DE19711288A1 - Surgical clamp with two arms for holding tissue e.g. blood vessels - Google Patents

Abstract

Both arms (11,12) are curved away from a centre line, where the ends of the arms are ground to a sharp point for better penetration of the tissue. Both arms are closed independently of each other in an applicator. The clamp is asymmetric in shape , the arms being of different lengths and having different curvatures. A cross sectional bevel (15) is located at the start of each arm so as to define the bending position of the arm on closing. A further additional cross sectional bevel (27) is provided in one or both of the arms whose cross section reduces in a distal direction, so that when the clamp is pressed in accordance with the first bevels, the corresponding arms are bent inwards to close tightly.

Description

For pinching vessels and holding wounds together, in today Medicine uses many different forms of brackets and clips that ent are designed according to their application. So z. B. closing wounds, in particular on the skin with clips, which the tissue in Gently close together and press the wound edges together z. B. DE 32 04 532. Special clips have also been developed for clamping vessels which have a V-shaped basic shape and then with the help of an applicator be pressed together over the vessel and keep it closed e.g. B. EP 0510826 B1. There are special clamps for the anastomosis on the intestine, which are hen arranged in an applicator and after appropriate preparation tion of the bowel ends can be closed with a tool in the applicator, so that the edges of the vessels are held together.

With all these clamps and clips, the closure is mechanically closed talking device accomplished, the two arms bent symmetrically or deformed by a tool and thus the desired clamp or Effect hold.

In coronary surgery anastomoses d. H. Seam connections between a Vein or internal artery and a coronary artery. The con conventional connection between two blood vessels, d. H. the anastomosis, is through achieved a continuous, overlocking seam.

Once the coronary surgery is endoscopic, i.e. H. without opening the Sternum, and only over small attached to the side and front of the chest Access holes to be made is a direct coronary suture Vascular or internal mammary artery is technically difficult. reasons for the high technical difficulty of joining seams with limited access are the depth of the surgical target area and the limited ability to use a needle both through the vein wall and the artery wall with the typical needle holder movement lead.

Here it makes sense to unite both vessels by means of a staple  put. The rapid through is crucial for a successful stapling technique feasibility, the secure fit of each clip and the tightness of the anastomosis.

But also in open surgery, a stapler has advantages because the setting of Staples take less time than the seam.

The clip described in the following invention is used for anastomosis of coronary blood vessels which e.g. B. is used in a bypass operation. Brackets are also known for this application, which are attached using tweezers pushed together the edges of the vessels and then pressed together which holds the edges of the vessels together. Have these brackets but the disadvantage that they come off relatively easily and thus serious complications tions z. B. bleeding may occur.

The object of the invention is to develop a bracket which this after turns off and firmly and securely connects coronary blood vessels by the Klam is formed in a special form, and allows them to do so the doctor's approach individually closed and thus the desired span can be adjusted on the fabric.

The task is in a generic bracket and applicator by the in characterizing part of claims 1 and 10 specified features. Before partial configurations are specified in the subclaims.

In contrast to the conventional clip, which is opened when open flat U corresponds, it is crucial for vascular anastomosis that the brace is constructed asymmetrically. Accordingly, one arm of the U should be longer than the other, the other should be shorter. The shorter arm is closed first. First you hook the bypass vessel with the shorter arm, i. H. the bypass vein or the internal mammary artery and leads it to the edge of the anas tomosing coronary artery and punctures it as well. The two vessels walls are adapted to each other and the shorter arm is closed. The Lan er, still open arm is now under the individual necessary tension in the epicardial adipose tissue is inserted, then closed and meets there with the Tip of the shorter arm already closed. After that, the bracket is removed the applicator solved.

A step-by-step, gradual closing is therefore crucial and new one arm, then the other of the asymmetrically shaped bracket. In the first Step only approximates the vein or mammary to the coronary artery and in hooked, in the second the staple seam is brought in by inserting the longer arm  the epicardial fat is closed and the clamp firmly anchored in it. This assumes that the mechanism that enables the closing movement of the two branches allows consecutive, can be finely dosed. The second tip meets the first Tip in this adipose tissue, so that after closing, a quasi closed one Ring is created.

Due to the asymmetrical structure of the clip and the gradual release solution of the clamp closing mechanism is the conventional seam sequence Imitated needle and thread, in which the vein of is pierced outside and led to the artery wall, the inside is pierced outwards.

The possibility of separate closing enables the tension of the Adjust the vein to the coronary vessel accordingly and by hooking the two to anchor this branch in the surrounding epicardial fat tissue. This will make a tight fit of the clip and thus the tight pressing of the vessel edges the tightness of the anastomosis is reached. Carry out the path of the arms of the clip as already mentioned, essentially a closed circuit and this then has approximately the same path as this with the conventional seam technique, which has proven itself in thousands of operations, the case is.

To absorb the asymmetrical closing force, the clamp must be in an open position seated firmly in the applicator, which is due to the rear extension and the dis tale recess is accomplished. A cross-sectional taper at the beginning of a each bending arm specifies the bending point when closing.

To easily penetrate the edges of the vessels and the tissue, it is necessary that the arms of the clip are sharpened at their tips. Furthermore an offset, one-sided grinding of the tip ensures that they are on top of each other Do not collide the moving tips and the further movement when Lock closing but slide past each other and therefore close without any problems eat. The cross section of the clip can be round, oval, square or rectangular, the edges must be rounded accordingly so that the tissue through the after the attached train does not tear. However, they are also technical easy to produce cross-sections conceivable that a regular polygon with abge rounded corners.

The shape of the bracket is preferably asymmetrical, the smaller part being the Hooks the edges of the vessels and the larger part is anchored in the cardiac fatty tissue. The ratio of asymmetry is essentially determined by the given anato  mie determined, it is for reasons of portability of the brackets in the Appli kator would be advantageous if the clip had the smallest possible asymmetry. So one can imagine that the asymmetry is not in the form ben is, but is generated during the closing process in which z. B. the one arm the clip bends twice and thus results in a smaller ring for itself and the other arm then hits the ring with its tip. The pivot point of the arm is determined by z. B. the cross section of the Armes is tapered at this point, then two tapers with under different cross-section are present in one arm. Generally it can be said that the smaller cross-section is always towards the tip of the arm. While closing the clamp is so that by pressing laterally on a place before the last Taper the arm at that taper and then at the next pro ximal lying rejuvenation etc. By the two quasi-joints in the arms of the Clamping achieves a strong gathering of the tissue. On the other hand, the Move the locking arm forwards relatively far to bie the front part of the arm gen. These statements show that there are many possibilities here and there must be selected the one that is optimal for the particular one emphasizes the purpose of the sentence.

The other arm is advantageously designed only with a taper, since at no small closing circle is required for anchoring in the epicardial tissue.

Usually the bend is at the beginning of the arm, next to the back ver extension.

The applicator required to close the clip has two independent Closing tools working from each other so that the vessel side is hooked in first and can be closed and then the anchor in which the corona surrounding epicardial tissue is performed. Advantageously the applicator is designed so that it can be used in conventional open surgery, as well as for a minimally invasive procedure. Here it may be necessary to equip the applicator with an additional joint to combine the adaptation of the tip to the anatomical conditions of the to better allow the vessels.

Furthermore, the applicator is designed so that it has a removable magazine with ver different sizes up to the maximum required number, approx. 20 staples can. After completely closing and ejecting a clip, a white manually push the staple out of the magazine into the staple  Recording position, with the remaining clips in the magazine all at one position be advanced. This advancement can also be designed so that it happens automatically after ejecting a closed bracket the operation of the device is simplified.

The previously mentioned second taper in the arm of the clip can of course also be used in the other arm can be realized if there is a stronger gathering effect when closing it is asked for. A minor disadvantage when closing the arms with multiple taper Conditions that are to be regarded as quasi-joints arise from the fact that the radial moving closers on the clamp arm on the distal side before the last taper must attack and thus also necessarily when closing on the tissue presses.

The shape of the clip itself is asymmetrical, with the one engaging in the vessel Arm is the smaller one and the larger one is anchored in the tissue. For fixation while closing in the applicator, the clip has at its proximal end an extension and in the middle distally a small recess around it when to fix one-sided clasps in the applicator and to apply the asymmetrical forces to take. The arms are closed by an advancing one Tappet, which has a groove-shaped recess at its distal end, in which the clamp arm rests and slides. By pushing the plunger forward the arm is bent at the point determined by cross-sectional tapering until it has reached its end position.

The invention is described in more detail below and supplemented by FIGS. 1-15.

Show it:

Fig. 1 is a skin clip with tissue gathering according to the prior art.

Fig. 2 shows a clamp for anastomosis of blood vessels.

Fig. 3 shows an asymmetrical bracket in a first embodiment of the invention.

Fig. 4 shows the anchoring of the clip in the tissue.

Fig. 5 shows a clamp with two cross-sectional tapering in the shorter arm open and closed.

Fig. 6 shows another embodiment of the clip made of profiled wire.

Fig. 7, the tips of the clamp ground on one side.

Fig. 8 sliding past each other when closing.

Fig. 9 is an applicator in principle for receiving and closing the clip.

Fig. 10 shows a further embodiment of the applicator with a magazine.

Fig. 11 combined version of an applicator for closing the clip with two tapers on one side and one on the other.

Fig. 12 applicator with stacking magazine and moving hold-down device.

Fig. 13 applicator with stacking magazine and moving holding pin.

Fig. 14 hold-down device with the magazine stretched.

Fig. 15 transport sheet with the magazine stretched.

Fig. 1 shows a clip according to the prior art, which is generally intended for the closure of skin wounds. The two arms 1 of the skin clip are pressed forward by the closer 2 moved in the direction of the arrow and bent around the abutment 3 , so that the clip closes. When closing, the preformed arms 1 describe a path inwards and gather the tissue hooked into the tips when they are in their end position 4 .

Fig. 2 shows a clamp 5 , which compresses the vessel edges 6 and 7 and is intended for the anastomosis of vessels. Since this clamp does not penetrate the edges of the vessels, it can slide off easily, which can cause bleeding.

Fig. 3 shows the asymmetrical bracket 10 according to the invention with a shorter arm 11 and the longer arm 12 and the rear extension 13 and the recess 14 , which serve as a counter bearing when closing. Likewise, the cross-sectional tapers 15 , which represent the joints of the arms, are visible at the beginning of the legs.

Fig. 4 shows the use of the clip in situ where the vein 20 is to be connected to the opened artery 21 by the shorter arm 24 of the clip 23 going through the vascular edge of the vein 20 and the coronary artery 21 and it with its longer arm 25 in the epicardial tissue 19 is anchored.

For the complete tight connection of the vessels, several clamps 23 are attached around the vessel opening.

Fig. 5 shows a further embodiment 26 of the bracket 10 , wherein a second Ver young point 27 is attached to the shorter arm and thus there are two bends on the arm. This has the advantage that the clamp closes more tightly, which, for. B. in the shorter arm 28 may be advantageous in the asymmetrical bracket, whereas the longer arm has only one bending point at the beginning of the arm. After closing completely, the clip 26 has the shape 29 .

The brackets can be manufactured from the materials approved for implants, such as. As titanium or certain stainless steels and made of Ti-Nl super elastic material with shape memory, the clips are advantageously punched out of a thin film and the edges of the clips are rounded accordingly so that they do not tear into the tissue when the clip due to the tension is anchored in the epicardial tissue with her second arm. But you can also imagine that these brackets are made of wire, which has the corresponding profile of the bracket arm so z. B. a rectangular profile with rounded corners 16 or an oval profile, but also a polygonal profile with rounded corners is possible Fig. 6. The cross-sectional tapering is made by embossing at the appropriate locations. So that the clamp 17 can absorb the one-sided forces which occur during bending, it is advantageous that the folding seam, which arises at the rear extension, is welded at the front end 18 . This results in a higher stability and the production can be carried out very efficiently from wire, which is advantageously pointed at the two ends in the still straight state. Receiving and closing the clip in the applicator is another part of the invention, which is causally related to the function of the clip.

Fig. 7 shows a view of the tips 30 and 31 of the clamp arms, which are ground on one side to easily pierce the tissue on the one hand and on the other hand as shown in Fig. 8 to slide past each other when closing.

Fig. 9 shows a basic embodiment of an applicator for receiving and closing the clip 10 according to the invention. Since the clip has to be closed in two steps functionally, arise on the clip one-sided forces on the rear extension 13 and the recess 14th be taken up by the applicator 43 . The clip 10 must be fixed in the applicator in that the pin 40 comes to rest in the recess 14 of the clip and the extension 13 in the recess 41 . Advantageously, the extension 13 is held in position by a fixation 32 , which advances after insertion of the clamp 41 via recess. As a result, the clip is sufficiently tight even when hooking the edges of the vessel. The fixation 32 is controlled via the actuation button 35 .

Now, with the shorter arm, the vessel edges are correspondingly detected, which is then closed by the actuating element 34 , by pushing the plunger 38 distally over the actuating element acting as the actuating element and closing the arm of the clamp. The plunger 38/39 have a groove at the distal end 42, comes into which the arm of the bracket to lie. The actuations 34 and 37 , which are shown as leaf springs, can also act on knee joints 33 FIG. 10, which push the joints 38 and 39 distally.

The same procedure is followed after the setting of the second arm by pressing the actuating element 37 , whereby the leaf spring or the corresponding knee joint causes the plunger 39 to be pushed forward and the longer arm of the clamp to be closed. After resetting the actuating elements 34 , 37 and triggering the fixation 32 , the clip can be removed from the applicator and a new clip inserted into the receptacle by manually pushing a clip out of the magazine attached to the applicator (not shown here) and in the receptacle 41 is fixed by the fixation 32 and then applied by the surgeon with the actuating elements 34 and 37 closed and released by the actuation of the fixation 32 again by the applicator.

The overall view of such an applicator is shown in FIG. 10, the actuator 39 reloading, ie introducing the clip into the receptacle and at the same time pushing the fixation 32 forward . Furthermore, the controls 34 and 37 can be seen for closing the arms. Advantageously, the controls 34 and 37 are offset, so that the closing with the thumb and opposite the index finger can be done against the applicator housing 43 and not accidentally both controls are operated simultaneously. Another embodiment of the applicator is that the operating elements are locked against each other via a corresponding mechanism, so that control element 37 can only be actuated when control element 34 has already been actuated and has been reset. Technically, this problem can be solved in this way that a slide with a corresponding bore after resetting the control element 34 is in a position in which a pin of the control element 37 can retract when the same is actuated. If control element 34 had not yet been moved, the pin hits the slide directly and locks control element 37 . The manual reloading 39 resets the slide to its starting position for locking via friction.

Another embodiment is an automatically operating applicator which essentially only has the operating elements 34 and 37 for closing the clip. In addition, a magazine 45 can be placed, which contains the corresponding number of brackets that are required, e.g. B. 10, 15 or 20 pieces, so that the necessary number of brackets is available according to the application. Furthermore, the operating element 37 for the second closure is locked as described above until the operating element 34 has been actuated. Closing the clamp takes place via the toggle joints 33 .

After the actuating element 34 has been actuated and is reset again, the actuating element 37 can now be actuated, as a result of which the long arm of the clip closes. If the control element 37 is pressed further, the fixation 32 is first reset and the locking of the clip is released so that it is released from the applicator. When the operating element 37 is pressed further, an internal lock is released, which releases a spring which causes a new clamp to be reloaded into the receptacle 41 and at the same time locks it via the fixing 32 . Operating element 37 jumps out and is manually pushed in again until it stops, as a result the spring is reloaded from the magazine and the lock for reloading snaps in again. Then the normal function of the control element 37 is fully available again, namely the closing of the longer arm of the clip.

To close the clamps with several tapering, i.e. several bending points per arm, it is necessary that the closer presses laterally on the arm of the clamp after the tapering in order to accomplish the first bend. FIG. 11. Afterwards, the next bending point is automatically moved when pressed further and one arm of the clamp is then in its end position. This locking function is also divided into two, ie a closer that can be operated separately for each side. Lateral closing is accomplished by pushing a sleeve 56 forward from behind via the closer 57 , which has its abutment in two grooves 55 in the center of the applicator housing 43 . Such a sleeve is also provided for the other side if the clip has several tapering on both sides, which is slidably anchored in the applicator.

Fig. 11 shows the function in principle. The closer 57 presses laterally on the clamp and is actuated by the sleeve 56 , which in turn is pushed forward over the rod 58 and runs with its bends in the grooves 55 . It is also possible that the applicator consists of a mixing function, the shorter arm of the clamp is closed laterally to the first bending point and the closer 57 then moves back and the further closure of the smaller arm is then carried out with it as in FIG Tip as a pestle, which moves distally. The larger arm of the clip is conventionally closed as described in Fig. 10. This somewhat more complex configuration, however, has the advantage that after the part arm is closed after the quasi-joint, the closer 57 no longer has a disruptive effect, since the further closing operation takes place from the rear of the clamp. The mechanics required for this can be accommodated in the applicator.

Fig. 12 shows an embodiment with a magazine in which the clips 10 are arranged one above the other and are guided on the outside in the magazine. The clips are held in the magazine 63 by a spring 64 and pushed and the holder 65 holds the remaining clips back when the transport slide 60 takes a clip 10 and pushes it under the guide plate 68 into the receptacle 41 . The resilient hold-down device holds this clamp down in the receptacle 41 , so that the clamp has a tight fit, as is necessary for closing the same. Via an increase 62 , the resilient hold-down device 61 is lowered when the feed slide 60 is pushed forward to hold the clamp. When pulling back the feed slide 60 to get another clip, the derder 61 is never raised and the clip can then be removed from its receptacle when it is closed.

A further embodiment of the holding down and release of the clip is shown in FIG. 13. Here the hold-down device 66 is shown as a resilient element and the bolt 40 , which serves as a stop for the clip, is lowered via a leaf spring 67 to which it is attached. By a wedge, which is pushed between the housing 43 and the leaf spring 67 . When pulling back the transport slide 69, the leaf spring 67 is lowered, which thus takes the bolt 40 downward, so that the clip is released and can be pulled distally out of the clip applicator. Instead of the wedge, the leaf spring can have a cutout 70 in which a ball slides, which is pulled proximally over the rod 72 with the transport slide and presses the leaf spring 67 downward through the tapering gap and the bolt 40 releases the clamp.

Another possibility of attaching a magazine 74 with brackets placed one behind the other is shown in FIG. 14. Here too, a resilient hold-down device 75 is provided, which can be part of the magazine or is also attached to the applicator itself, which holds the clip in its receptacle 41 . The Maga zin 74 is designed so that the brackets are guided in series in the magazine. The clamps are transported in stages in the magazine in that a transport strip 78 in which the clamps lie is pushed forward and pushed back again by a little more than one clamp position. This transport strip 78 has, as shown in FIG. 15, two tabs 79 , which protrude slightly resiliently from the strip and a counter-holder 80 on which the rear extension 13 of the clamp rests. When pushed forward, the resilient tabs 79 on the rear of the clip push it forward. The counter plate 80 prevents the resilient plates 79 from slipping off. The clip is pushed into the receptacle 41 with these tabs 79 and the shortened counter-holder 81 and the hold-down device 75 is held there by the springs. When the transport strip 78 is pulled back, the resilient tabs 79 slide through under the next clamp and, when pushed forward, bring it forward by one position and thus into the position for reloading. So that the clamps are not moved backwards when the transport slide is pulled back by the resilient tabs, the magazine has a toothing 82 on its upper side with a locking effect, which prevents the clamp from sliding back in the magazine, because when the clamp is pushed back, the rearward extension into the Toothing engages and is stopped there. Since the transport paths of the clips are fixed in the magazine, it is sufficient to attach as many locking teeth as there are clips.

The movement of the transport strip 78 or of the transport slide 60 takes place either manually or automatically as described earlier.

In this case, the clamp is released with a resilient hold-down device by lowering the bolt 40 .

The options shown for closing the clip by the applicator can combine even greater variety by combining the specified solutions achieve which are also within the meaning of this invention.

Claims (24)

1. Surgical clip with two arms ( 11 , 12 ) for holding tissue together, characterized in that the two arms are bent towards the center line and the ends are sharpened for better penetration of the tissue and that the two arms of the clips in an applicator be closed independently. 2. Surgical clip with two arms ( 11 , 12 ) according to claim 1, characterized in that the clip is asymmetrical, the arms are of different lengths and bent differently. 3. Surgical clip with two arms ( 11 , 12 ), characterized in that a cross-sectional taper ( 15 ) is attached to the beginning of the arms, which pretends the bending of the arms when closing. 4. A surgical clip according to claim 1, characterized in that at least one additional cross-sectional taper ( 27 ) is present in one or both arms, the cross-sections of which decrease distally, so that when the clip is pressed after the foremost cross-sectional taper, the corresponding one Arm is successively bent at the cross-sectional taper and closes tightly. 5. Surgical clip according to claim 1, characterized in that a rearward extension ( 13 ) is present in the middle of the clip and also a recess ( 14 ) in the middle of the clip distalward, which serve to close the clip when closing on one side Hold applicator and absorb the asymmetrical closing force. 6. Surgical clip according to claim 1, characterized in that the ends of the arms in the tips ( 30 , 31 ) run out and are ground so that they slide past each other when closed. 7. Surgical clip according to claims 1-6, characterized in that the Clamp made of flat material suitable for implants, e.g. B. Nitinol, titanium, or Stainless steel is cut out.   8. Surgical clip according to claims 1-6, characterized in that the clip is bent from profiled wire ( 16 ), the predetermined bending points are generated by impressions and the rear extension ( 18 ) is welded to increase stability. 9. Surgical clip according to claim 8, characterized in that the wire profile ( 16 ) has a round, oval, square to rectangular or other polygonal cross-section with rounded corners. 10. Applicator for receiving and closing the clip, characterized in that the clip with the receiving elements ( 13 , 14 ) according to claim 5 is fixed in a holder ( 40 , 41 ) in the applicator and that by pushing a plunger ( 38 ) Arm of the clamp after the cross-sectional taper is gripped and bent around this towards the center. 11. Applicator for receiving and closing the clip according to claim 10, characterized in that the applicator has two impacts ( 38 , 39 ) which each act on one arm of the clip and that these can be actuated independently of one another. 12. Applicator for receiving and closing the clip according to claim 11, characterized in that the joints ( 38 , 39 ) at their distal end each have a groove-shaped recess ( 42 ) in which the arm of the clip is guided and can slide and the shape the sliding surface is designed so that the arm of the clamp closes with as little friction as possible when the plunger is pushed distally. 13. Applicator for receiving and closing the clip according to claim 11, characterized in that instead of the plunger ( 38 ) moved distally, a closer ( 57 ) detects the arm of the clip distally after the last taper ( 27 ) and towards the center in the radial direction to close the arm of the clamp ( 10 ) is moved by moving a sleeve ( 56 ) guided above it in the applicator. 14. Applicator for receiving and closing the clip according to claim 13, characterized in that two independently working closers ( 57 ) are present. 15. Applicator for receiving and closing the clip according to claim 12 and 13, characterized in that one side of the applicator has a radial closer ( 57 ) and the other side a plunger ( 39 ) which is actuated to close the arm of the clip accordingly . 16. Applicator for receiving and closing the clip according to claim 12 and 13, characterized in that on one side of the applicator both a radially working closer ( 57 ) and a distally working bumps ( 38 ) is attached and the other side a distal has working plunger ( 39 ), which is bent back after the pre-bending of the arm by actuating the radial closer ( 57 ) and is pushed forward in a corresponding guide and then as the distal working plunger ( 38 ) is used to completely close the arm the bracket. 17. Applicator for receiving and closing the clip according to claim 1, characterized in that the applicator has a magazine ( 45 , 63 , 74 ) with up to 20 clips, characterized in that this magazine is removable and that the brackets lined up automatically be pushed when the previous clip is ejected after closing completely and leaves the applicator. 18. Applicator for receiving and closing the clip according to claim 17, characterized in that the clips are pushed forward in the magazine ( 45 , 74 ) manually after a clip has been removed from the magazine and applied. 19. Applicator for receiving and closing the clip according to claim 17, characterized in that the clips are arranged one above the other as a stack and are released by the corresponding guide plate ( 65 ). 20. Applicator for receiving and closing the clip according to claim 17, characterized in that the clips in the magazine ( 74 ) are arranged one behind the other and that a transport plate ( 78 ) which has correspondingly resilient, raised tabs ( 79 ) for advancing the Clamps is used by symmetrically engaging the tabs on the back of the bracket ( 10 ) and that when the transport plate is pushed back, the tabs slide under the next bracket and then the back of this bracket is grasped and that the transport plate ( 78 ) for each bracket in Magazine has a pair of tabs ( 79 ) and counter holder ( 80 ) and that the magazine has a locking toothing ( 82 ) on its inside, in which the rear extension ( 13 ) of the clip ( 10 ) engages to slide back the clip ( 10 ) to prevent when pushing back the transport plate ( 78 ). 21. Applicator for receiving and closing the clip according to claim 10, characterized in that the clip ( 11 ) can only be closed in a certain order and the second actuating element ( 37 ) remains locked until the first ( 34 ) after Pressing is brought back to its rest position. 22. Applicator for receiving and closing the clip according to claim 10, characterized in that for holding down the clip ( 10 ) in its receptacle ( 41 ) a holding-down device is attached, which encloses the magazine ( 63 ) and presses resiliently when the Clip is pushed into the receptacle ( 41 ) and that when the transport slide ( 60 ) is withdrawn, the hold-down device ( 66 ) is raised and thus releases the clip for ejection. 23. Applicator for receiving and closing the clip according to claim 10, characterized in that the hold-down ( 66 ) consists of a resilient element which holds the clip ( 10 ) in its receptacle ( 41 ) and that to throw out the clip of the pin ( 40 ) is lowered when the transport slide ( 60 ) is pulled back, so that the clip can slide distally out of the applicator. 24. Applicator for receiving and closing the clip according to claim 10, characterized in that the actuating elements ( 34 ) and ( 37 ) are laterally offset for ergonomic and trouble-free operation of the applicator with thumb and forefinger.