WO1997047245A1

WO1997047245A1 - Ligating instrument

Info

Publication number: WO1997047245A1
Application number: PCT/US1997/009499
Authority: WO
Inventors: Steven Ek; George J. Sikora
Original assignee: Smith & Nephew, Inc.
Priority date: 1996-06-12
Filing date: 1997-06-02
Publication date: 1997-12-18
Also published as: ZA975157B; AU3153297A

Abstract

A ligating instrument has a pair of jaws which are offset from the axis of the instrument. The jaws are mounted at the distal end of a shaft, extend from the shaft to one side of the longitudinal axis of the shaft, and are positioned to hold a ligating clip therebetween. An actuator is disposed at a proximal end of the shaft and is linked to the jaws to produce relative movement between the jaws and compress the clip.

Description

LIGATING INSTRUMENT

This invention relates to ligating instruments for applying tissue fasteners, such as ligator clips, to tissue, particularly in endoscopic surgery.

A typical ligating instrument includes a pair of pivotal jaws which extend distally from the tip of an elongated shaft, and a movable handle disposed at the proximal end of the shaft and linked to the jaws through the shaft. In use, a tissue fastener such as a ligator clip (which is, e.g., generally U-shaped) is inserted between the jaws, the shaft is inserted into the body endoscopically, and the tip is maneuvered to position the jaws (and hence the clip legs) over tissue which is to be ligated. Actuating the handle causes the jaws to pivot toward each other and squeeze the legs of the clip together to clamp the tissue.

In accordance therefore with the present invention, there is provided a surgical instrument comprising a shaft having proximal and distal ends disposed along a longitudinal axis, said shaft having mounted at a distal end thereof a pair of jaws offset from said axis and actuator means disposed at a proximal end of said shaft, said actuator means being operatively linked to said jaws to produce relative movement between said jaws.

This invention features a surgical instrument having jaws which hold and compress a tissue fastener and which are offset from the longitudinal axis of the instrument.

In one general aspect of the invention, the jaws are mounted at the distal end of a shaft and extend from the shaft to one side of the longitudinal axis. An actuator is disposed at a proximal end of the shaft and is linked to the jaws to produce relative movement between the jaws and compress the tissue fastener.

Advantages of the invention include one or more of the following. Because of the offset positioning of the jaws, the jaws hold and compress the fastener - such as a ligating clip -- at an angle to the shaft, rather than in-line with (i.e., along the axis of) the shaft. This allows the user to fully visualize all aspects of the procedure - inserting the jaws and ligating clip over the tissue, compressing the clip, and releasing the compressed clip and ligated tissue from the jaws -- with a far more accurate perspective than with in-line instruments.

That is, the tips of the offset jaws are not only fully visible, but are also seen within a frame of reference provided by the distal end of the instrument. The user thus can accurately access the positions of the jaws with respect to the tissue to be ligated (e.g., a blood vessel or duct) as well as adjacent body structures (e.g., adjacent or parallel vessels or ducts, or organs) that are to be avoided.

The visual frame of reference provided by the invention is particularly important in endoscopic procedures, in which the user's direction of view approaches the longitudinal axis of the instrument. With the invention, the user can ensure that the ligating clip is fully inserted over the vessel (thereby avoiding incomplete ligation) and avoid accidentally ligating adjacent organs far more easily than with an in-line instrument, in which the jaws extend away from the distal end of the instrument (and thus away from the user along the direction of view). Preferred embodiments may include one or more of the following features.

In one embodiment, the jaws are oriented perpendicularly to the longitudinal axis. In other implementations, the jaws are oriented at an acute or obtuse angle to the axis. Preferably, the relative movement between the jaws is in the axial direction. A first one of the jaws is rigidly mounted to the shaft, and the second jaw is slidably mounted to the shaft. A member links the second jaw to the actuator for relative axial movement with respect to the first jaw.

The member is configured to bias the second jaw axially toward the first jaw. A resilient section of the member is compressible by a ligating clip positioned between the jaws. Alternatively, a resilient body disposed between the member and the shaft provides the compression.

The axial movement of the member (and hence the range of motion of the second jaw) may be limited by one or both of the following "stops." One of the stops may include a pin connected to the shaft and disposed in an axially elongated slot in the member. The other stop includes a protrusion on the member disposed in an axially elongated aperture in the shaft. The axial motion of the member is limited by the pin/protrusion engaging the ends of the slot/aperture. This helps avoid applying excessive force to the jaws, which might otherwise damage the jaws, the ligating clip, or the tissue being ligated.

Each jaw may include a grasping surface that engages a portion of a ligating clip. The grasping surfaces may be parallel to each other, or not, and may include notches which receive the corresponding portion of the clip. In addition, a support may be positioned between the jaws and the longitudinal axis of the instrument to engage the ligating clip in response to transversely- applied loads. These features (together with the above-discussed biasing of the jaws) help ensure that the jaws reliably hold the clip between them while the instrument is being manipulated in the body and until the clip is positioned over the tissue, "fired" (i.e., compressed around the tissue), and released.

In one embodiment, the jaws are mounted for rotation relative to the longitudinal axis of the instrument. This feature further facilitates the task of positioning the jaws around the tissue to be ligated. The actuator may include a handle which is movable to close and open the jaws; a lock may be provide to selectively prevent the handle from being moved. This feature further helps avoid accidental compression of the clip.

In another general aspect of the invention, the jaws are mounted on the shaft for relative axial movement in response to actuation by the actuator.

Among other advantages, the axial movement of the jaws allows the user to apply the clip compressing forces directly, rather than through a pivot pin or the like. In addition to simplifying construction, this direct transmission of force may increase the user's sensitivity and tactile feedback to resistance to jaw movement that might be caused the jaws inadvertently engaging structures other than the tissue being ligated. This is particularly important in when ligating pulmonary arteries and veins, which are thin-walled structures and thus easily damaged. The invention allows the user to treat these delicate structures carefully. 5

Preferred embodiments may include one or more of the following features discussed above. In addition, the jaws may extend from the shaft to one side of the longitudinal axis of the instrument. The jaws may be perpendicular to the axis, or may be oriented at an acute or obtuse angle to the axis.

The instrument is easy to use. A ligating clip is installed between the jaws, and the instrument is then inserted into the body and manipulated, to position the jaws about the tissue to be ligated. The actuator is then used to move the jaws together and compress the ligating clip around the tissue.

Preferably, the instrument is used endoscopically, but the instrument can be inserted into the body via an open incision. In either case, the offset nature of the jaws facilitates passing the instrument through the endoscope, a cannula, or the open incision without prematurely dislodging the clip or inadvertently closing the jaws and compressing the clip. In particular, the rigidly mounted jaw precedes the movable jaws during insertion to shield the clip and the movable jaw. In addition, the rigidly mounted jaw has a blunt distal surface, a feature particularly useful in open-incision applications to avoid the jaws from becoming snagged on the sides of the incision, as well as allowing the instrument to be used to separate and dissect the tissue to be ligated from adjacent structures. This avoids the need to subsequently introduce a separate dissecting instrument to separate the ligated tissue from the adjacent structures.

Other features and advantages will become apparent from the following description, and from the claims. Fig. 1 shows a ligating instrument having jaws which are offset perpendicularly from the axis of the instrument.

Figs. 2 and 3 show the operative tip of the instrument of Fig. 1 with the jaws in the open position and a ligating clip between the jaws.

Fig. 4 shows the operative tip of the instrument of Fig. 1 with the jaws in the closed position and the ligating clip compressed.

Fig. 5 shows a portion of a mechanism for applying a compressive force to help retain the clip between the jaws. Fig. 6 illustrates the instrument of Fig. 1 in use during endoscopic surgery.

Fig. 7 shows a ligating instrument the jaws of which are offset at a 45° angle to the axis of the instrument.

Fig. 8 shows a ligating instrument with a mechanism for rotating the offset jaws with respect to the axis of the instrument.

Fig. 9 illustrates an alternative jaw configuration.

Fig. 10 shows an alternative mechanism for applying a compressive force to help retain the clip between the jaws.

Referring to Fig. 1, ligating instrument 10 includes an operative tip 12 comprising a pair of jaws 14, 16 mounted at the distal end of an elongated shaft 18. Shaft 18 extends along a longitudinal axis 20 between a proximal handle assembly 22 and operative tip 12. Jaws 14, 16 are offset from axis 20 rather than being in-line with axis 20. In particular, jaws 14, 16 extend from shaft 18 perpendicularly to one side of axis 20 (upwardly in Fig. 1), rather than to opposite sides of the longitudinal axis as with in-line instruments. Accordingly, the grasping surface 44 (Fig. 2) of each jaw 14, 16 - that is, the surface that engages the ligating clip -- is generally parallel to an axis 24 oriented 90° to longitudinal axis 20. Referring also to Figs. 2 and 3, jaw 14 is stationary and is rigidly mounted to the distal end of a shaft 18 (e.g., jaw 14 is formed as an integral, one-piece extension of shaft 18). The distal surface 13 of operative tip 12 and jaw 14 is rounded and thus blunt. The proximal end of shaft 18 is rigidly secured to handle assembly 22 by a set screw 17.

Shaft 18 is metal, such as stainless steel. For most of its length, shaft 18 is round. At operative tip 12, however, shaft 18 is milled to form a pair of tapered surfaces 19 that meet a pair of flat surfaces 21 of jaw 14 (only one of each tapered surface 19 and flat surface 21 is shown in Fig. 2). The tapering of shaft 18 reduces the size of operative tip 12 and further enhances the visibility of jaws 14, 16 during use.

Jaw 16 is mounted at the distal end 26a of a stainless steel rod 26 (e.g., as an integral, one-piece extension of rod 26) which is received within a channel 28 extending along the length of shaft 18. As with jaw 14, the surfaces 23 (only one of which is shown in Fig. 2) of jaw 16 which are parallel to longitudinal axis 20 are flat to increase the visibility of the space between jaws 14, 16. The sides of channel 28, and hence those of rod 26, are flat and are parallel to longitudinal axis 20. The distal end 28a of slot 28 is curved and receives a similarly-shaped distal end 26a of rod 26 when jaws 14, 16 are closed (Fig. 4).

Rod 26 links jaw 16 to an actuator handle 30 pivotally mounted by a pivot pin 31a on a handle assembly 22. In particular, the proximal end 26b of rod 26 is pivotally mounted by a pivot pin 31 b to handle 30 such that when actuating handle 30 is squeezed by the user (in the direction of arrow 36), handle 30 slides rod 26 axially within channel 28 and axially moves jaw 16 toward jaw 14, closing the jaws (Fig. 4).

Jaws 14, 16 and shaft 18 are sized for insertion into the body through a portal, such as a cannula or an open incision. For example, shaft 18 is 3.5 mm in diameter, and jaws 14, 16 extend 6.5 mm to one side of longitudinal axis 20. As a result, the maximum width of operative tip 12 (i.e., the span between the tips 15 of jaws 14, 16 and the opposite surface of shaft 18 is 8.2 mm.

Rod 26 is secured to shaft 18 at operative tip 12 by a pin 40 in shaft 18 that extends through an axially elongated slot 42 in rod 26. As explained further below, pin 40 also limits the axial movement of rod 26 (and hence of jaw 16) in response to the actuation of handle 30. This helps prevent jaws 14, 16 from applying excessive force to, and possibly damaging, the ligating clip or the ligated vessel.

Ligating instrument 10 can be used with a tissue fastener such as a ligating clip 50 of any suitable material. Examples of suitable clip material include metal (such as titanium) or plastic. Ligating instrument 10 includes several features which assist in retaining clip 50 between jaws 14, 16 while instrument 10 is being manipulated to, e.g., position clip 50 over a vessel or other tissue to be ligated. For example, the grasping surfaces 44 of jaws 14, 16 are provided with notches 46 which extend along jaws 14, 16 away from shaft 18 to closed ends 45 near the tips 15 of jaws 14, 16. (Only the notch 46 of jaw 16 can be seen in Fig. 2.) Each notch 46 receives and captures a leg 52 of ligating clip 50, which in this example is generally U-shaped, against a surface 47 at the base of notch 46. In this example, surfaces 47 of jaws 14, 16 are parallel to each other.

Referring to Figs. 1 and 5, additional security for retaining clip 50 between jaws 14, 16 is provided by a resilient section 60 of rod 26 located near proximal end 26b. Resilient section 60 is formed by providing a series of (e.g., five) oppositely-directed, U-shaped notches 62 in rod 26. Notches 62 define an undulating series of strips 64 which integrally interconnect proximal end 26b to the remainder of rod 26. Proximally of resilient section 60, a tab 66 on rod 26 extends through an elongated opening 68 in shaft 18. When jaw 16 is moved to its open position (Fig. 3) by handle 30, tab 66 engages the proximal end 70 of opening 68. Thereafter, when the user inserts clip 50 between jaws 14, 16, clip 50 urges rod 26 proximally, thereby compressing resilient section 60. As a result, rod 26 applies a slight compressive force against clip 50 between jaws 14, 16 to assist in holding clip 50 in place.

As also shown in Fig. 5, a notch 27 is formed in the underside of rod proximal end 26b, and a shallow depression 17a is disposed in shaft 18 proximally of opening 68. Notch 27 receives handle pivot pin 31b, and depression 17a accommodates set screw 17 (Fig. 1) to secure shaft 18 and rod 26 to handle assembly 22.

Referring to Figs. 3 and 4, instrument 10 is operated to compress clip 50 as follows. First, clip 50 is loaded by inserting clip 50 between the open tips 15 of jaws 14, 16 with a loading device (not shown). The loading device moves jaw 16 slightly proximally to provide sufficient room between jaws 14, 16 to receive clip 50, and as a result compresses resilient section 60. Closed ends 45 of notches 46 engage the tips of clip legs 52 to retain clip 50 between jaws 14, 16 as the loading device is removed. Thereafter, the compressive force applied by resilient section 60 securely retains clip 50 seated within notches 46 as instrument 10 is manipulated.

Clip 50 is compressed simply by squeezing handle 30 in the direction of arrow 36 (Fig. 1). The resulting axial forces applied to rod 26 within channel 28 are directly applied to jaw 16, causing jaw 16 to slide distally toward jaw 14. Resilient section 60 is substantially more axially stiff than clip 50, and thus the motion of handle 30 is transferred to jaw 16 with little "take-up" by resilient section 60.

The compressive forces applied between jaws 14, 16 bend ligator clip 50 at the apex 54 of the "U" shape and urges clip legs 52 together (Fig. 4). When clip 50 first begins to bend at apex 54, the tips of legs bend toward each other. The remaining portions of legs 52 remain within notches 46, however, so that clip 50 does not become dislodged from between jaws 14, 16 prematurely.

The range of motion of jaw 16 (and hence the compression of clip 50) is limited by several mechanisms. The primary motion stop is provided by the engagement of the proximal end 43 of slot 42 against pin 40 (Fig. 4). A secondary stop is provided by tab 66 (Fig. 5) near the proximal end of rod 26. More specifically, as rod 26 reaches the end of its distal travel range (as limited by pin 40 and slot 42), tab 66 engages the distal end 72 of shaft opening 68. As a result, further pressure applied by the user to handle 30 is prevented from being transferred to jaws 14, 16 and ligating clip 50.

The fully compressed clip 50 is released by releasing handle

30. The resiliency of section 60 may apply a slight proximal bias to jaw 16, and thus causes jaw 16 to slide proximally away from jaw 14 when handle 30 is released. The user may fully open jaws 14, 16 simply by manually opening handle 30 (i.e., by moving handle 30 in the opposite direction of arrow 36).

In use during surgery, instrument 10 (loaded with a clip 50 as described above) is inserted into a patient's body through, for example, a cannula or an open incision. The offset configuration of jaws 14, 16 helps protect clip 50 from being dislodged while also avoiding accidental compression of clip 50 as the user passes instrument 10 into the body. For example, stationary jaw 14 precedes movable jaw 16, and thus helps prevent jaw 16 from "catching" on, e.g., the loose tissue or the sides of the incision (which could open jaw 16 and dislodge clip 50). Also, even if jaw 14 were to become caught, because jaw 14 is stationary there is little risk of accidentally closing jaws 14, 16 and compressing clip 60.

Fig. 6 shows the image of the surgical site and instrument 10 provided, e.g., by an endoscope on a display device (not shown). Using the displayed image as a guide, the user manipulates instrument 10 to position jaws 14, 16 as desired. For example, blunt end 13 may be used to probe and push aside loose tissue to more clearly expose a vessel 80 to be ligated. In addition, the user may choose to use side-facing jaws 14, 16 as a hook to capture vessel 80 and separate vessel 80 from adjacent structures 82. Thus, instrument 10 can be used to dissect, as well as ligate.

With vessel 80 ready for ligation, the user positions jaws 14, 16 around (i.e., on either side of) vessel 80 so that vessel 80 lies between clip legs 52 (only one of which is shown). The side-facing nature of jaws 14, 16 not only affords the user with an unobstructed view of both jaws 14, 16, but also gives the user a clear sense of the jaw positions with respect to vessel 80. As a result, the user can determine when jaws 14, 16 are fully inserted around vessel 80 more easily than if jaws 14, 16 extended in-line from the distal tip of shaft 18. Accordingly, the user can ensure that jaws 14, 16 are accurately and fully placed around vessel 80 so that ligation of adjacent structures 82 and incomplete ligation of vessel 80 are avoided. The tapered configuration of operative tip 12 also increases the visibility of jaws 14, 16.

Once jaws 14, 16 are positioned over vessel 80 as desired, the user applies clip 50 by squeezing actuating handle 30 in the direction of arrow 36, as described above. Jaws 14, 16 compress the legs of clip 50 together, thereby clamping vessel 80 securely shut. The user then opens jaws 14, 16 with handle 30, withdraws jaws 14, 16 from clip 50, and removes instrument 10 through the endoscope working channel. Instrument 10 can then be reloaded with another clip 50 to perform another ligation.

Other embodiments are within the scope of the following claims.

For example, the offset jaws may face in directions other than those shown. That is, although upwardly-facing jaws 14, 16 (relative to handle assembly 22) are illustrated in the figures, the jaws may be oriented, e.g., downwardly, to the right or left, or otherwise.

The jaws can be offset at other angles. Referring to Fig. 7, jaws 114, 116 of instrument 100 are oriented at an acute angle to the longitudinal axis 120 of instrument 100. In the implementation shown, jaws 114, 116 are arranged at a 45° angle to axis 120, but they may be positioned at any other suitable angle. For example, jaws 114, 116 may be oriented retrograde to the distal tip of the shaft (i.e., generally facing the handle assembly at an obtuse angle to the shaft axis).

Jaw 114 is stationary and is formed as an integral, one piece extension of the distal end of a shaft 118 that extends from the handle assembly (not shown). Shaft 118 is flattened 119 at operative tip 112, as well as proximally of tip 112, to enhance the visualization of jaws 114, 116.

Jaw 116 is an integral extension of a rod 126 which slides within a slot 128 in shaft 118 to open and close jaw 114 with respect to jaw 116. The grasping surfaces 130 of jaws 114, 116 are substantially identical to those of instrument 10. A pair of arms 132 integrally formed on shaft 118 extend at a 45° angle to axis 120 at the distal end of channel 128 on either side of movable jaw 116. Arms 132 can be omitted, if desired, to fully expose jaw 116 (see Fig. 1).

The base surfaces 47 of notches 46 (Fig. 3) can be nonparallel to each other. For example, surfaces 47 can be slightly canted toward each other (e.g., by a few degrees) so that surfaces 47 are closer together near shaft 18 than they are near tips 15. This inward cant of notch bases 47 may additionally assist in capturing the ligating clip 50 as the loading device is being withdrawn, and according may further avoid the clip becoming accidentally dislodged.

In any of the embodiments discussed herein, the jaws can be rotatable with respect to the axis of the instrument by providing suitable rotary joint. For example, referring to Fig. 8, ligating 14 instrument 150 includes a rotary joint 152 between the proximal end of jaw actuating rod 154 and the pivotal handle 156 of the handle assembly. Rotary joint 152 includes a ball 158 on the proximal end of rod 154 which is seated within a corresponding socket 160 on handle 156.

Rod 154 slides within a channel (not shown) in shaft 162 in response to the actuation of handle 156. Offset jaws 164, 166 are mounted at the distal ends of shaft 162 and rod 154, respectively, as discussed above. Jaws 164, 166 are rotated using a knob 170 that is rotatably mounted to the handle assembly and attached to shaft 162. Rotating knob 170 either clockwise (CW) or counterclockwise (CCW) with respect to instrument axis 172 causes a corresponding rotation of jaws 164, 166. Ball 158 spins in socket 160 allows rod 154 to rotate with shaft 162 without interfering with the operative connection with handle 156.

In addition, any suitable trigger lock 151 can be provided on the handle assembly to guard against accidentally compressing the ligating clip.

Referring to Fig. 9, the operative tip 12 of instrument 10 (or any of the other embodiments discussed herein) can be modified to provide transverse support 180 for ligating clip 50 positioned between jaws 14', 16'. Support 180 is an integral, distal extension of rod 26' and movable jaw 16', and is received within a corresponding tunnel 182 formed in shaft 18' adjacent to stationary jaw 14'. As shown, support 180 blocks clip 50 from being ejected from jaws 14', 16' into the space 184 between rod distal end 26' and shaft distal end 28a' in response to transversely-applied loads (e.g., forces applied along axis 24, Fig. 1). When jaws 14', 16' are closed, support 180 slides into tunnel 182. This embodiment is particularly useful if the instrument is to be used to probe tissue and hook vessels using jaws 14', 16' (i.e., as a dissector).

Approaches other than resilient section 60 (Fig. 5) may be taken to bias the jaws together and assist in holding a ligating clip between them. For example, referring to Fig. 10, a resilient silicone O-ring 190 is secured in a groove 192 formed around shaft 18" at the proximal end 70' of opening 68'. O-ring 190 is nominally 0.77mm (0.030 inches) thick, but is compressible to a thickness of approximately 0.38mm (0.015 inches) when tab 66' (on rod 26") is urged proximally by the presence of a ligating clip between the jaws of the instrument. The resiliency of O-ring 190 urges the movable jaw axially toward the stationary jaw to help retain the clip between the jaws.

The ligating instruments may be curved rather than straight. The actuating rod must be sufficiently flexible to operate the movable jaw through the curve.

In other implementations, the ligating instrument can include a magazine of clips to allow the user to perform several ligating procedures without having to withdraw the instrument from the body for repeated loading. The retrograde jaw orientation discussed above may be particularly useful in this embodiment, as it may facilitate loading the clips from the magazine.

Other stops may be provided to limit the range of motion of the movable jaw. Indeed, the jaws themselves can provide the motion stop. Although flat-sided shafts, rods, and channels have been illustrated, other configurations (e.g., cylindrical) may be used instead.

The ligating instruments may be used in open, rather than endoscopic surgery. As discussed above, the offset nature of the jaws helps avoid premature clip compression and accidental dislodgement while the instrument is being inserted through an incision. In addition, blunt distal end 13 (Fig. 1) avoids jaw 14 becoming snagged on loose tissue or the sides of the incision and allows the instrument to be used as a probe to separate the tissue to be ligated from other structures.

The ligating instruments, if made sufficiently small, may be introduced into the body through the working channel of an endoscope.

Claims

1. A surgical instrument comprising a shaft having proximal and distal ends disposed along a longitudinal axis, said shaft having mounted at a distal end thereof a pair of jaws offset from said axis and actuator means disposed at a proximal end of said shaft, said actuator means being operatively linked to said jaws to produce relative movement between said jaws.

2. The instrument of claim 1 wherein said jaws are oriented perpendicularly to said axis.

3. The instrument of claim 1 wherein said jaws are oriented at an acute angle with respect to said axis.

4. The instrument of claim 1 wherein said jaws are oriented at an obtuse angle with respect to said axis.

5. The instrument of any preceding claim wherein said jaws are mounted for relative axial movement therebetween in response to said actuator means.

6. The instrument of claim 5 wherein a first one of said jaws is rigidly mounted to said shaft and a second one of said jaws is slidably mounted to said shaft and linked to said actuator means for axial movement with respect to said first jaw.

7. The instrument of claim 6 further comprising a member linking said second jaw to said actuator means, said member being disposed for axial movement in a channel in said shaft. 8. The instrument of claim 7 wherein said member is configured to bias said second jaw axially toward said first jaw.

9. The instrument of claim 8 wherein said member includes a resilient section which is compressible by a tissue fastener held between said jaws.

10. The instrument of claim 8 further comprising a resilient body disposed between said member and said shaft and compressible by said tissue fastener held between said jaws.

11. The instrument of claim 7 further comprising a pin connected to said shaft and disposed in an axially elongated slot in said member, said pin engaging an end of said slot to limit the axial movement of said member.

12. The instrument of claim 11 further comprising a protrusion on said shaft disposed in an axially elongated aperture in said member, said protrusion engaging an end of said aperture to further limit the axial movement of said member.

13. The instrument of any preceding claim wherein said jaws include grasping surfaces configured to engage portions of a tissue fastener.

14. The instrument of claim 13 wherein said grasping surfaces each includes a notch configured to receive a corresponding portion of the tissue fastener. 16. The instrument of claim 13 further comprising a support positioned between said jaws and said axis to engage the tissue fastener in response to transversely applied loads.

17. The instrument of any preceding claim wherein said jaws are mounted for rotation relative to said longitudinal axis.

18. The instrument of any preceding claim wherein said actuator means includes a handle which is movable to produce said relative movement between said jaws.

19. The instrument of claim 18 further comprising a lock for selectively preventing movement of said handle.

20. The instrument of any preceding claim together with a tissue fastener.

21. The instrument of claim 20 wherein said tissue fastener is a ligating clip.

22. A method of applying a fastener to tissue in a body, comprising providing a surgical instrument that includes a shaft disposed along a longitudinal axis, a pair of jaws mounted at a distal end of said shaft and extending from said shaft to one side of said axis, and an actuator disposed at a proximal end of said shaft and linked to said jaws, installing the fastener between said jaws, 20 installing the fastener between said jaws, inserting said instrument into the body and manipulating said instrument so that said jaws are positioned about the tissue, and using said actuator to move said jaws together and compress the fastener against the tissue.

23. The method of claim 22 wherein said fastener is a ligating clip.

24. The method of claim 22 further comprising performing said inserting and using steps endoscopically.

25. The instrument substantially as described herein with reference to, and illustrated by, the accompanying drawings.