhering the cable  130  to the endoscope  140 . In some embodiments, the cable fastener  150  comprises a press-fit fastener, a clamp, an adhesive, a tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the endoscopic suturing system  100  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more cable fasteners  150 . 
     Proximal Assembly 
       FIGS. 2 and 3  show illustration of an exemplary proximal assembly  110  coupled to an endoscope  140 . As shown the exemplary proximal assembly  110  comprises a second housing  111  and an actuator  112 . In some embodiments, the second housing  111  comprises a second housing fastener  111 A, an actuator support portion  111 B, and a main second housing body  111 C. In some embodiments, the main second housing body  111 C couples the second housing fastener  111 A to the actuator support portion  111 B. In some embodiments, the proximal assembly  110  has a length of about 10 mm to about 50 mm. In some embodiments, the proximal assembly  110  has a length of at most about 50 mm. 
     In some embodiments, the second housing  111  couples to the endoscope  140 . In some embodiments, the second housing  111  removably couples to the endoscope  140 . In some embodiments, the second housing  111  couples to the endoscope  140  and an endoscope biopsy port (or instrument channel port)  140 A of the endoscope  140 . In some embodiments, the second housing  111  removably couples to the endoscope  140  at a juncture between the endoscope  140  and the endoscope cable  140 A. In some embodiments, the second housing  111  surrounds a portion of the endoscope  140 , the endoscope cable  140 A, or both. In some embodiments, the second housing  111  partially surrounds a portion of the endoscope  140 , the endoscope cable  140 A, or both. In some embodiments, the coupling of the second housing  111  to both the endoscope  140  and the endoscope cable  140 A enables greater stability of the proximal assembly  110  on the endoscope  140 . 
     In some embodiments, the second housing fastener  111 A and the main second housing body  111 C couple to the endoscope  140 . In some embodiments, the second housing fastener  111 A and the main second housing body  111 C removably couple to the endoscope  140 . In some embodiments, the second housing fastener  111 A and the main second housing body  111 C couple to the endoscope  140  and an endoscope biopsy port (or instrument channel port)  140 A of the endoscope  140 . In some embodiments, the second housing fastener  111 A and the main second housing body  111 C removably couple to the endoscope  140  at a juncture between the endoscope  140  and the endoscope cable  140 A. In some embodiments, the second housing fastener  111 A and the main second housing body  111 C surround a portion of the endoscope  140 , the endoscope cable  140 A, or both. In some embodiments, the second housing fastener  111 A and the main second housing body  111 C partially surround a portion of the endoscope  140 , the endoscope cable  140 A, or both. In some embodiments, the coupling of the second housing fastener  111 A and the main second housing body  111 C to both the endoscope  140  and the endoscope cable  140 A enables greater stability of the proximal assembly  110  on the endoscope  140 . In some embodiments, the second housing  111 A fastener rigidly connects to the endoscope  140  without allowing any relative motion between the endoscope  140  and the second housing  111 . 
     As shown, the main second housing body  111 C comprises a first concave portion and a second concave portion. In some embodiments, the first concave surrounds a portion of the endoscope  140 . In some embodiments, the second concave surrounds a portion of the endoscope cable  140 A. In some embodiments, the first concave portion has an inner diameter equal to or greater than an outer diameter of the endoscope  140 . In some embodiments, the inner diameter of the first concave portion is about 5 mm to about 50 mm. In some embodiments, the second concave portion has an inner diameter equal to or greater than an outer diameter of the endoscope cable  140 A. In some embodiments, the inner diameter of the second concave portion is about 5 mm to about 50 mm. In some embodiments, an angle between a centerline of the first concave portion and a centerline of a second concave portion is about 30 degrees. In some embodiments, an angle between a centerline of the first concave portion and a centerline of a second concave portion is about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90 degrees including increments therein. In some embodiments, the an angle between a centerline of the first concave portion and a centerline of a second concave portion is from about 5 to about 90 degrees, from about 10 to about 90 degrees, from about 10 to about 80 degrees, from about 20 to about 70 degrees, from about 5 to about 60 degrees, from about 10 to about 60 degrees, from about 20 to about 60 degrees, from about 10 to about 50 degrees, from about 5 to about 45 degrees, from about 10 to about 50 degrees, from about 15 to about 65 degrees, from about 25 to about 65 degrees, from about 30 to about 60 degrees, from 5 to 90 degrees, from 10 to 90 degrees, from 10 to 80 degrees, from 20 to 70 degrees, from 5 to 60 degrees, from 10 to 60 degrees, from 20 to 60 degrees, from 10 to 50 degrees, from 5 to 45 degrees, from 10 to 50 degrees, from 15 to 65 degrees, from 25 to 65 degrees, or from 30 to 60 degrees. In some embodiments, at least one of the first concave portion or the second concave portion of the main second housing body  111 C has a uniform thickness. 
     In some embodiments, the main second housing body  111 C comprises a fastening mechanism that couples to the second housing fastener  111 A. As shown, the fastening mechanism of the main second housing body  111 C comprises a plurality of raised ridges. Alternatively, in some embodiments, the fastening mechanism of the main second housing body  111 C comprises a tie, a string, a band, a hook and loop fastener, a tape, a strap, a magnet, a cinch, a press fit, a set screw, an adhesive, or any combination thereof. 
     In some embodiments, the second housing fastener  111 A couples with the fastening mechanism of the main second housing body  111 C to secure the proximal assembly  110  to the endoscope  140 . As seen the exemplary second housing fastener  111 A comprises a strap extending from the main second housing body  111 C. In some embodiments, the second housing fastener  111 A and the main second housing body  111 C are coupled by a hinge (not shown), wherein the second housing fastener  111 A rotates about the main second housing body  111 C via the hinge. In some embodiments, the second housing fastener  111 A comprises a flexible strap that is permanently attached to the main second housing body  111 C. In some embodiments, the second housing fastener  111 A comprises a flexible strap that is over-molded onto the main second housing body  111 C. In some embodiments, at least a portion of the second housing fastener  111 A is flexible. Further, as shown, the terminus of the strap of the second housing fastener  111 A comprises a hook that engages and disengages with the fastening mechanism of the main second housing body  111 C. Additionally, as shown, in some embodiments, the fastening mechanism of the main second housing body  111 C comprises an extrusion for gripping by a user during engagement and disengagement with the fastening mechanism of the main second housing body  111 C. In some embodiments, the strap of the second housing fastener  111 A comprises a hook that engages and disengages with the fastening mechanism of the main second housing body  111 C. In some embodiments, the strap of the second housing fastener  111 A and the fastening mechanism of the main second housing body  111 C enable the second housing  111  to secure to a variety of sizes of endoscopes  140 . In some embodiments, the hook of the second housing fastener  111 A and the 
     In some embodiments, the second housing  111  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more second housing fasteners  111 A. Alternatively, the second housing  111  does not couple to the endoscope  140 . In some embodiments, the proximal assembly  110  is configured to be used as a handheld assembly. In some embodiments, the proximal assembly  110  is configured to be mounted to a surface, a rod, a stand, or any combination thereof. 
     In some embodiments, the wheel  113  is confined to rotate about at least degree of freedom with respect to the second housing  111 . In some embodiments, the actuator support portion  111 B comprises a hole to house a pin  114 . In some embodiments, the actuator support portion  111 B encircles at least a portion of the actuator  112 . As seen, the exemplary actuator  112  comprises a wheel  113  that rotates about the pin  114  within the second housing  111 . In some embodiments, the actuator  112  freely rotates about the pin  114  within the second housing  111 . In some embodiments, at least one of the second housing  111 , the pin  114 , or the wheel  113  comprise a bearing that allows the wheel  113  to rotate about the pin  114  within the second housing  111 . In some embodiments, at least one of the wheel  113  or the actuator support portion  111 B comprise a lock, wherein rotation of the wheel  113  about the pin  114  is temporarily locked in a single position by the lock. In some embodiments, at least one of the second housing  111 , the pin  114 , or the wheel  113  comprise a divot, a ridge, a valley, a spring, or any combination thereof, that couple and decouple upon rotation of the wheel  113  about the pin  114  to allow for manually advancement of the wheel  113 . In some embodiments, the divot, ridge, valley, spring, or any combination thereof, couple and decouple upon rotation of the wheel  113  about the pin  114  to provides a tactile feedback indicating an incrementation or angle of rotation. Additionally, in some embodiments, the actuator  112  further comprises a spring, a divot, a magnet or any combination thereof to bias the actuator  112  to one or more positions relative to the second housing  111 . 
     Alternatively, in some embodiments, the second housing  111  does not have a pin  114 , wherein the wheel  113  rotates about a protrusion in the actuator support portion  111 B. In some embodiments, the wheel  113  comprises the pin  114  or an extrusion wherein the wheel  113  and the pin  114  or extrusion rotate about a corresponding hole within the actuator support portion  111 B. Alternatively, in some embodiments, the wheel  113  is confined to rotate with respect to the second housing  111  via a circular channel, a spring, a cam, a pin, a screw, a bolt, or any combination thereof. In some embodiments, the pin  114  is removable for cleaning of the wheel  113 . As shown in  FIG. 3 , the wheel  113  is round. In some embodiments, the round wheel  113  has an outer diameter. Alternatively, in some embodiments, the wheel  113  has a shape comprising a triangle, a square, a pentagon, a hexagon, or any other polygon. 
     As shown the exemplary actuator  112  comprises a knob  119  that allows a user to rotate the wheel  113  about the second housing  111 . In some embodiments, the knob  119  further serves as an indicator of the position of the actuator  112  with respect to the second housing  111 . In some embodiments, the knob  119  prevents the wheel  113  from rotating more than 360 degrees in a primary direction  131 , or rotating more than 360 degrees in a secondary direction opposite the primary direction  131 . In some embodiments, the wheel  113  rotates up to about 360 degrees in a primary direction  131 , and rotates up to about 360 degrees in a secondary direction opposite the primary direction  131 . In some embodiments, the wheel  113  rotates up to about 20 degrees, up to about 30 degrees, up to about 40 degrees, up to about 50 degrees, up to about 60 degrees, up to about 70 degrees, up to about 80 degrees, up to about 90 degrees, up to about 110 degrees, up to about 120 degrees, up to about 130 degrees, up to about 140 degrees, up to about 150 degrees, up to about 160 degrees, up to about 170 degrees, up to about 180 degrees, up to about 190 degrees, up to about 200 degrees, up to about 210 degrees, up to about 220 degrees, up to about 230 degrees, up to about 240 degrees, up to about 250 degrees, up to about 260 degrees, up to about 270 degrees, up to about 280 degrees, up to about 290 degrees, up to about 300 degrees, up to about 310 degrees, up to about 320 degrees, up to about 330 degrees, up to about 340 degrees, up to about 350 degrees, or up to about 360 degrees in a primary direction  131 , and rotates up to about 20 degrees, up to about 30 degrees, up to about 40 degrees, up to about 50 degrees, up to about 60 degrees, up to about 70 degrees, up to about 80 degrees, up to about 90 degrees, up to about 110 degrees, up to about 120 degrees, up to about 130 degrees, up to about 140 degrees, up to about 150 degrees, up to about 160 degrees, up to about 170 degrees, up to about 180 degrees, up to about 190 degrees, up to about 200 degrees, up to about 210 degrees, up to about 220 degrees, up to about 230 degrees, up to about 240 degrees, up to about 250 degrees, up to about 260 degrees, up to about 270 degrees, up to about 280 degrees, up to about 290 degrees, up to about 300 degrees, up to about 310 degrees, up to about 320 degrees, up to about 330 degrees, up to about 340 degrees, up to about 350 degrees, or up to about 360 degrees in a secondary direction opposite the primary direction  131 . In some embodiments, the actuator  112  further comprises an indicator that indicates its position relative to the second housing  111 . Alternatively, in some embodiments, the actuator  112  comprises or further comprises a pulley, a wheel, a clamp, a knot, a post, a gear, a cog, a chain, or any combination thereof. 
     As shown the exemplary wheel  113  comprises a first channel  115  that receives a first portion of a cable  132  and a second channel  116  that receives a second cable portion  133 . In some embodiments, at least one of the first channel  115  or the second channel  116  have a circular cross section. In some embodiments, the wheel  113  does not comprise the second channel  116 . In such embodiments, the first channel  115  comprises a single spiral channel. In some embodiments, at least one of the first channel  115  or the second channel  116  have an inner width equal to or greater than a width of the cable  130 . In some embodiments, a radius of the first channel  115  is equal to a radius of the second channel  116 . In some embodiments, the radius of the first channel  115  is greater than the radius of the second channel  116 . In some embodiments, the radius of the first channel  115  is less than the radius of the second channel  116 . In some embodiments, a circumference of the first channel  115  is equal to a circumference of the second channel  116 . In some embodiments, the circumference of the first channel  115  is greater than the circumference of the second channel  116 . In some embodiments, the circumference of the first channel  115  is less than the circumference of the second channel  116 . In some embodiments, the first channel  115  and the second channel  116  are concentric. In some embodiments, the first channel  115  and the second channel  116  are not concentric. In some embodiments, the first channel  115  and the second channel  116  overlap. 
     In some embodiments, the actuator  112  further comprises a first fastener  118  that couples the first cable portion  132  to the wheel  113 , and a second fastener (not shown) that couples the second cable portion  130  to the actuator  112 . In some embodiments, the first fastener  118  maintains the first cable portion  133  within the first channel  115 . In some embodiments, the second fastener maintains the second cable portion  133  within the second channel  116 . In some embodiments, the first fastener  118  prevents the wheel  113  from rotating more than 360 degrees in the primary direction  131 , or rotating more than 360 degrees in a secondary direction opposite the primary direction  131 . In some embodiments, the proximal assembly  110  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more fasteners. In some embodiments, the wheel  113  does not comprise the first fastener  118  or the second fastener. In some embodiments, the wheel  113  comprises a knob, a tie, or an extrusion that couples the first cable portion  132 , the second cable portion  133 , or both to the wheel  113 . In some embodiments, the first cable portion  132  and the second cable portion  133  are connected, whereas the cable  130  comprises one or two components. In some embodiments, cable  130  comprises two or more components In some embodiments, the first cable portion  132  and the second cable portion  133  are not connected, whereas the cable  130  comprises a two or more components. In some embodiments, at least one of the first cable portion  132  or the second cable portion  133  are constantly in tension during rotation of the wheel  113  of the actuator  112 . In some embodiments, at least one of the first cable portion  132  or the second cable portion  133  do not have slack during rotation of the wheel  113  of the actuator  112 . In some embodiments, at least one of the first cable portion  132  or the second cable portion  133  are in tension when the wheel  113  of the actuator  112  is rotated in the primary direction  131 . In some embodiments, at least one of the first cable portion  132  or the second cable portion  133  are in tension when the wheel  113  of the actuator  112  is rotated in the secondary direction opposite the primary direction  131 . 
     In some embodiments, per  FIG. 3 , when rotated in the primary direction  131 , the actuator  112  translates the first cable portion  132  away from the second housing  111  by a first distance, and translates the second cable portion  133  towards the second housing  111  by a second distance. In some embodiments, when rotated in a secondary direction opposite the primary direction  131 , the actuator  112  translates the first cable portion  132  towards from the second housing by a third distance, and translates the second cable portion  133  away the second housing  111  by a fourth distance. In some embodiments, the first distance, the second distance, the third distance, and the fourth distance are equal. In some embodiments, at least two of the first distance, the second distance, the third distance, and the fourth distance are equal. In some embodiments, the first distance equals the third distance and the second distance equals the fourth distance. 
     As seen in  FIG. 3 , in some embodiments, the endoscopic suturing system  100  further comprises a sheath  130 A that surrounds at least a portion of the cable  130 . In some embodiments, the cable  130  translates freely back and forth in one direction within the sheath  130 A. In some embodiments, the cable  130  and the sheath  130 A comprise a Bowden cable. In some embodiments, the cable  130  comprises a multi-strand cable, a single strand cable, a rope, a thread, a string, a wire, or any combination thereof. In some embodiments, the cable  130  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more cables. In some embodiments, at least a portion of the cable  130  is not covered by the cable sheath  130 A. In some embodiments, the cable  130  is rigid. In some embodiments, the cable  130  is not elastic. In some embodiments, the cable sheath  130 A comprises a hollow tube that protects the cable  130  within. In some embodiments, the cable sheath  130 A is rigid. In some embodiments, the cable sheath  130 A is not elastic. 
     As shown, the second housing  111  comprises a proximal sheath fastener  117  that couples the sheath  130 A to the second housing  111 . As shown, the sheath fastener  117  is connected to the actuator support portion  111 B of the second housing  111 . Alternatively, in some embodiments, the sheath fastener  117  is connected to any portion of the second housing  111 . In some embodiments, the proximal sheath fastener  117  fixes a portion of the sheath  130 A with respect to the second housing  111  such that the cable  130  is allowed to travel within the sheath  130 A upon rotation of the wheel  113 . In some embodiments, the proximal sheath fastener  117  prevents the wheel  113  from rotating more than 360 degrees in the primary direction  131 , or rotating more than 360 degrees in a second direction opposite the primary direction  131 . As shown, the exemplary proximal sheath fastener  117  comprises a clamp. In some embodiments, the clamp comprises a first plate, a second plate, and one or more screws that compress the cable  130  between the first plate and the second plate. Alternatively in some embodiments, the proximal sheath fastener  117  comprises a screw, a tie, a tape, a bolt, a nut, or any combination thereof. In some embodiments, the proximal assembly  110  comprises at least one proximal sheath fastener  117  for the first cable portion  132 , and at least one proximal sheath fastener  117  for the second cable portion  133 . In some embodiments, the proximal assembly  110  comprises a single proximal sheath fastener  117  for both the first cable portion  132  and the second cable portion  133 . In some embodiments, the proximal assembly  110  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more proximal sheath fasteners  117 . 
     In some embodiments, the cable  130  is composed of fabric, metal, plastic, carbon, or any combination thereof. In some embodiments, at least one of the second housing  111 , the actuator  112 , the wheel  113 , the pin  114 , the proximal sheath fastener  117 , the first fastener  118 , or the sheath  130 A are composed of plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. In some embodiments, the actuator does not comprise at least one of a crank, a gear, a rack, or a pinion. 
     First Distal Assembly 
       FIGS. 4 and 5  show illustrations of an exemplary first distal assembly  120 . As shown the exemplary first distal assembly  120  comprises a first housing  121  comprising an endoscope fastener  121 A. In some embodiments, the distal assembly is c-shaped, or comprises a c-shaped portion, thus being referred to as being c-shaped. In some embodiments, the distal assembly has an arcuate needle guide  121 B that is c-shaped, thus providing the distal assembly a c-shape. In some embodiments the portion of the distal assembly that is c-shaped is the arcuate needle guide, at least. The devices, apparatus, and systems actuate an arcuate needle (as used herein, an “arcuate needle” is synonymous with a “circular needle” and is an arced needle that is not fully circular, but travels in a circular path or a substantially circular path) through the c-shaped portion of a distal assembly, wherein such c-shaped portion of the distal assembly is non-perpendicularly angled relative to the major axis of the endoscope and has a non-aligned angle relative to the major axis  502  of the endoscope (see needle axis  501 , elsewhere herein). As such, a tissue grabber is not necessary when suturing using the arcuate needle of the distal assembly, as the distal assembly is easily manipulated to seat the tissue between open ends of the c-shape portion of the distal assembly and into the gap formed by the “C” of the c-shaped portion of the distal assembly for suturing once in such position without separate support required. In some embodiments, the ends of the c-shaped portion of the distal assembly form an angle relative to the needle axis  501  that is less than 180 degrees, is less than about 170 degrees, is less than about 160 degrees, is less than about 150 degrees, is less than about 145 degrees, is less than about 120 degrees, is less than about 100 degrees, is about 20 to about 170 degrees, is about 30 to about 150 degrees, about 40 to about 120 degrees, about 45 to about 110 degrees, about 50 to about 120 degrees, or is about 60 to about 120 degrees. In some embodiments, such angle is measured from the central axis of pulley  2121 AA or the equivalent pin thereof, depending on the embodiment. In some embodiments, such angle is measured from the termini of the c-shaped portion that form the minimum angle possible to measure for such angle. 
     In some embodiments, the endoscope fastener  121 A couples the first housing  121  to an endoscope  140 . In some embodiments, the endoscope fastener  121 A removably couples the first housing  121  to the endoscope  140 . As shown, the endoscope fastener  121 A comprises a press fit fastener. In some embodiments, the press fit endoscope fastener  121 A attaches to the endoscope  140  by firmly pressing the press fit endoscope fastener  121 A onto a distal end of the endoscope  140 . In some embodiments, the press fit endoscope fastener  121 A attaches to the endoscope  140  by firmly pressing and rotating the press fit endoscope fastener  121 A onto a distal end of the endoscope  140 . In some embodiments, the press fit endoscope fastener  121 A detaches from the endoscope  140  by firmly pulling the press fit endoscope fastener  121 A off the distal end of the endoscope  140 . In some embodiments, the press fit endoscope fastener  121 A detaches from the endoscope  140  by firmly pulling and rotating the press fit endoscope fastener  121 A off the distal end of the endoscope  140 . Alternatively, in some embodiments, the endoscope fastener  121 A comprises a clamp, an adhesive, a tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the first distal assembly  120  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more endoscope fasteners  121 A. 
     As shown, in some embodiments, the endoscope fastener  121 A is rounded. In some embodiments, the endoscope  140  has a proximal outer diameter of about 5 mm to about 16 mm. As such, in some embodiments, the endoscope fastener  121 A has an inner diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope fastener  121 A has an inner diameter of at least about 5 mm. In some embodiments, the endoscope fastener  121 A has an inner diameter of at most about 16 mm. In some embodiments, the press fit endoscope fastener  121 A has a diameter equal to or lesser than the diameter of the endoscope  140 . In some embodiments, the endoscope fastener  121 A has a diameter equal to or greater than the diameter of the endoscope  140 . In some embodiments, the endoscope fastener  121 A is tapered and has a first inner diameter and a second inner diameter, wherein the first inner diameter is distal to the second inner diameter. In some embodiments, the first inner diameter is greater than the second inner diameter. In some embodiments, the second inner diameter is greater than the first inner diameter. In some embodiments, the diameter of the endoscope fastener  121 A is measured as a maximum, a minimum, or an average interior width. In some embodiments, the diameter of the endoscope  140  is measured as a maximum, a minimum, or an average exterior width. Alternatively, in some embodiments, the endoscope fastener  121 A has a cross sectional shape comprising a triangle, a square, a hexagon, or any other polygon. In some embodiments, the endoscope fastener  121 A has an inner length of about 10 mm to about 30 mm. In some embodiments, the inner length of the endoscope fastener  121 A is measured as a minimum, a maximum, or an average length from a distal termination of the endoscope fastener  121 A to a proximal termination of the endoscope fastener  121 A. In some embodiments, the inner length of the endoscope fastener  121 A is measured as a minimum, a maximum, or an average normal length from a distal termination of the endoscope fastener  121 A to a proximal termination of the endoscope fastener  121 A. 
     As shown in  FIG. 4 , the exemplary first distal assembly  120  further comprises a distal sheath fastener  128  that couples a portion of the sheath  130 A to the first housing  121 . As shown, the first housing  121  comprises a distal sheath fastener  117  that couples the sheath  130 A to the first housing  121 . In some embodiments, the distal sheath fastener  117  fixes a portion of the sheath  130 A with respect to the first housing  121 , such that the cable  130  is allowed to travel within the sheath  130 A upon rotation of the wheel. As shown, the exemplary distal sheath fastener  128  comprises a clamp. In some embodiments, the distal sheath fastener  128  comprises a plate and one or more sheath fastener screws  128 A that compress the cable sheath  130 A between the plate and the first housing  121 . Alternatively in some embodiments, the distal sheath fastener  128  comprises a screw, a tie, a tape, or any combination thereof. In some embodiments, the first housing  112  comprises at least one distal sheath fastener  128  for the first cable portion  132 , and at least one distal sheath fastener  128  for the second cable portion  133 . In some embodiments, the first housing  112  comprises a distal sheath fastener  128  for both the first cable portion  132  and the second cable portion  133 . In some embodiments, a portion of the cable sheath  130 A extends past the termination of the distal sheath fastener  128  and into the first housing  121 . In some embodiments, the distal assembly  120  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more distal sheath fasteners  128 . Alternatively, in some embodiments, the distal sheath fastener  128  comprises a clamp, a tie, a band, a hook and loop fastener, an adhesive, or any combination thereof. 
     In some embodiments, per  FIG. 5 , an angle between a needle axis  501  and a proximal axis (or major axis)  502  of the endoscope  140  is about 5 degrees to about 85 degrees. In some embodiments, an angle between a the needle axis  501  and a proximal axis  502  of the endoscope  140  is adjustable within about 5 degrees to about 85 degrees. In some embodiments, a specific angle between the needle axis  501  and a proximal axis  502  of the endoscope  140  allows a camera of the endoscope  140  to view the entrance, the exit, or both of the arcuate needle the tissue that is being sutured. In some embodiments, the needle axis  501  is defined as an axis normal to a plane of symmetry of the arcuate needle  123  and coincident with a centerpoint of the radius of the arcuate needle  123 . In some embodiments, the proximal axis  502  of the endoscope  140  is defined as the center axis or major axis of a distal portion of the endoscope  140 . In some embodiments, the proximal axis  502  of the endoscope  140  is defined as the center axis of the endoscope fastener  121 A of the first housing  112 . In some embodiments, the angle between a center axis  501  of the arcuate needle guide  121 B and a proximal axis  502  of the endoscope  140  is defined as a maximum, a minimum, or an average angle. 
       FIGS. 6-9  show detailed illustrations of the exemplary first distal assembly  120 . Per  FIG. 6 , the exemplary first housing  121  comprises a primary first housing portion  601 , a secondary first housing portion  602  and a pin fastener  603 . In some embodiments, the secondary first housing portion  602  fits within the primary first housing portion  601 . In some embodiments, the primary first housing portion  601  and the secondary first housing portion  602  are adjoined by the pin fastener  603 . In some embodiments, the primary first housing portion  601  and the secondary first housing portion  602  are removably adjoined by the pin fastener  603 . In some embodiments, the primary first housing portion  601  and the secondary first housing portion  602  are made of the same material. In some embodiments, the primary first housing portion  601  and the secondary first housing portion  602  are made of different materials. As shown the exemplary pin fastener  603  comprises a press fit fastener, wherein the press fit fastener has an outer diameter greater than a diameter of a corresponding hole in the primary first housing portion  601  and the secondary first housing portion  602 . Alternatively, in some embodiments, the pin fastener  603  comprises a screw, a bolt, a threaded feature, a nut, a rivet, an adhesive, a pulley, a bearing, a weld, or any combination thereof. As shown the exemplary first housing  121  comprises two pin fasteners  603 . Alternatively, the exemplary first housing  121  comprises 1, 3, 4, 5, 6, 7, 8, 9, 10 or more pin fasteners  603 . 
     Further, in some embodiments, the first distal assembly  120  comprises an arcuate needle  122  disposed within an arcuate needle guide  121 B within the first housing  121 . In some embodiments, at least one of the primary first housing portion  601  or the secondary first housing portion  602  comprise the arcuate needle guide  121 B. In some embodiments, the arcuate needle  122  slides freely within the arcuate needle guide  121 B. In some embodiments, the arcuate needle guide  121 B constrains the arcuate needle  122  to rotate within one degree of freedom. In some embodiments, the arcuate needle guide  121 B constrains the arcuate needle  122  to rotate within at least one rotational degree of freedom. As seen, the exemplary arcuate needle guide  121 B encloses at least a portion of the arcuate needle  122 . In some embodiments, the exemplary arcuate needle guide  121 B encloses at least a portion of the arcuate needle  122 , when it is positioned within the first housing  121 . In some embodiments, the arcuate needle guide  121 B has an interior width greater than a thickness of the arcuate needle  122 . In some embodiments, the arcuate needle guide  121 B has a cross sectional shape comprising a circle, a square, a rectangle, or any other polygon. In some embodiments, a gulf  604  is formed between a first termination of the arcuate needle guide  121 B and a second opposing termination of the arcuate needle guide  121 B within the first distal assembly  120 . As seen therein, the arcuate needle guide  121 B surrounds about 280 degrees of the cross sectional circumference of the arcuate needle  122 . Alternatively, in some embodiments, the arcuate needle guide  121 B surrounds about 100, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320 degrees or more of the cross sectional circumference of the arcuate needle  122 , including increments therein. 
     In some embodiments, a gulf  604  is formed between a first pin fastener  603  and a second opposing pin fastener  603  within the first distal assembly  120 . In some embodiments, the gulf  604  accepts a tissue for suturing by the arcuate needle  122 . In some embodiments, the tissue is supported against the arcuate needle  122  throughout the suturing process. In some embodiments, the first distal assembly  120  does not comprise an anchor exchange catheter. In some embodiments, the first distal assembly  120  does not require a dedicated grabber to keep the tissue against the arcuate needle  122 . In some embodiments, lack of a required dedicated grabber enables the use of a standard endoscope  140  without an additional dedicated working channel. 
     Per  FIGS. 7-9 , the exemplary first distal assembly  120  further comprises a shuttle  123  having a pawl  124 . As shown the exemplary shuttle  123  translates within a shuttle guide  121 C within the first housing  121 . In some embodiments, at least one of the shuttle  123  or the shuttle guide  121 C within the first housing  121  is arcuate. In some embodiments, the shuttle  123  slides within the shuttle guide  121 C. In some embodiments, the shuttle  123  translates within the shuttle guide  121 C about at least one degree of rotation. In some embodiments, the shuttle  123  translates about one degree of rotation within a 270 degree arc within the shuttle guide  121 C. In some embodiments, the shuttle  123  translates in an arc about one degree of rotation over 90, 100, 110, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320, or greater degrees within the shuttle guide  121 C. In some embodiments, at least one of the shuttle  123  or the shuttle guide  121 C has a cross sectional shape comprising a circle, a square, a rectangle, or any other polygon. 
     In some embodiments, at least one of the primary first housing portion  601  or the secondary first housing portion  602  comprises the shuttle guide  121 C. In some embodiments, the shuttle  123  slides within the shuttle guide  121 C of the distal assembly  120 . As shown, the shuttle  123  is arcuate to slide within the arcuate shuttle guide  121 C. In some embodiments, the primary first housing portion  601  constrains a bottom surface of the shuttle  123 , wherein the secondary first housing portion  602  constrains an inner surface, an outer surface, and a portion of the top surface of the shuttle  123 . Alternatively, in some embodiments, at least one of the primary first housing portion  601  or the secondary first housing portion  602  constrain one or more of the bottom, inner, outer, and top surfaces of the shuttle  123 . In some embodiments, the shuttle  123  is constrained by at least one of the primary first housing portion  601  or the secondary first housing portion  602  as it translates within the shuttle guide  121 C. As shown, a bottom surface of the shuttle  123  contacts a portion of the primary first housing portion  601 , while an inner portion and an outer portion of the shuttle  123  contacts a portion of the secondary first housing portion  602 . In some embodiments, the shuttle  123  contacts at least one of the primary first housing portion  601  or the secondary first housing portion  602  as it translates within the shuttle guide  121 C. As shown, an arcuate channel between the shuttle guide  121 C and the arcuate needle guide  121 B provides clearance for the pawl  124  to contact the arcuate needle  122  as the shuttle  123  translates through the shuttle guide  121 C. In some embodiments, the arcuate channel has a width greater than a width of the pawl  124  but lesser than a width of the arcuate needle  122 . 
     In some embodiments, the inner surface of the shuttle  123  is defined as a surface of the shuttle  123  that is closest to the needle axis  501 . In some embodiments, the outer surface of the shuttle  123  is defined as a surface of the shuttle  123  that is farthest from the needle axis  501 . In some embodiments, the top surface of the shuttle  123  is defined as a surface of the shuttle  123  that is closest to the arcuate needle  122 . In some embodiments, the bottom surface of the shuttle  123  is defined as a surface of the shuttle  123  that is furthest to the arcuate needle  122 . 
     In some embodiments, the arc length of the shuttle guide  121 C is equal to the distance traveled by at least one of the first cable portion or the second cable portion during rotation of the actuation wheel minus a width of the shuttle  123 . In some embodiments, the shuttle  123  travels within the shuttle guide  121 C a distance traveled by at least one of the first cable portion or the second cable portion during rotation of the actuation wheel. In some embodiments, a ratio between a length of the shuttle  123  and the arc length of the shuttle guide  121 C is about 1:3 to about 1:15. In some embodiments, a ratio between a length of the shuttle  123  and an arc length of the shuttle guide  121 C is at least about 1:3. In some embodiments, a ratio between a length of the shuttle  123  and an arc length of the shuttle guide  121 C is at most about 1:15. In some embodiments, a ratio between the arc length of the shuttle guide  121 C and a diameter of at least one of the first channel or the second channel of the wheel of the actuator is about 2:1 to about 1:5. In some embodiments, a ratio between the arc length of the shuttle guide  121 C and a diameter of at least one of the first channel or the second channel of the wheel of the actuator is at least about 2:1. In some embodiments, a ratio between the arc length of the shuttle guide  121 C and a diameter of at least one of the first channel or the second channel of the wheel of the actuator is at most about 1:5. 
     Per  FIG. 8  the exemplary shuttle  123  further comprises a cable attachment  127  to connect to the cable  130 . As shown, the cable attachment  127  comprises a cavity that receives and secures a portion of the cable  130 . Alternatively, in some embodiments, the cable attachment  127  comprises a clamp, a hole, a screw, a bolt, a nut, a clip, a pin, or any combination thereof. In some embodiments, the cable attachment  127  comprises a terminal cable attachment, wherein the cable terminates at the cable attachment  127 . In some embodiments, the cable attachment  127  comprises a non-terminal cable attachment, wherein the cable passes through and couples to the cable attachment  127 . In some embodiments, the shuttle  123  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more cable attachments  127 . As seen, the exemplary shuttle  123  is rigidly connected to the cable  130  at the cable attachment  127  such that a tensile force on the cable  130  causes the shuttle  123  to translate in the direction of the tensile force. 
     In some embodiments, the shuttle  123  comprises a pawl  124 , a cushion  126 , or both. In some embodiments, the shuttle  123  comprises a cavity  123 A that accepts the pawl  124 , the cushion  126 , or both. In some embodiments, the cavity  123 A has an inner width greater than an outer width of the pawl  124 , an outer width of the cushion  126 , or both. In some embodiments, the cavity  123 A has a depth that terminates within the shuttle  123 . In some embodiments, the cavity  123 A extends through the shuttle  123 . In some embodiments, the cavity  123 A has a cross-sectional shape comprising a square, a circle, a triangle, a hexagon, or any other polygon. 
     In some embodiments, the pawl  124  is biased towards engagement with the notch  122 A of the arcuate needle  122 . In some embodiments, the pawl  124  is biased towards the first direction  1000 . In some embodiments, the pawl  124  comprises a pivot  127  to rotate about the shuttle  123 . In some embodiments, the pivot  127  comprises a pin extrusion element of the pawl  124 . In some embodiments, the pivot  127  comprises a pin that is rigidly attached to the pawl  124 , and which rotates about a hole in the shuttle  123 . In some embodiments, the pivot  127  comprises a pin that is rigidly attached to shuttle  123 , and which rotates about a hole in the pawl  124 . Alternatively, in some embodiments, the pivot  127  comprises a divot, a slot, a screw, or any combination thereof within the pawl  124 , the shuttle  123 , or both. 
     In some embodiments, the pawl  124  is biased towards engagement by the cushion  126 . In some the cushion  126  is elastic. In some the cushion  126  comprises a spring. In some embodiments, the cushion  126  presses against the pawl  124  in a second direction opposite the first rotational direction  1000 . In some embodiments, the cushion  126  presses against the pawl  124  to drive the pawl  124  upwards and out of the cavity  123 A to engage with the notch  122 A of the arcuate needle  122 . In some embodiments, a position of the pivot  127  relative to the termination of the cavity  123 A, in combination with a position of the cushion  126  enables the pawl to be engagement bias. In some embodiments, when the pawl  124  is engaged, the cushion  126  presses the pawl  124  against the termination of the cavity  123 A of the shuttle  123 . In some embodiments, when the pawl  124  is disengaged, the arcuate needle  122  presses the pawl  124  against the cushion  126  such that the pawl moves upward into the cavity  123 A and away from termination of the cavity  123 A of the shuttle  123 . In some embodiments, an upper face of the pawl  124  is slanted towards one end of the shuttle  123 . In some embodiments, an upper face of the pawl  124  is slanted upwards in a second rotational direction opposite the first rotational direction  1000 . In some embodiments, an upper face of the pawl  124  is slanted to engage with the ramp of the arcuate needle. In some embodiments, the pawl  124  further comprises a spring, a flexure, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the first distal assembly  120  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more pawls  124 . 
     In some embodiments, the cushion  126  is integrated into the pawl  124 . In some embodiments, the cushion  126  is integrated into the shuttle  123 . In some embodiments, the cushion  126  is integrated into the cavity  123 A of the shuttle  123 . In some embodiments, the shuttle  123  does not comprise a cushion  126 . In some embodiments, the shuttle  123  does not comprise a cushion  126 , wherein the pawl  124  comprises a flexure, a spring, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof to bias the pawl  124  against the arcuate needle. In some embodiments, the shuttle  123  does not comprise a pawl  124  or a cushion  126 , wherein the shuttle  123  comprises a flexure, a spring, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof to engage and disengage with the arcuate needle. 
     Further, per  FIG. 7 , the exemplary first housing  121  comprises a cable pulley  121 D that guides the cable  130  from the proximal assembly, through the shuttle guide  121 C, to the shuttle  123  and out the first housing  121 . In some embodiments, at least one of the primary first housing portion  601 , the secondary first housing portion  602 , or the pin fastener  603  of the first housing  121  comprises the cable pulley  121 D. In some embodiments, the first housing  121  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more cable pulleys  121 D. In some embodiments, the cable pulley  121 D comprises a bearing, a rod, a curved surface, or any combination thereof. In some embodiments, the cable pulley  121 D comprises a rigid portion of the first housing  121 . Alternatively, in some embodiments, the cable pulley  121 D rotates within the first housing  121 . Alternatively, in some embodiments, the cable pulley  121 D rotates within the primary first housing portion  601 , the secondary first housing portion  602 , or both. In some embodiments, at least one of the primary first housing portion  601  or the secondary first housing portion  602  further comprise one or more cable guides that direct the cable  130  towards and away from the cable pulley  121 D. 
       FIGS. 10-13  show the progression of the arcuate needle  122  as it is translated by the shuttle  123  and the pawl  124  through the arcuate needle guide  121 B. Per  FIG. 10 , in a first position, the arcuate needle  122  is completely housed within the arcuate needle guide  121 B within the first housing  121 . As the cable  130  pulls the shuttle  123  within the shuttle guide  121 C in a first rotational direction  1000  with respect to the first housing  121 , the pawl  124  engages with a notch  122 A in the arcuate needle  122 , per  FIG. 11 , causing a portion of the arcuate needle  123  to exit the first housing  121 . Once the shuttle  123  cannot move any further within the shuttle guide  121 C of the first housing  121  in the first rotational direction  1000 , the cable  130  then pulls the shuttle  123  in a second rotational direction opposite the first rotational direction  1000  such that the pawl  124  engages with a suture end  1201  of the arcuate needle  122 . The cable  130  is then pulled in the first rotational direction  1000  such that the shuttle  123  translates in the first rotational direction  1000 , while the pawl  124  pushes against the suture end  1201  of the arcuate needle  122  to translate the arcuate needle  122 , per  FIG. 12 , such that majority of the arcuate needle  122  exits the first housing  121  and only a portion of a pointed end  1101  and a suture end  1201  of the arcuate needle  122  are within the first housing  121 . After the shuttle  123  cannot move any further within the shuttle guide  121 C of the first housing  121  in the first rotational direction  1000 , the cable  130  pulls the shuttle  123  through the shuttle guide  121 C of the first housing  121  in the second rotational direction, per  FIG. 13 , such that the pawl  124  reengages with the notch  122 A in the arcuate needle  122 . The cable then 130 pulls the shuttle  123  in the second rotational direction within the shuttle guide  121 C of the first housing  121  to translate the arcuate needle  122  in the first rotational direction  1000  and back within the first housing  121  to perform one suture. 
     As such, a single suturing maneuver comprises, pulling the cable  130  in the first direction  1000 , pulling the cable  130  in a second direction opposite the first direction  1000 , pulling the cable  130  in the first direction  1000  a second time, pulling the cable  130  in the second direction a second time, pulling the cable  130  in the first direction  1000  a third time, and pulling the cable  130  in the second direction a third time. As shown, the first rotational direction  1000  is counterclockwise with respect to the first housing  121 . Alternatively, in some embodiments, the first rotational direction  1000  is clockwise with respect to the first housing  121 . 
     In some embodiments, per  FIGS. 3, 4 and 10 , pulling the cable  130  in the first rotational direction  1000  comprises pulling the primary cable portion  132  towards the second housing  111  of the proximal assembly  110 . In some embodiments, pulling the cable  130  in the first rotational direction  1000  comprises rotating the wheel  113  of the actuator  112  in the secondary direction opposite the primary direction  131 . In some embodiments, pulling the cable  130  in the second rotational direction opposite the first rotational direction  1000  comprises pulling the secondary cable portion  133  towards the second housing  111  of the proximal assembly  110  In some embodiments, pulling the cable  130  in the second rotational direction opposite the first rotational direction  1000  comprises rotating the wheel  113  of the actuator  112  in the primary direction  131 . In some embodiments, translating the shuttle  123  in the first rotational direction  1000  comprises pulling the primary cable portion  132  towards the second housing  111  of the proximal assembly  110 . In some embodiments, translating the shuttle  123  in the first rotational direction  1000  comprises rotating the wheel  113  of the actuator  112  in the secondary direction opposite the primary direction  131 . In some embodiments, translating the shuttle  123  in the second rotational direction opposite the first rotational direction  1000  comprises pulling the secondary cable portion  133  towards the second housing  111  of the proximal assembly  110 . In some embodiments, translating the shuttle  123  in the second rotational direction opposite the first rotational direction  1000  comprises rotating the wheel  113  of the actuator  112  in the primary direction  131 . 
     In some embodiments, when pulled by the cable  130  in the first direction  1000  or the second direction, the shuttle  123  translates about one or more degrees of rotation within the shuttle guide  121 C. In some embodiments, when pulled by the cable  130  in the first direction  1000  or the second direction, the shuttle  123  translates about one degree of rotation within a 270 degree arc within the shuttle guide  121 C. In some embodiments, when pulled by the cable  130  in the first direction  1000  or the second direction, the shuttle  123  translates about one degree of rotation within a 90, 100, 110, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320 or greater degree arc within the shuttle guide  121 C, including increments therein. 
     In some embodiments, at least one of the first housing  111 , the arcuate needle  112 , the shuttle  123 , the pawl  124 , the suture  125 , the cushion  126 , the primary first housing portion  601 , the secondary first housing portion  602 , or the pin fastener  603 , are composed of plastic, metal, fiberglass, carbon fiber, wood, or any combination thereof. 
     Arcuate Needle and Suture 
       FIGS. 14-18  show illustrations of exemplary arcuate needles  122  and sutures  125 . Per  FIGS. 14 and 15 , in some embodiments, the arcuate needle  122  has a notch  122 A, a pointed end  1101 , and a suture end  1201 . In some embodiments, the notch  122 A is ramped in a direction opposite the first rotational direction. Alternatively, in some embodiments, the notch  122 A is ramped in the first rotational direction. In some embodiments, the notch  122 A is ramped at an angle of about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65 or more degrees, including increments therein. In some embodiments, the notch  122 A is ramped at an angle of at least about 5 degrees. As shown, an angle between the notch  122 A and the suture end  1201  of the exemplary arcuate needle  122  is about 180 degrees. Alternatively, in some embodiments, the angle between the notch  122 A and the suture end  1201  of the exemplary arcuate needle  122  is about 90, 100, 120, 140, 160, 180, 200, 220, 240, 260, 2800 degrees or more, including increments therein. In some embodiments, the angle between the notch  122 A and the suture end  1201  of the exemplary arcuate needle  122  is at least about 90 degrees. 
     In some embodiments, an outer diameter of the arcuate needle  122  is about 7 mm to about 20 mm. In some embodiments, an outer diameter of the arcuate needle  122  is at least about 7 mm. In some embodiments, an outer diameter of the arcuate needle  122  is at most about 20 mm. In some embodiments, a thickness  1510  of the arcuate needle  122  is about 0.5 mm to about 2 mm. In some embodiments, a thickness  1510  of the arcuate needle  122  is at least about 0.5 mm. In some embodiments, a thickness  1510  of the arcuate needle  122  is at most about 2 mm. In some embodiments, a ratio between an outer diameter and a thickness  1510  of the arcuate needle  122  is about 3:1 to about 15:1. In some embodiments, a ratio between an outer diameter and a thickness  1510  of the arcuate needle  122  is at least about 3:1. In some embodiments, a ratio between an outer diameter and a thickness  1510  of the arcuate needle  122  is at most about 15:1. In some embodiments, a ratio between an outer diameter and the thickness  1510  of the arcuate needle  122  is about 3:1, 4:1, 5:1, 6:1, 7:1, 8:1, 9:1, 10:1, 11:1, 12:1, 13:1, 14:1, or 15:1. In some embodiments, a ratio between an outer diameter and the thickness  1510  of the arcuate needle  122  is at least about 3:1. In some embodiments, the outer diameter of the arcuate needle  122  is measured as a maximum distance between two points on the surface of the arcuate needle  122 . In some embodiments, the outer diameter of the arcuate needle  122  is measured as a maximum outer diameter of the arcuate needle  122 . In some embodiments, the width of the arcuate needle  122  is measured as a thickness  1510  of the arcuate needle  122 . In some embodiments, the thickness  1510  of the arcuate needle  122  is measured as a thickness  1510  of the arcuate needle  122  that is not within the pointed end  1101 , the suture end  1201 , or the notch  122 A. In some embodiments, the thickness  1510  of the arcuate needle  122  is measured as a maximum, a minimum, or an average thickness  1510  of the arcuate needle  122 . 
     In some embodiments, the pointed end  1101  is pointed at an angle of about 5, 10, 15, 20, 25, 30, 35, 40, 45 degrees or greater, including increments therein. In some embodiments, the pointed end  1101  is pointed at an angle of at least about 5 degrees. As shown, the exemplary suture end  120  is flat. Alternatively, in some embodiments, the suture end  120  is rounded, tapered, or angled. 
     As shown, in some embodiments, the arcuate needle  122  has two notches  122 A. In some embodiments, the arcuate needle  122  has 2, 3, 4, 5, 6, 7, 8, 9, 10 or more notches  122 A. In some embodiments, the arcuate needle  122  has two or more notches  122 A. As shown, each notch  122 A is spaced about the arcuate needle  122  at an angle of about 180 degrees. 
     In some embodiments, the notches  122 A are spaced about the arcuate needle  122  at an angle of about 10 degrees to about 180 degrees. In some embodiments, the notches  122 A are spaced about the arcuate needle  122  at an angle of about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 10 degrees to about 140 degrees, about 10 degrees to about 160 degrees, about 10 degrees to about 180 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 20 degrees to about 140 degrees, about 20 degrees to about 160 degrees, about 20 degrees to about 180 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 30 degrees to about 140 degrees, about 30 degrees to about 160 degrees, about 30 degrees to about 180 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 40 degrees to about 140 degrees, about 40 degrees to about 160 degrees, about 40 degrees to about 180 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 100 degrees, about 50 degrees to about 120 degrees, about 50 degrees to about 140 degrees, about 50 degrees to about 160 degrees, about 50 degrees to about 180 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 60 degrees to about 140 degrees, about 60 degrees to about 160 degrees, about 60 degrees to about 180 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 80 degrees to about 140 degrees, about 80 degrees to about 160 degrees, about 80 degrees to about 180 degrees, about 100 degrees to about 120 degrees, about 100 degrees to about 140 degrees, about 100 degrees to about 160 degrees, about 100 degrees to about 180 degrees, about 120 degrees to about 140 degrees, about 120 degrees to about 160 degrees, about 120 degrees to about 180 degrees, about 140 degrees to about 160 degrees, about 140 degrees to about 180 degrees, or about 160 degrees to about 180 degrees. In some embodiments, the notches  122 A are spaced about the arcuate needle  122  at an angle of about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 80 degrees, about 100 degrees, about 120 degrees, about 140 degrees, about 160 degrees, or about 180 degrees. In some embodiments, the notches  122 A are spaced about the arcuate needle  122  at an angle of at least about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 80 degrees, about 100 degrees, about 120 degrees, about 140 degrees, or about 160 degrees. In some embodiments, the notches  122 A are spaced about the arcuate needle  122  at an angle of at most about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 80 degrees, about 100 degrees, about 120 degrees, about 140 degrees, about 160 degrees, or about 180 degrees. 
     In some embodiments, per  FIG. 15 , a ratio between the thickness  1510  of the arcuate needle  122  and the depth  1520  of the notch  122 A is about 2:1 to about 15:1. In some embodiments, a ratio between the thickness  1510  of the arcuate needle  122  and the depth  1520  of the notch  122 A is at least about 2:1. In some embodiments, a ratio between the thickness  1510  of the arcuate needle  122  and the depth  1520  of the notch  122 A is at most about 15:1. As shown, in some embodiments, the depth  1520  of the notch  122  is measured as a maximum normal distance between a surface of the notch and an outer surface of the arcuate needle  122 . 
     In some embodiments, per  FIG. 16 , the suture end  1201  of the arcuate needle  122  comprises a primary suture attachment  122 D that couples the suture  125  to the arcuate needle  122 . Further, in some embodiments, the suture  125  comprises a secondary suture attachment  125 A that mates with the primary suture attachment  122 D. In some embodiments, the primary suture attachment  122 D and the secondary suture attachment  125 A removably mate. In some embodiments, the primary suture attachment  122 D and the secondary suture attachment  125 A removably mate such that the suture  125  does not disconnect from the arcuate needle  122  during suturing. In some embodiments, the primary suture attachment  122 D and the secondary suture attachment  125 A removably connect and/or disconnect in-situ. 
     As shown the exemplary primary suture attachment  122 D comprises an open channel having a first channel portion and a second channel portion, wherein the first channel portion breaches the suture end  1201  of the arcuate needle  122 , and wherein the second channel portion is further from the suture end  1201  than the proximal width. As seen, a width of the second channel portion is greater than a width of the first channel portion. In some embodiments, a ratio between the width of the first channel portion and the width of the second channel portion is about 1.1:1 to about 3:1. In some embodiments a ratio between the width of the first channel portion and the width of the second channel portion is at least about 1.1:1. In some embodiments, the proximal width partially encases the suture. In some embodiments, the first channel portion partially encases the secondary suture attachment  125 A. In some embodiments, the first channel portion is equal to or greater than a width of the suture  125 . In some embodiments, a center plane of the first channel portion and a center plane of the second channel portion are coplanar. In some embodiments, at least one of the first channel portion or a second channel portion comprises a rounded channel. In some embodiments, a centerpoint of the rounded surface of the first channel portion, a centerpoint of the rounded surface of the rounded second channel portion, or both are aligned with a center arcuate axis of the arcuate needle  122 . 
     As shown the secondary suture attachment  125 A comprises a knot or bulb. In some embodiments, a thickness of the suture  125  is less than a thickness of the suture attachment  125 A. In some embodiments, a ratio between the thickness of the suture  125  and the thickness of the suture attachment  125 A is about 1:1.1 to about 1:3. 
     Alternatively, exemplary at least one of the primary suture attachment  122 D or the secondary suture attachment  125 A comprises a tie, a string, a band, a hook and loop fastener, a tape, a strap, a magnet, a cinch, a press fit, a set screw, an adhesive, or any combination thereof. 
     Per  FIGS. 17 and 18 , the primary suture attachment  122 D within the arcuate needle  122 , and the secondary suture attachment  125 A of the exemplary suture  125  couple, decouple, or both in-vitro by a pincer  1701  employed in a working channel  1801  of the endoscope. Such a feature enables quick and easy suture  125  exchanges during procedures requiring suturing at more than one location. As shown, the secondary suture attachment  125 A is located on an inner surface of the arcuate needle  122  to allow the pincer  1701  to connect and disconnect the suture  125  to the arcuate needle  122 . 
     Shuttle Assembly 
       FIG. 19A  shows an exemplary illustration of the shuttle  123  where the pawl  124  is engaged.  FIG. 19B  is an exemplary illustration of a shuttle  123  where the pawl  124  is disengaged. Further, as shown the pawl  124  rotates within the shuttle  123  about a pivot  129 . In some embodiments, the pawl  124  comprises a spring, a flexure, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the first distal assembly  120  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more pawls  124 . In some embodiments, the shuttle slides within the shuttle guide of the distal assembly. As seen, the shuttle  123  is arcuate to slide within the shuttle guide. 
     In some embodiments, the shuttle  123  comprises a pawl  124 , a cushion  126 , or both. In some embodiments, the pawl  124  rotates about a pivot  127  in the shuttle  123 . In some embodiments, the shuttle  123  comprises a cavity that accepts the pawl  124 . In some embodiments, the pawl  124  is biased towards engagement. In some embodiments, the pawl  124  is biased towards engagement by a cushion  126 . In some embodiments, the cushion  126  presses against the pawl  124  to drive the pawl  124  upwards to engage with the notch  122 A of the arcuate needle  122 . In some embodiments, a position of the pivot  127  relative to the termination of the cavity  123 A, in combination with the cushion  126 , enables the pawl to be engagement bias. In some embodiments, when the pawl  124  is engaged, the cushion  126  presses the pawl  124  against the termination of the cavity  123 A of the shuttle  123 . In some embodiments, when the pawl  124  is disengaged, the arcuate needle  122  presses the pawl  124  against the cushion  126  and away from termination of the cavity  123 A of the shuttle  123 . In some embodiments, an upper face of the pawl  124  is slanted towards one end of the shuttle  123 . In some embodiments, an upper face of the pawl  124  is slanted to engage with the ramp of the arcuate needle. 
     In some embodiments, the cushion  126  is integrated into the pawl  124 . In some embodiments, the cushion  126  is integrated into the shuttle  123 . In some embodiments, the shuttle  123  does not comprise a cushion  126 . In some embodiments, the shuttle  123  does not comprise a cushion  126 , wherein the pawl  124  comprises a flexure, a spring, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof to bias the pawl  124 . In some embodiments, the shuttle  123  does not comprise a pawl  124  or a cushion  126 , wherein the shuttle  123  comprises a flexure, a spring, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof to engage and disengage with the arcuate needle. 
     In some embodiments, the exemplary shuttle  123  further comprises a cable attachment  127  to connect to the cable. In some embodiments, the cable attachment  127  comprises a clamp, a hole, a screw, a bolt, a nut, a clip, a pin, or any combination thereof. In some embodiments, the cable attachment  127  comprises a terminal cable attachment, wherein the cable terminates at the cable attachment  127 . In some embodiments, the cable attachment  127  comprises a non-terminal cable attachment, wherein the cable passes through and couples to the cable attachment  127 . In some embodiments, the shuttle  123  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more cable attachments  127 . In some embodiments, the shuttle  123  slides within the shuttle guide of the distal assembly. As seen, the shuttle  123  is arcuate to slide within the shuttle guide. 
     Second Distal Assembly 
       FIGS. 20-30B  show illustrations of an exemplary second proximal assembly  2120  and a cable  2130  having a pawl  2124 . In some embodiments, the second proximal assembly  2120  comprises an arcuate needle  2122  having a notch  2122 A and a first housing  2121  comprising a primary housing portion  2121 A and a secondary housing portion  2121 B. In some embodiments, the cable  2130  comprises a sheath surrounding at least a portion of the cable  2130 . 
     As seen in  FIGS. 21-25 and 28 , the primary housing portion  2121 A and the secondary housing portion  2121 B are connected by a housing fastener  2140 . In some embodiments, the primary housing portion  2121 A and the secondary housing portion  2121 B are connected by 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more housing fasteners  2140 . As shown the housing fastener  2140  comprises a screw which passes through a clearance hole within the secondary housing portion  2121 B and fastens to a threaded feature  2140 A within the primary housing portion  2121 A. Alternatively, in some embodiments, the housing fastener  2140  comprises a bolt, a rivet, a nut, a weld, an adhesive, or any combination thereof within at least one of the primary housing portion  2121 A or the secondary housing portion  2121 B. In some embodiments, the first housing  2121  does not comprise the primary housing portion  2121 A or the secondary housing portion  2121 B. In some embodiments, the first housing  2121  further comprises a tertiary housing portion or more housing portions. In some embodiments, at least one of the primary housing portion  2121 A or the secondary housing portion  2121 B comprises one or more cable guides that direct the cable  2130  towards and away from the first housing  2121 . In some embodiments, the primary housing portion  2121 A and the secondary housing portion  2121 B are made of the same material. In some embodiments, the primary housing portion  2121 A and the secondary housing portion  2121 B are made of different materials. 
     In some embodiments, at least one of the primary housing portion  2121 A or the secondary housing portion  2121 B comprises an endoscope fastener  2401  that couples the second proximal assembly  2120  to an endoscope  2150 . In some embodiments, the endoscope fastener  2401  removably couples the first housing  121  to the endoscope  2150 . As shown, the endoscope fastener  2401  comprises a press fit fastener. In some embodiments, the press fit endoscope fastener  2401  couples to the endoscope  2150  by firmly pressing the press fit endoscope fastener  2401  onto a distal end of the endoscope  2150 . In some embodiments, the press fit endoscope fastener  2401  couples to the endoscope  2150  by firmly pressing and rotating the press fit endoscope fastener  2401  onto a distal end of the endoscope  2150 . In some embodiments, the press fit endoscope fastener  2401  detaches from the endoscope  2150  by firmly pulling the press fit endoscope fastener  2401  off the distal end of the endoscope  2150 . In some embodiments, the press fit endoscope fastener  2401  detaches from the endoscope  2150  by firmly pulling and twisting the press fit endoscope fastener  2401  off the distal end of the endoscope  2150 . 
     As shown, in some embodiments, the endoscope fastener  2401  is rounded. In some embodiments, the endoscope  2150  has a proximal outer diameter of about 5 mm to about 16 mm. As such, in some embodiments, the endoscope fastener  2401  has an inner diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope fastener  2401  has an inner diameter of at least about 5 mm. In some embodiments, the endoscope fastener  2401  has an inner diameter of at most about 16 mm. In some embodiments, the press fit endoscope fastener  2401  has a diameter equal to or lesser than the diameter of the endoscope  2150 . In some embodiments, the endoscope fastener  2401  has a diameter equal to or greater than the diameter of the endoscope  2150 . In some embodiments, the endoscope fastener  2401  is tapered and has a first inner diameter and a second inner diameter, wherein the first inner diameter is distal to the second inner diameter. In some embodiments, the first inner diameter is greater than the second inner diameter. In some embodiments, the second inner diameter is greater than the first inner diameter. In some embodiments, the diameter of the endoscope fastener  2401  is measured as a maximum, a minimum, or an average interior width. In some embodiments, the diameter of the endoscope  2150  is measured as a maximum, a minimum, or an average exterior width. Alternatively, in some embodiments, the endoscope fastener  2401  has a cross sectional shape comprising a triangle, a square, a hexagon, or any other polygon. Alternatively, in some embodiments, the endoscope fastener  2401  comprises a clamp, an adhesive, a tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the first distal assembly  120  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more endoscope fasteners  2401 . 
     In some embodiments, per  FIGS. 20 and 28 , an angle between a needle axis  2160 A and a proximal axis of the endoscope  2160 B is about 5 degrees to about 85 degrees. In some embodiments, an angle between a center axis of the arcuate needle guide  2121 BA and a proximal axis of the endoscope  2160 B is adjustable within about 5 degrees to about 85 degrees. In some embodiments, the needle axis  2160 A is defined as an axis normal to a plane of symmetry of the arcuate needle  123  and coincident with a centerpoint of the radius of the arcuate needle  123 . In some embodiments, the proximal axis of the endoscope  2160 B is defined as the center axis of a distal portion of the endoscope  2150 . In some embodiments, the proximal axis of the endoscope  2160 B is defined as the center axis of the endoscope fastener  2140  of the first housing  2121 A. In some embodiments, the angle between a center axis of the arcuate needle guide  2160 A and a proximal axis of the endoscope  2160 B is defined as a maximum, a minimum, or an average angle. 
     As shown, in some embodiments, per  FIGS. 25 and 26 , the primary housing portion  2121 A comprises a pulley  2121 AA and the secondary housing portion  2121 B comprises a pulley hole  2121 BB. Alternatively, the secondary housing portion  2121 B comprises the pulley  2121 AA and the primary housing portion  2121 A comprises the pulley hole  2121 BB. As shown, the primary housing portion  2121 A comprises two pulleys  2121 AA. Alternatively, in some embodiments, at least one of the primary housing portion  2121 A or the secondary housing portion  2121 B comprises more than two pulleys  2121 AA. In some embodiments, the pulley  2121 AA supports and directs the cable  2130  as it travels through the first housing  2121 . In some embodiments, at least a portion of the pulley  2121 AA fits within the pulley hole  2121 BB. In some embodiments, at least a portion of the pulley  2121 AA press fits within the pulley hole  2121 BB. In some embodiments, at least a portion of the pulley  2121 AA fits within the pulley hole  2121 BB to align the primary housing portion  2121 A with respect to the secondary housing portion  2121 B. As shown, the pulley  2121 AA and the pulley hole  2121 BB have a cross sectional shape comprising a circle. Alternatively, in some embodiments, at least one of the pulley  2121 AA or the pulley hole  2121 BB have a cross sectional shape comprising a triangle, a square, a pentagon, a hexagon, or any other polygon. In some embodiments, the pulley  2121 AA rotates with respect to at least one of the primary housing portion  2121 A or the secondary housing portion  2121 B. In some embodiments, the pulley  2121 AA is fixed with respect to at least one of the primary housing portion  2121 A or the secondary housing portion  2121 B. In some embodiments, the pulley  2121 AA comprises a bearing, a rod, a curved surface, or any combination thereof. 
     As shown, the first housing  2121  comprises a distal sheath fastener that couples the sheath to the first housing  2121 . In some embodiments, at least one of the primary housing portion  2121 A or the secondary housing portion  2121 B further comprises a distal sheath fastener that couples a portion of the sheath to the first housing  2121 . In some embodiments, the distal sheath fastener fixes a portion of the sheath with respect to the first housing  2121 , such that the cable  130  is allowed to travel within the sheath upon rotation of the wheel. As shown, the exemplary distal sheath fastener comprises a clamp. In some embodiments, the distal sheath fastener comprises a plate and one or more sheath fastener screws that compress the cable sheath between the plate and the first housing  2121 . Alternatively in some embodiments, the distal sheath fastener comprises a screw, a tie, a tape, or any combination thereof. In some embodiments, the first housing  2121  comprises at least one distal sheath fastener for the first cable portion, and at least one distal sheath fastener for the second cable portion. In some embodiments, the first housing  2121  comprises a single distal sheath fastener for both the first cable portion and the second cable portion. In some embodiments, a portion of the cable sheath extends past the termination of the distal sheath fastener and into the first housing  2121 . In some embodiments, the first housing  2121  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more distal sheath fasteners. Alternatively, in some embodiments, the distal sheath fastener comprises a clamp, a tie, a band, a hook and loop fastener, an adhesive, or any combination thereof. 
     In some embodiments, the first housing  2121  has an arcuate needle guide  2121 BA. In some embodiments, at least one of the primary housing portion  2121 A or the secondary housing portion  2121 B has the arcuate needle guide  2121 BA. In some embodiments, the arcuate needle  2122  slides freely within the arcuate needle guide  2121 BA. In some embodiments, the arcuate needle guide  2121 BA constrains the arcuate needle  2122  to rotate within one degree of freedom. In some embodiments, the arcuate needle guide  2121 BA constrains the arcuate needle  2122  to rotate within at least one rotational degree of freedom. As seen, the exemplary arcuate needle guide  2121 BA encloses at least a portion of the arcuate needle  122 . In some embodiments, the arcuate needle guide  2121 BA has an interior width greater than a thickness  1510  of the arcuate needle  2122 . In some embodiments, at least one of the arcuate needle  2122  or the arcuate needle guide  2121 BA has a cross sectional shape comprising a circle, a square, a rectangle, or any other polygon. 
     In some embodiments, a gulf  2170  is formed between a first termination of the arcuate needle guide  2121 BA and a second opposing termination of the arcuate needle guide  2121 BA within the second proximal assembly  2120 . In some embodiments, a gulf  2170  is formed between a first pulley hole  2121 BB and a second opposing pulley hole  2121 BB within the first distal assembly second proximal assembly  2120 . In some embodiments, the gulf  2170  accepts a tissue for suturing by the arcuate needle  2122 . In some embodiments, the tissue is supported against the arcuate needle  2122  throughout the suturing process. In some embodiments, the second proximal assembly  2120  does not comprise an anchor exchange catheter. 
     Per  FIG. 26  in some embodiments, the arcuate needle  2122  has a notch  2122 A. In some embodiments, the arcuate needle  2122  has 2, 3, 4, 5, 6, 7, 8, 9, 10 or more notches  2122 A. In some embodiments, the notch  2122 A and the pawl  2124  engage when the cable  2130  translates in a first rotational direction  2600  about the first housing portion  2121 A, the second housing portion  2121 B, or both. In some embodiments, the notch  2122 A and the pawl  2124  disengage when the cable  2130  translates opposite the first rotational direction  2600 . In some embodiments, the notch  2130  is ramped in a direction opposite the first rotational direction  2600 . In some embodiments, the ramped the notch  2130  ensures that the second pawl portion  2124 B properly seats within the notch  2130 . In some embodiments, the notch  2130  is ramped at an angle of about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65 or more degrees, including increments therein. As shown, in some embodiments, the arcuate needle  2122  has two notches  2122 A, wherein each notch  2122 A is spaced about the arcuate needle  2122  at an angle of about 180 degrees. 
     In some embodiments, an outer diameter of the arcuate needle  2122  is about 7 mm to about 20 mm. In some embodiments, an outer diameter of the arcuate needle  2122  is at least about 7 mm. In some embodiments, an outer diameter of the arcuate needle  2122  is at most about 20 mm. In some embodiments, a thickness  1510  of the arcuate needle  2122  is about 0.5 mm to about 2 mm. In some embodiments, a thickness  1510  of the arcuate needle  2122  is at least about 0.5 mm. In some embodiments, a thickness  1510  of the arcuate needle  2122  is at most about 2 mm. In some embodiments, a ratio between an outer diameter and a thickness  1510  of the arcuate needle  2122  is about 3:1 to about 15:1. In some embodiments, a ratio between an outer diameter and the thickness  1510  of the arcuate needle  2122  is about 3:1, 4:1, 5:1, 6:1, 7:1, 8:1, 9:1, 10:1, 11:1, 12:1, 13:1, 14:1, or 15:1, including increments therein. In some embodiments, a ratio between an outer diameter and the thickness  1510  of the arcuate needle  2122  is at least about 3:1. In some embodiments, the outer diameter of the arcuate needle  2122  is measured as a maximum distance between two points on the surface of the arcuate needle  2122 . In some embodiments, the outer diameter of the arcuate needle  2122  is measured as a maximum outer diameter of the arcuate needle  2122 . In some embodiments, the width of the arcuate needle  2122  is measured as a thickness  1510  of the arcuate needle  2122 . In some embodiments, the width of the arcuate needle  2122  is measured as a thickness  1510  of the arcuate needle  2122  that is not within the pointed end, the suture end, or the notch  2122 A. In some embodiments, the width of the arcuate needle  2122  is measured as a maximum, a minimum or an average thickness  1510  of the arcuate needle  2122 . 
     In some embodiments, the notches  2122 A are spaced about the arcuate needle  2122  at an angle of about 10 degrees to about 180 degrees. In some embodiments, the notches  2122 A are spaced about the arcuate needle  2122  at an angle of about 10 degrees to about 20 degrees, about 10 degrees to about 30 degrees, about 10 degrees to about 40 degrees, about 10 degrees to about 50 degrees, about 10 degrees to about 60 degrees, about 10 degrees to about 80 degrees, about 10 degrees to about 100 degrees, about 10 degrees to about 120 degrees, about 10 degrees to about 140 degrees, about 10 degrees to about 160 degrees, about 10 degrees to about 180 degrees, about 20 degrees to about 30 degrees, about 20 degrees to about 40 degrees, about 20 degrees to about 50 degrees, about 20 degrees to about 60 degrees, about 20 degrees to about 80 degrees, about 20 degrees to about 100 degrees, about 20 degrees to about 120 degrees, about 20 degrees to about 140 degrees, about 20 degrees to about 160 degrees, about 20 degrees to about 180 degrees, about 30 degrees to about 40 degrees, about 30 degrees to about 50 degrees, about 30 degrees to about 60 degrees, about 30 degrees to about 80 degrees, about 30 degrees to about 100 degrees, about 30 degrees to about 120 degrees, about 30 degrees to about 140 degrees, about 30 degrees to about 160 degrees, about 30 degrees to about 180 degrees, about 40 degrees to about 50 degrees, about 40 degrees to about 60 degrees, about 40 degrees to about 80 degrees, about 40 degrees to about 100 degrees, about 40 degrees to about 120 degrees, about 40 degrees to about 140 degrees, about 40 degrees to about 160 degrees, about 40 degrees to about 180 degrees, about 50 degrees to about 60 degrees, about 50 degrees to about 80 degrees, about 50 degrees to about 100 degrees, about 50 degrees to about 120 degrees, about 50 degrees to about 140 degrees, about 50 degrees to about 160 degrees, about 50 degrees to about 180 degrees, about 60 degrees to about 80 degrees, about 60 degrees to about 100 degrees, about 60 degrees to about 120 degrees, about 60 degrees to about 140 degrees, about 60 degrees to about 160 degrees, about 60 degrees to about 180 degrees, about 80 degrees to about 100 degrees, about 80 degrees to about 120 degrees, about 80 degrees to about 140 degrees, about 80 degrees to about 160 degrees, about 80 degrees to about 180 degrees, about 100 degrees to about 120 degrees, about 100 degrees to about 140 degrees, about 100 degrees to about 160 degrees, about 100 degrees to about 180 degrees, about 120 degrees to about 140 degrees, about 120 degrees to about 160 degrees, about 120 degrees to about 180 degrees, about 140 degrees to about 160 degrees, about 140 degrees to about 180 degrees, or about 160 degrees to about 180 degrees. In some embodiments, the notches  2122 A are spaced about the arcuate needle  2122  at an angle of about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 80 degrees, about 100 degrees, about 120 degrees, about 140 degrees, about 160 degrees, or about 180 degrees. In some embodiments, the notches  2122 A are spaced about the arcuate needle  2122  at an angle of at least about 10 degrees, about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 80 degrees, about 100 degrees, about 120 degrees, about 140 degrees, or about 160 degrees. In some embodiments, the notches  2122 A are spaced about the arcuate needle  2122  at an angle of at most about 20 degrees, about 30 degrees, about 40 degrees, about 50 degrees, about 60 degrees, about 80 degrees, about 100 degrees, about 120 degrees, about 140 degrees, about 160 degrees, or about 180 degrees. 
     As shown in  FIGS. 23-25  (without the second housing portion  2121 B) the cable  2130  having a pawl  2124  enters the first housing  2121 , wrap around a first pulley  2121 AA, around the arcuate needle  2122 , around a second pulley  2121 AA, and passes out the first housing  2121 . As shown, the cable  2130  comprises a flattened portion  2130 A. In some embodiments, the flattened portion  2130 A increases stability of the cable  2130  as it wraps around the pulley  2121 AA. Further, in some embodiments, the pawl  2124  is located on the flattened portion of the cable  2130 A. In some embodiments, the flattened portion of the cable  2130 A is manufactured by mechanically flattening a portion of the cable  2130 A, or by adhering a flattened material to the cable  2130 . In some embodiments, the pawl  2124  is attached to the cable  2130 . In some embodiments, the pawl  2124  is coupled to the flattened portion of the cable  2130 A. 
     As shown per  FIG. 24 , the pawl  2124  comprises a first pawl portion  2124 A and a second pawl portion  2124 B, wherein the first pawl portion  2124 A is attached to the cable  2130  or the flattened a portion of the cable  2130 A, and wherein the second pawl portion  2124 B is not coupled to the cable  2130  and the flattened a portion of the cable  2130 A. In some embodiments, the pawl  2124  comprises a flexure. In some embodiments, the second pawl portion  2124 B is bent inwards towards the arcuate needle  2122 , at rest, and flexes about an intersection between the second pawl portion  2124 B and the first pawl portion  2124 A. In some embodiments, the second pawl portion  2124 B bends outward and away from the arcuate needle  2122  about an intersection between the second pawl portion  2124 B and the first pawl portion  2124 A when the arcuate needle  2122  contacts the second pawl portion  2124 B. As shown in  FIG. 26 , a terminal end of the second pawl portion  2124 B contacts and presses against the notch  2122 A of the arcuate needle  2122  to translate the arcuate needle  2122  in the first direction  2600 . Additionally or alternatively, the terminal end of the second pawl portion  2124 B contacts and presses against the suture end  2122 B of the arcuate needle  2122  to translate the arcuate needle  2122  in the first direction  2600 . Alternatively, in some embodiments, the pawl  2124  comprises a spring, a dual spring gate, a cushion, a piston, a rod, a pin, a tooth, or any combination thereof. In some embodiments, the pawl  2124  is engagement biased. 
       FIGS. 27A-F  show the exemplary second proximal assembly in a first, second, third, fourth, fifth, and sixth position, respectively. Per  FIG. 27A , suturing with the second proximal assembly comprises translating the cable  2130  such that the pawl  2124  travels to a terminal position of a second rotational direction opposite the first rotational direction  2600  within the secondary housing portion  2121 B (the position of the pawl  2124  shown in  FIG. 27A ) while the arcuate needle  2122  is fully enclosed within the secondary housing portion  2121 B. When the pawl  2124  and arcuate needle  2122  are in this position, the pawl  2124  automatically engages with a first notch within the arcuate needle  2122 , as shown. Thereafter, per  FIGS. 27B-C  the cable  2130  is translated such that the engaged arcuate needle  2122  and pawl  2124  travel in the first rotational direction  2600  to the terminal position of the pawl  2124  in the first rotational direction  2600  within the secondary housing portion  2121 B. The translation of the cable  2300  and pawl  2124  thereby moves a portion of the arcuate needle  2122  out of the secondary housing portion  2121 B to perform a first suture. Per  FIG. 27D , the cable  2130  is then be translated back to its terminal position in the second rotational direction within the secondary housing portion  2121 B to automatically engage a second notch within the arcuate needle  2122 . As seen in  FIGS. 27E-F , translation of the cable  2130  and the pawl  2124  in the first direction  2600  thereafter, returns the arcuate needle  2122  to its original position within the secondary housing portion  2121 B, whereas further translation of the cable  2130  and the pawl  2124  in the second direction returns the pawl to its terminal position of a second rotational direction within the secondary housing portion  2121 B per  FIG. 27A . Therefore, translation of the cable  2130  in the first direction  2600 , a second direction opposite the first direction  2600 , the first direction  2600 , and then the second direction completes a single suture, whereas repeating this process enables repetitive suturing. 
       FIG. 29  shows the arcuate needle  2122  within the arcuate needle guide  2121 BA of the secondary housing portion  2121 B. As shown per  FIG. 28 , the arcuate needle guide  2121 BA surrounds a portion of the arcuate needle  2122 . As seen therein, the arcuate needle guide  2121 BA surrounds about 280 degrees of the cross sectional circumference of the arcuate needle  2122 . Alternatively, in some embodiments, the arcuate needle guide  2121 BA surrounds about 100, 120, 140, 160, 180, 200, 220, 240, 260, 280, 300, 320 degrees or more of the cross sectional circumference of the arcuate needle  2122 , including increments therein. 
     In some embodiments, per  FIGS. 30A-C  the cable and the pawl comprise a single cable pawl  3000 A  3000 B comprising a flattened portion  2124 B having a tab  2124 A. As shown, the tab  2124 A comprises a flexure. Alternatively, in some embodiments, the  2124 A comprises an indent, a spring, or any combination thereof. In some embodiments, the tab  2124 A engages and disengages with the notch of the arcuate needle in the same way as the pawl. As shown, in some embodiments, the tab  2124 A has an expanded position where the tab  2124 A is at rest and projects at an angle from the flattened portion  2124 B. In some embodiments, the tab  2124 A projects at an angle from the flattened portion  2124 B of about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60 or more degrees including increments therein. As shown in  FIG. 30C , in some embodiments the tab  2124 A engages with the notch  2122 A of the arcuate needle  2122  when in the expanded position. In some embodiments, a distal tip of the tab  2124 A presses against the notch  2122 A of the arcuate needle  2122  when engaged. In some embodiments, the tab  2124 A has a collapsed position, where the tab  2124 A and the flattened portion  2124 B are generally coplanar. In some embodiments, in the collapsed position, the tab  2124 A is compressed against the flattened portion  2124 B by the arcuate needle  2122 . In some embodiments, the tab  2124 A disengages with the notch  2122 A of the arcuate needle  2122  when in the collapsed position. In some embodiments, the tab  2124 A is configured to be repeatedly compressed and released to disengage and engage with a notch of the arcuate needle, repeatedly. In some embodiments, per  FIG. 30A  the cable pawl  3000 A is formed within a sheet of material that is adhered to the cable  2130 A. Alternatively, in some embodiments, per  FIG. 30B , the cable pawl  3000 A is formed from a single continuous piece of material. 
     In some embodiments, at least one of the primary housing portion  2121 A, the pulley  2121 AA, the secondary housing portion  2121 B, the cable  2130 , the pawl  2124 , the tab  2124 A, or the single cable pawl  3000 A,  300 B is composed of metal, plastic, wood, carbon fiber, ceramic, or any combination thereof. 
     Tilting First Housing 
       FIGS. 31A-36  show illustrations of an exemplary tilting first housing  3120  comprising a primary tilting housing  3121 A, a secondary tilting housing  3121 B, and a tertiary tilting housing  3121 C. In some embodiments, the tilting first housing  3120  further comprises a fourth or more tilt housings. As shown the secondary tilting housing  3121 B and the tertiary tilting housing  3121 C are rigidly attached to each other, wherein the secondary tilting housing  3121 B and the tertiary tilting housing  3121 C rotate with respect to the primary tilt housing  3121 A about a tilt axis  3151 . In some embodiments, the secondary tilting housing  3121 B, and the tertiary tilting housing  3121 C are a single component. In some embodiments, the tilt axis  3151  is perpendicular to a proximal endoscope axis  3152 . In some embodiments, the tilt axis  3151  does not intersect the proximal endoscope axis  3152 . In some embodiments, the secondary tilting housing  3121 B and the tertiary tilting housing  3121 C are rigidly attached to each other by a fastener. In some embodiments, the fastener comprises a press fit fastener, a screw, a nut, a bolt, a hook and loop fastener, an adhesive, a weld, or any combination thereof. 
     As shown in  FIGS. 31A-B , the primary tilting housing  3121 A comprises an endoscope fastener  3120  that couples the primary tilting housing  3121 A to the endoscope  3140 . In some embodiments, the endoscope fastener  3120  removably couples the primary tilting housing  3121 A to the endoscope  3140 . As shown, the endoscope fastener  3120  comprises a screw, wherein the primary tilting housing  3121 A comprises a threaded feature or threaded insert that accepts the screw, such that the endoscope fastener  3120  and the threaded feature or threaded insert within the primary tilting housing  3121 A clamp around a distal end of the endoscope  3140  to secure the primary tilting housing  3121 A to the endoscope  3140 . As shown, the primary tilting housing  3121 A comprises a slot configured to separate the endoscope fastener  3120  from the remainder of the tilting housing  3121 A such that the tilting housing  3121 A can deform when the screw is tightened. Alternatively, in some embodiments, the primary tilting housing  3121 A does not comprise the slot. 
     As shown, in some embodiments, the endoscope fastener  3120  is rounded. In some embodiments, the endoscope  3140  has a proximal outer diameter of about 5 mm to about 16 mm. As such, in some embodiments, the endoscope fastener  3120  has an inner diameter of about 5 mm to about 16 mm. In some embodiments, the endoscope fastener  3120  has an inner diameter of at least about 5 mm. In some embodiments, the endoscope fastener  3120  has an inner diameter of at most about 16 mm. In some embodiments, the press fit endoscope fastener  3120 . In some embodiments, the press fit endoscope fastener  3120  has a diameter equal to or lesser than the diameter of the endoscope  3140 . In some embodiments, the endoscope fastener  3120  has a diameter equal to or greater than the diameter of the endoscope  3140 . In some embodiments, the endoscope fastener  3120  is tapered and has a first inner diameter and a second inner diameter, wherein the first inner diameter is distal to the second inner diameter. In some embodiments, the first inner diameter is greater than the second inner diameter. In some embodiments, the second inner diameter is greater than the first inner diameter. In some embodiments, the diameter of the endoscope fastener  3120  is measured as a maximum, a minimum, or an average interior width. In some embodiments, the diameter of the endoscope  3140  is measured as a maximum, a minimum, or an average exterior width. Alternatively, in some embodiments, the endoscope fastener  3120  has a cross sectional shape comprising a triangle, a square, a hexagon, or any other polygon. 
     Alternatively, in some embodiments, the endoscope fastener  3120  comprises a press fit fastener. In some embodiments, the press fit endoscope fastener  3120  attaches to the endoscope  3140  by firmly pressing the press fit endoscope fastener  3120  onto a distal end of the endoscope  3140 . In some embodiments, the press fit endoscope fastener  3120  attaches to the endoscope  3140  by firmly pressing and rotating the press fit endoscope fastener  3120  onto a distal end of the endoscope  3140 . In some embodiments, the press fit endoscope fastener  3120  detaches from the endoscope  3140  by firmly pulling the press fit endoscope fastener  3120  off the distal end of the endoscope  3140 . Alternatively, in some embodiments, the endoscope fastener  3120  comprises a clamp, an adhesive, a tape, a strap, a set screw, a hook and loop fastener, a magnet, or any combination thereof. In some embodiments, the first distal assembly  120  comprises 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more endoscope fasteners  3120 . 
     Further, as shown, at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C secure the cable sheath of the cable  3130 . In some embodiments, at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C comprise a hole that accepts the cable sheath of the cable  3130 . In some embodiments, the cable sheath of the cable  3130  is clamped between the secondary tilting housing  3121 B and the tertiary tilting housing  3121 C. Alternatively, in some embodiments, the cable sheath of the cable  3130  is coupled to at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C by an adhesive, a clamp, a tie, a hook and loop fastener, or any combination thereof. 
     Per  FIGS. 32-36 , the exemplary primary tilting housing  3121 A comprises a primary tilt mechanism  3121 AA and the exemplary secondary tilting housing  3121 B comprises a secondary tilt mechanism  3121 BA, wherein the primary tilt mechanism  3121 AA and the secondary tilt mechanism  3121 BA couple the primary tilting housing  3121 A and the secondary tilting housing  3121 B. In some embodiments, the primary tilt mechanism  3121 AA and the secondary tilt mechanism  3121 BA enable at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C to rotate with respect to the primary tilting housing  3121 A. In some embodiments, the primary tilt mechanism  3121 AA and the secondary tilt mechanism  3121 BA enable at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C to rotate with respect to the primary tilting housing  3121 A about the tilt axis  3151 . In some embodiments, the primary tilt mechanism  3121 AA and the secondary tilt mechanism  3121 BA enable at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C to rotate with respect to the primary tilting housing  3121 A about 300 degrees about the tilt axis  3151 . In some embodiments, the primary tilt mechanism  3121 AA and the secondary tilt mechanism  3121 BA enable at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C to rotate with respect to the primary tilting housing  3121 A such that an angle between an arcuate needle axis  3153  and the proximal endoscope axis  3152  increases from about 0 degrees (where arcuate needle axis  3153  and the proximal endoscope axis  3152  are parallel) to about 300 degrees. In some embodiments, the primary tilt mechanism  3121 AA and the secondary tilt mechanism  3121 BA enable at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C to rotate with respect to the primary tilting housing  3121 A such that an angle between an arcuate needle axis  3153  and the proximal endoscope axis  3152  increases continuously from about 0 degrees to about 300 degrees. In some embodiments, the primary tilt mechanism  3121 AA and the secondary tilt mechanism  3121 BA enable at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C to rotate with respect to the primary tilting housing  3121 A such that an angle between an arcuate needle axis  3153  and the proximal endoscope axis  3152  increases in discrete increments from about 0 degrees to about 300 degrees. In some embodiments, the primary tilt mechanism  3121 AA and the secondary tilt mechanism  3121 BA enable at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C to rotate with respect to the primary tilting housing  3121 A such that an angle between an arcuate needle axis  3153  and the proximal endoscope axis  3152  increases in discrete increments of about 1, 2, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60 or more degrees. In some embodiments, the primary tilt mechanism  3121 AA and the secondary tilt mechanism  3121 BA enable at least one of the secondary tilting housing  3121 B or the tertiary tilting housing  3121 C to rotate with respect to the primary tilting housing  3121 A such that an angle between an arcuate needle axis  3153  and the proximal endoscope axis  3152  increases in discrete increments of at least about 1 degree. In some embodiments, the arcuate needle axis  3153  and the proximal endoscope axis  3152  are coincident. In some embodiments, the arcuate needle axis  3153  and the proximal endoscope axis  3152  are not coincident. 
     As seen per  FIGS. 35 and 36 , in one example, the primary tilt mechanism  3121 AA comprises a clamp having a knurled interior surface and the secondary tilt mechanism  3121 BA comprises a knob having a knurled exterior surface. As shown, the secondary tilt mechanism  3121 BA comprises 19 knurls and valleys, such that engagement of one knurl of the primary tilt mechanism  3121 AA with one valley of the secondary tilt mechanism  3121 BA defines a specific angle between the arcuate needle axis  3153  and the proximal endoscope axis  3152 . As shown, the primary tilt mechanism  3121 AA comprises 13 knurls and valleys, such that engagement of one knurl of the secondary tilt mechanism  3121 BA with one valley of the primary tilt mechanism  3121 AA defines a specific angle between the arcuate needle axis  3153  and the proximal endoscope axis  3152 . Alternatively, in some embodiments, at least one of the primary tilt mechanism  3121 AA or the secondary tilt mechanism  3121 BA comprises 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25 or more knurls and valleys. Alternatively, in some embodiments, the primary tilt mechanism  3121 AA does not comprise the primary tilt housing  3121 A. Alternatively, in some embodiments, the secondary tilt housing  3121 B does not comprise the secondary tilt mechanism  3121 BA. 
     In some embodiments, the clamp of the primary tilt mechanism  3121 AA is tightened by fastening a screw  3151  to compress the clamp and prevent rotation of the secondary tilting housing  3121 B with respect to the primary tilt housing  3121 A about the tilt axis  3151 . In some embodiments, the clamp of the primary tilt mechanism  3121 AA is released by unscrewing a screw  3151  to decompress the clamp and allow rotation of the secondary tilting housing  3121 B with respect to the primary tilt housing  3121 A about the tilt axis  3151 . In some embodiments, the clamp of the primary tilt mechanism  3121 AA is tightened during surgical use. Alternatively, in some embodiments, the rotation between the primary tilting housing  3121 A and the secondary tilting housing  3121 B is achieved through a clamp, a pin, a screw, a knob, a tie, a band, a magnet, or any combination thereof. 
     As seen the secondary tilting housing  3121 B comprises a gap  3601  between the secondary tilt mechanism  3121 BA and the remainder of the secondary tilting housing  3121 B. In some embodiments, the gap  3601  accepts a portion of the primary tilting housing  3121 A as the secondary tilting housing  3121 B rotates about the primary tilting housing  3121 A. In some embodiments, a width of the gap  3601  is greater than a thickness of the primary tilt mechanism  3121 AA. 
     Terms and Definitions 
     Unless otherwise defined, all technical terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this disclosure belongs. 
     As used herein, the singular forms “a,” “an,” and “the” include plural references unless the context clearly dictates otherwise. Any reference to “or” herein is intended to encompass “and/or” unless otherwise stated. 
     As used herein, the term “about” refers to an amount that is near the stated amount by 10%, 5%, or 1%, including increments therein. 
     As used herein, the term “about” in reference to a percentage refers to an amount that is greater or less the stated percentage by 10%, 5%, or 1%, including increments therein. 
     As used herein, the phrases “at least one”, “one or more”, and “and/or” are open-ended expressions that are both conjunctive and disjunctive in operation. For example, each of the expressions “at least one of A, B and C”, “at least one of A, B, or C”, “one or more of A, B, and C”, “one or more of A, B, or C” and “A, B, and/or C” means A alone, B alone, C alone, A and B together, A and C together, B and C together, or A, B and C together. 
     As used herein, the term “arcuate” refers to an arc of a circle or a portion of a circle.