US20040176751A1 - Robotic medical instrument system - Google Patents
Robotic medical instrument system Download PDFInfo
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- US20040176751A1 US20040176751A1 US10/639,785 US63978503A US2004176751A1 US 20040176751 A1 US20040176751 A1 US 20040176751A1 US 63978503 A US63978503 A US 63978503A US 2004176751 A1 US2004176751 A1 US 2004176751A1
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/11—Surgical instruments, devices or methods, e.g. tourniquets for performing anastomosis; Buttons for anastomosis
- A61B17/1114—Surgical instruments, devices or methods, e.g. tourniquets for performing anastomosis; Buttons for anastomosis of the digestive tract, e.g. bowels or oesophagus
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0469—Suturing instruments for use in minimally invasive surgery, e.g. endoscopic surgery
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0491—Sewing machines for surgery
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/30—Surgical robots
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- A61B34/32—Surgical robots operating autonomously
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- A61B34/37—Master-slave robots
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- A61B34/70—Manipulators specially adapted for use in surgery
- A61B34/71—Manipulators operated by drive cable mechanisms
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- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/068—Surgical staplers, e.g. containing multiple staples or clamps
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- A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
- A61B2017/00292—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery mounted on or guided by flexible, e.g. catheter-like, means
- A61B2017/003—Steerable
- A61B2017/00305—Constructional details of the flexible means
- A61B2017/00309—Cut-outs or slits
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- A61B17/11—Surgical instruments, devices or methods, e.g. tourniquets for performing anastomosis; Buttons for anastomosis
- A61B2017/1135—End-to-side connections, e.g. T- or Y-connections
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- A61B17/22—Implements for squeezing-off ulcers or the like on the inside of inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; Calculus removers; Calculus smashing apparatus; Apparatus for removing obstructions in blood vessels, not otherwise provided for
- A61B2017/22051—Implements for squeezing-off ulcers or the like on the inside of inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; Calculus removers; Calculus smashing apparatus; Apparatus for removing obstructions in blood vessels, not otherwise provided for with an inflatable part, e.g. balloon, for positioning, blocking, or immobilisation
- A61B2017/22054—Implements for squeezing-off ulcers or the like on the inside of inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; Calculus removers; Calculus smashing apparatus; Apparatus for removing obstructions in blood vessels, not otherwise provided for with an inflatable part, e.g. balloon, for positioning, blocking, or immobilisation with two balloons
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- A61B17/22—Implements for squeezing-off ulcers or the like on the inside of inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; Calculus removers; Calculus smashing apparatus; Apparatus for removing obstructions in blood vessels, not otherwise provided for
- A61B2017/22051—Implements for squeezing-off ulcers or the like on the inside of inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; Calculus removers; Calculus smashing apparatus; Apparatus for removing obstructions in blood vessels, not otherwise provided for with an inflatable part, e.g. balloon, for positioning, blocking, or immobilisation
- A61B2017/22065—Functions of balloons
- A61B2017/22069—Immobilising; Stabilising
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- A61B2017/2901—Details of shaft
- A61B2017/2905—Details of shaft flexible
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- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2926—Details of heads or jaws
- A61B2017/2927—Details of heads or jaws the angular position of the head being adjustable with respect to the shaft
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- A61B2034/301—Surgical robots for introducing or steering flexible instruments inserted into the body, e.g. catheters or endoscopes
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- A61B34/00—Computer-aided surgery; Manipulators or robots specially adapted for use in surgery
- A61B34/30—Surgical robots
- A61B2034/305—Details of wrist mechanisms at distal ends of robotic arms
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- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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- A61B90/00—Instruments, implements or accessories specially adapted for surgery or diagnosis and not covered by any of the groups A61B1/00 - A61B50/00, e.g. for luxation treatment or for protecting wound edges
- A61B90/36—Image-producing devices or illumination devices not otherwise provided for
- A61B90/361—Image-producing devices, e.g. surgical cameras
Abstract
Description
- This application claims the benefit of U.S. Provisional Application No. 60/403,621, filed Aug. 14, 2002. The entire teachings of the above application are incorporated herein by reference.
- Robotically controlled surgical instruments are usually controlled from a master station at which a surgeon or other medical practitioner is situated. The master station may include one or more input devices manipulated by the user for, in turn, controlling, at an operative site, respective instruments used in performing a surgical procedure or application.
- Reference is made to co-pending U.S. patent applications identified as Ser. No. 10/023,024 filed Nov. 16, 2001, and Ser. No. 10/014,143 filed Nov. 16, 2001 relating, respectively, to a flexible instrument system and a rigid instrument system, both applications of which are hereby incorporated by reference herein in their entirety. Reference is also made to copending application Ser. No. 10/077,233 filed Feb. 15, 2002 and Ser. No. 10/097,923, filed Mar. 15, 2002 both relating to interchangeable instrument concepts, and both applications of which are hereby incorporated by reference herein in their entirety.
- The descriptions set forth herein use instrument systems as described in these earlier applications but in a different combination so as to provide instrument use combining both flexible and rigid instruments for performing surgical procedures in a more efficient and effective manner. These combined uses include, but are not limited to, use of a flexible instrument intralumenally and the use of a rigid instrument extralumenally. This technique greatly enhances the efficiency of a wide variety of surgical procedures. These flexible and rigid instruments also preferably carry active work elements usually for the purpose of tissue manipulation. These work elements or end effectors may be used for grasping, dissection, resection, cauterizing, etc. Several examples of uses are set forth hereinafter.
- One embodiment covers the concept of using two separate robotically controlled instruments with their operative ends locatable at a target site at which a medical procedure or application is performed, and which are disposed, respectively, intralumenally (within an anatomic lumen) and extralumenally (outside of an anatomic lumen). In a preferred embodiment the first instrument is rigid, entering the anatomy, for example, laparoscopically, while the second instrument is flexible and meant to enter a body lumen such as through a natural body orifice or percutaneously. If used, for example, in a procedure to be performed in the bowel, the rigid instrument may be used with a MIS incision, while the flexible instrument enters the bowel through a natural body orifice (anus). Both instruments are robotically and computer controlled from the same master station at input devices such as illustrated in the aforementioned incorporated applications.
- Position control means may be employed to keep track of the relative positions of the instruments. This enables fine control of interaction between instruments which is important in many surgical procedures. The concepts described herein cover many different combinations of rigid and flexible instruments. Also covered is the use of more than two instruments for certain surgical procedures. The instruments may be used for surgical procedures or for other reasons such as, for example, drug (stem cells) delivery. Both instruments preferably have end effectors or the like and are deemed active instruments with articulating shafts or the like, used for the purpose of tissue holding, securing, dissecting, manipulating, etc.
- Also described herein is a novel instrument that incorporates two functions in a single instrument system. This may be used for sewing, suturing or a number of other surgical procedures. This single instrument system eliminates the need for separate instrument coordination at different locations.
- In accordance with one concept, there is provided a robotic medical apparatus for performing a medical procedure or application on an anatomy. The apparatus comprises a first medical instrument member having a working end adapted to be disposed at an internal target area at which the medical procedure or application is to be performed, and a second medical instrument member having a working end adapted to be disposed at an internal target area at which the medical procedure or application is to be performed. The said first medical instrument member is disposed so as to extend into the anatomy at a first ingress location and passes intraluminally. The second medical instrument member is disposed so as to extend into the anatomy at a second ingress location different than said first ingress location and passes extraluminally. There is also provided a controller for receiving remotely generated control commands for respectively controlling the motion of said first and second medical instrument members so that the first and second medical instrument members are separately and controllably operable to perform the medical procedure or application.
- In accordance with other important concepts, the first and second medical instrument members are separately and controllably operable, in unison, to perform the medical procedure or application. The first medical instrument member comprises a rigid shaft instrument, and said second medical instrument member comprises a flexible shaft instrument. The first medical instrument member may extend into the anatomy at the first ingress location defined by a small incision. The second medical instrument member may extend into the anatomy at the second ingress location defined by a percutaneous or surgical access, or by introduction through a natural orifice. The first medical instrument member may comprise a rigid shaft instrument, and said second medical instrument member may comprise a flexible shaft instrument, with the flexible shaft instrument adapted to extend intralumenally through an anatomic vessel, or the like. The rigid shaft instrument may be adapted to extend extralumenally about the anatomic vessel. In another version the first and second medical instruments may be flexible shaft instruments. Alternatively, the first and second medical instruments may both be rigid shaft instruments.
- In accordance with other concepts and embodiments, the first medical instrument member is rigid entering the anatomy laparoscopically, while the second medical instrument member is flexible and meant to enter a body lumen such as through a natural body orifice or percutaneously. The working end of each instrument member is preferably at its distal end and includes a tool for performing the medical procedure or application. The tool may be for sewing, suturing, grasping, or for applying clips, staples, or clamps. There are also separate input devices communicating with the controller. The input devices issue the control commands for respectively controlling the motion of the first and second medical instrument members, and are disposed at a master control station remote from the instrument members.
- In accordance with other aspects of the disclosed embodiments there is provided a robotic medical apparatus for performing a securing procedure, at an internal body site. The apparatus comprises a medical instrument member having a working end adapted to be disposed at the internal body site at which the securing procedure is to be performed, and a controller for receiving a remotely generated control command for controlling the motion of the medical instrument member to perform the securing procedure. The medical instrument member includes, at a distal section thereof, a securing tool having one and another ends adapted to be disposed at opposite sides of a tissue that is to be secured. At least one of the tool ends is adapted to hold a securing member for securing said tissue.
- In accordance with other aspects the medical instrument member includes an instrument shaft including a controllably bendable section along the instrument shaft for directing the position of the tool. There is included a remote input device controlled by an operator, and coupled by way of the controller to remotely control the bendable section. The instrument shaft may be rigid or flexible and the tool may be for sewing, suturing, or applying clips, staples or the like.
- In accordance with other embodiments there is provided a robotic medical apparatus for performing a medical procedure or application on an anatomy. The apparatus comprises a first medical instrument member having a working end adapted to be disposed at an internal target area at which the medical procedure or application is to be performed, and a second medical instrument member having a working end adapted to be disposed at an internal target area at which the medical procedure or application is to be performed. The first medical instrument member is disposed so as to extend into the anatomy at a first ingress location, while the second medical instrument member is disposed so as to extend into the anatomy at a second ingress location different than the first ingress location. A controller is for receiving remotely generated control commands for respectively controlling the motion of the first and second medical instrument members so that the first and second medical instrument members are separately and controllably operable to perform the medical procedure or application. Both the first and second medical instrument members comprise active work elements at respective member working ends and disposed at opposite sides of an anatomic wall. The active work elements are being controlled cooperatively to perform the medical procedure or application.
- Still other aspects include the active work elements having at least one element that extends a securing piece through the anatomic wall. The active work element preferably comprises an end effector. The first medical instrument preferably passes intralumenally and the second medical instrument preferably passes extralumenally. The system preferably also is robotic including a first master input device remote from the first medical instrument for control thereof, and a second master input device remote from the second medical instrument for control thereof.
- The foregoing and other objects, features and advantages of the invention will be apparent from the following more particular description of preferred embodiments of the invention, as illustrated in the accompanying drawings in which like reference characters refer to the same parts throughout the different views. The drawings are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the invention.
- FIG. 1 is a perspective view of one embodiment of a robotic surgical system in which the principles of the present invention are applied;
- FIG. 2 schematically illustrates a surgical procedure using intralumenal and extralumenal instruments, one flexible and one rigid;
- FIG. 3 illustrates respective end effectors of rigid and flexible instruments used in performing a suturing procedure at a wall of a lumen;
- FIG. 3A shows a next step in the suturing process with the needle having punctured the anatomic wall;
- FIG. 3B shows still another suturing step with the suture being pulled through the wall, and further illustrating the placement of a viewing endoscope attached internally;
- FIG. 3C is a schematic illustration of dual end effectors used in a sewing technique for attaching vessel segments together;
- FIG. 3D illustrates the completion of the sewing technique of FIG. 3C;
- FIG. 3E illustrates a surgical procedure in the stomach using dual instruments, a flexible instrument passing into the stomach and either a rigid or flexible instrument outside the stomach wall;
- FIG. 3F schematically shows the end of the sewing or suturing technique at the stomach wall;
- FIG. 3G illustrates the dual instruments used for securing or re-securing an internal object such as a stent in an artery, vein, or other anatomic lumen or vessel;
- FIG. 3H illustrates a first step in a procedure for attaching one vessel to another such as in bypass surgery;
- FIG. 3I illustrates a second step in a procedure for attaching one vessel to another;
- FIG. 3J illustrates a third step in a procedure for attaching one vessel to another;
- FIG. 3K shows the use of dual instruments in a bladder procedure;
- FIG. 3L illustrates the use of dual instruments in a stomach procedure;
- FIG. 4 is an exploded perspective view of another version of the cable drive mechanism and tool in accordance with the present invention;
- FIG. 5 is a top plan view of the instrument insert itself;
- FIG. 6 is a perspective view of another embodiment of the present invention;
- FIG. 7 is an enlarged detail perspective view of the tool;
- FIG. 8 is a perspective view at the tool;
- FIG. 9 is a side elevation view of the needle driver;
- FIG. 10 is a perspective view of an embodiment of a flexible or bendable wrist just proximal to the tool;
- FIGS. 11-14 illustrate different end effector constructions that may be used with either flexible or rigid instruments;
- FIG. 15 is a perspective view at the slave station of the system of FIG. 1 illustrating the interchangeable instrument concepts;
- FIG. 16 is a cross-sectional view through the storage chamber and as taken along line16-16 of FIG. 15;
- FIG. 17 is a longitudinal cross-sectional view, as taken along line17-17 of FIG. 15, and showing both a stored articulating instrument and a stored fluid dispensing;
- FIG. 18 is schematic diagram of the instrument systems of the present invention as deployed through the urethra for a surgical procedure in the bladder;
- FIG. 19 gives further details of the bladder procedures of FIG,18; and
- FIG. 20 illustrates still another concept using a single controllable instrument.
- A description of preferred embodiments of the invention follows.
- FIG. 1 is a perspective view of one embodiment of a robotic surgical system in which the principles of the present invention are applied. FIG. 1 illustrates a
surgical instrument system 10 that includes a master M at which asurgeon 2 manipulates an input device, and a slave station S at which is disposed a surgical instrument. In FIG. 1 the input device is illustrated at 3 being manipulated by the hand or hands of the surgeon. The surgeon is illustrated as seated in a comfortable chair 4. The forearms of the surgeon are typically resting uponarmrests 5. - FIG. 1 illustrates a master assembly7 associated with the master station M and a
slave assembly 8 associated with the slavestation S. Assembly 8 may also be referred to as a drive unit.Assemblies 7 and 8 are interconnected by means of cabling 6 with a controller 9. As illustrated in FIG. 1, controller 9 typically has associated therewith one or more displays and a keyboard. Reference is also made to, for example, the aforementioned U.S. Ser. No. 10/014,143, for further detailed descriptions of the robotic and computer controller operation and associated operating algorithm. - As noted in FIG. 1, the
drive unit 8 is remote from the operative site and is preferably positioned a distance away from the sterile field. Thedrive unit 8 is controlled by a computer system, part of the controller 9. The master station M may also be referred to as a user interface vis-à-vis the controller 9. Commands issued at the user interface are translated by the computer into an electronically driven motion in thedrive unit 8. The surgical instrument, which is tethered to the drive unit through the cabling connections, produces the desired replicated motion. FIG. 1, of course, also illustrates an operating table T upon which the patient P is placed. - FIG. 1 illustrates both a flexible system and a rigid system. Only one drive unit is depicted it being understood that there is also a drive unit associated with the rigid instrument system such as shown in FIG. 4. Each of the drive units is controlled from cabling that couples from the controller. This is electrical cabling that drives corresponding motors in each drive unit.
- Thus, the controller couples between the master station M and the slave station S and is operated in accordance with a computer algorithm. The controller receives a command from the
input device 3 and controls the movement of the surgical instrument so as to replicate the input manipulation. The controller may also receive commands from the master station for controlling instrument interchange. - With further reference to FIG. 1, associated with the patient P is the
surgical instrument 14, which in the illustrated embodiment actually comprises two separate instruments one rigid and one flexible, along with an endoscope E. The endoscope includes a camera to remotely view the operative site. The camera may be mounted on the distal end of the instrument insert, or may be positioned away from the site to provide additional perspective on the surgical operation. In certain situations, it may be desirable to provide the endoscope through an opening other than the one used by the rigid surgical instrument. In this regard, in FIG. 1 three separate ingress locations are shown, two for accommodating the rigid surgical instrument and the endoscope, and the third accommodates the flexible instrument through a natural body orifice. A drape is also shown. - The viewing endoscope may also be formed integral with the instrument whether it be a rigid instrument or a flexible instrument. The optics and camera may be mounted directly on the distal part of the instrument such as at or adjacent the end effector. In particular, with respect to a flexible instrument the optics and camera may be supported at the distal end of the instrument.
- In FIG. 1, as indicated previously two separate instruments are depicted, a
rigid instrument system 14 and aflexible instrument system 500. In the rigid instrument system there is an instrument insert that carries at its distal end anend effector 18A entering the anatomy through a small incision. This may be for the purpose of providing access to the area about the bowel or bladder, for example. In the flexible instrument system there is a flexible and bendable instrument section terminating at theend effector 500A, and entering the anatomy, for example, through a natural body orifice such as through the anus in the case of a bowel procedure. - An end effector is usually associated with each of the instrument systems. In FIG. 1 this is illustrated by the
end effectors - The
instrument system 14 is generally comprised of two basic components, including a surgical adaptor or guide 15 and aninstrument insert 16. FIG. 1 illustrates thesurgical adaptor 15, which is comprised primarily of theguide tube 24, but also includes a mechanical interface that interfaces with a corresponding mechanical interface of the instrument itself. In FIG. 1 theinstrument 14 is not clearly illustrated but extends through theguide tube 24. Theinstrument 14 carries at its distal end the instrument member or insert. Thesurgical adaptor 15 is basically a passive mechanical device, driven by the attached cable array. - In FIG. 1 there is illustrated cabling that couples from the
instrument 14 to the drive unit. Thecabling 22 is preferably detachable from the drive unit. Furthermore, thesurgical adaptor 15 may be of relatively simple construction. It may thus be designed for particular surgical applications such as abdominal, cardiac, spinal, arthroscopic, sinus, neural, etc. As indicated previously, theinstrument 14 couples to theadaptor 15 and essentially provides a means for exchanging the instrument tools. The tools may include, for example, forceps, scissors, needle drivers, electrocautery etc. Other tool interchanges are also shown in further drawings herein. - Referring still to FIG. 1, the
surgical system 10 includes a surgeon'sinterface 11, computation system or controller 9, driveunit 8 and thesurgical instrument 14. Thesurgical system 10, as mentioned previously, is comprised of an adaptor or guide 15 and theinstrument insert 16. The system is used by positioning the instrument, which is inserted through the surgical adaptor or guide 15. During use, a surgeon may manipulate theinput device 3 at the surgeon'sinterface 11, to affect desired motion of the distal end of the instrument within the patient. The movement of the handle or hand assembly atinput device 3 is interpreted by the controller 9 to control the movement of theguide tube 24, instrument, and, when an articulating instrument is used, the end effector ortool 18A. Also, movements at the master station may control instrument exchange. - The
surgical instrument 14, along with theguide tube 24 is mounted on arigid post 19 which is illustrated in FIG. 1 as removably affixed to the surgical table T. This mounting arrangement permits the instrument to remain fixed relative to the patient even if the table is repositioned. As indicated previously, connecting between thesurgical instrument 14 and thedrive units 8, are cablings. These include two mechanical cable-in-conduit bundles. These cable bundles may terminate at two connection modules, not illustrated in FIG. 1, which removably attach to the rigidinstrument drive unit 8. Although two cable bundles are described here, it is to be understood that more or fewer cable bundles may be used. Also, thedrive unit 8 is preferably located outside the sterile field, although it may be draped with a sterile barrier so that it may be operated within the sterile field. - In the preferred technique for setting up the system, and with reference to FIG. 1, the
surgical instrument 14 is inserted into the patient through an incision or opening. Theinstrument 14 is then mounted to therigid post 19 using a mounting bracket. The cable bundle or bundles are then passed away from the operative area to the drive unit. The connection modules of the cable bundles are then engaged into the drive unit. The separate instrument members ofinstrument 14 are then selectively passed through theguide tube 24. This action is in accordance with the interchangeable instrument concepts also described herein. - The
instrument 14 is controlled by theinput device 3, which is be manipulated by the surgeon. Movement of the hand assembly produces proportional movement of theinstrument 14 through the coordinating action of the controller 9. It is typical for the movement of a single hand control to control movement of a single instrument. However, FIG. 1 shows a second input device that is used to control an additional instrument. Accordingly, in FIG. 1 two input devices are illustrated and two corresponding instruments. These input devices are usually for left and right hand control by the surgeon. Many other forms of input device control may also be used. For example, instead of finger graspers a joystick arrangement may be used. - The surgeon's
interface 11 is in electrical communication with the controller 9. This electrical control is primarily by way of thecabling 6 illustrated in FIG. 1 coupling from the bottom of the master assembly 7.Cabling 6 also couples from the controller 9 to the actuation or drive units. Thiscabling 6 is electrical cabling. Each of the actuation or drive units, however, is in mechanical communication with the corresponding instrument. The mechanical communication with the instrument allows the electromechanical components to be removed from the operative region, and preferably from the sterile field. The surgical instrument provides a number of independent motions, or degrees-of-freedom, when an articulating type instrument such as a tool, gripper, etc. is used. These degrees-of-freedom are provided by both theguide tube 24 and the instrument insert. - FIG. 1 shows primarily the overall surgical system. FIGS. 15-17 show further details particularly of the interchangeable instrument concepts as applied to this system. The rigid instrument part of the system is adapted to provide seven degrees-of-freedom when an articulating tool is used such as the
tool 18A shown in FIG. 1. Three of the degrees-of-freedom are provided by motions of theadaptor 15, while four degrees-of-freedom may be provided by motions of the instrument. As will be described in detail later, the adaptor is remotely controllable so that it pivots, translates linearly, and has its guide tube rotate. The instrument insert also rotates (via rotation of the instrument driver), pivots at its wrist, and has two jaw motions at the tool. - Now, mention has been made of bowel and bladder procedures illustrated schematically in FIG. 2. This shows the two separately controlled instruments including
rigid instrument system 14 that may be engaged laparoscopically through a small incision, andflexible instrument system 500 that may be engaged through the anus in the case of a bowel procedure or the urethra in the case of a bladder procedure. FIG. 2 also shows therespective end effectors - Refer now also to FIG. 3 for an illustration of further details showing the
end effectors needle 19A being grasped by theend effector 18A. The rigid instrument has been passed through a small incision and is positioned outside thevessel wall 20A. The flexible instrument withend effector 500A is positioned within thelumen 20C betweenwalls end effector 500A is shown grasping a tissue at the wall, assisting in the suturing step. In FIG. 3 both of the instruments include at their distal ends, proximal of the end effectors,bendable sections - Reference is now made to FIG. 3A showing a next step in the suturing procedure. The
needle 19A has now passed through thevessel wall 20A. Thesuture 19B is attached to the end of theneedle 19A, as illustrated. In FIG. 3A there is illustrated aviewing endoscope 19C that is attached to theinstrument 18 just proximal of theend effector 18A. - In FIG. 3B the
needle 19A is shown in the next step with thesuture 19B having passed through theanatomic wall 20A. In this arrangement theviewing endoscope 19C is shown secured to thechest wall 19E. There may be provided aclamp 19D, or the like for holding the viewing endoscope in place and in a good viewing location for the surgical procedure that is being performed. In both FIGS, 3A and 3B theinstrument system 500 is within thelumen 20C, while theinstrument system 14 is outside thelumen 20C. Theinstrument systems 500 within the lumen are usually of the flexible type so as to be able to maneuver through an anatomic body part. The instrument system outside the lumen is illustrated as being of the rigid type but could also be of the flexible type. - FIG. 3C shows the use of another dual instrument system that is adapted for intralumenal/extralumenal positioning. This particular arrangement is for sewing between two separate vessels V1 ands V2. This procedure may be used in a variety of different types of operations in which it is desirable to secure together two vessels or lumens, end-to-end. For this purpose there are provided two instrument systems, both of which are preferably robotically controlled from a master station input device. The control of the two systems may be under direct surgeon control such as from an input device manipulated by the surgeon, or, alternatively the systems may be automatically controlled so that once a sequence is initiated the ensuing steps are performed automatically. For example in a sewing procedure it may be desirable to position the instrument systems and, once positioned, it may be desirable to initiate a sequence of suturing steps or stitches so that the suturing occurs essentially automatically, with little or no surgeon intervention except for safety concerns.
- Now, in FIG. 3C there is illustrated a dual instrument system that includes an internally disposed
system 150, and an externally disposedsystem 160. Thesystem 150 is usually of the flexible type as the instrument shaft has to negotiate a vessel or lumen that typically has non-straight portions. Theinstrument system 160, on the other hand, may be flexible or rigid, but would usually be rigid as it would enter the anatomy through an incision or percutaneously. In FIG. 3C the instrument systems together define a sewing system including, on the instrument system 150 ahook end effector 152, and on the instrument system 160 aneedle end effector 162. Together these instrument systems are adapted to be operated in unison and usually in an automatic manner, although the sewing steps can also be performed under manual control of the surgeon from a master station. - The combination of the
instrument systems system 150 with itshook end effector 152 cooperates with theneedle end effector 162 supported by theinstrument system 160. This arrangement may be used to provide a chain stitch. Both of the end effectors are controllable with multiple degrees of freedom. Thus, if the systems are used under manual robotic control thehook end effector 152 is moved in unison with theneedle end effector 162 to provide thestitch 164. Theneedle end effector 162 is adapted to reciprocate relative to itspresser foot 166. At the beginning of each stitch, theneedle end effector 160 pulls a loop of suture material through the tissue. Thehook end effector 150 moves in synchronism with theneedle end effector 160 and grabs the loop of suture material before theneedle end effector 160 pulls up. The instrument system proceed about the vessel portions and FIG. 3D shows thefinal stitch 164 that attaches the vessels or lumens together, end-to-end. - In connection with the systems shown in FIGS. 3C and 3D these instrument systems may also be controlled automatically and under computer control. In that case, once the instrument systems are in place, sensors associated with each instrument system detects the relative position between them. Then the computer at the controller that is disposed between master and slave stations, controls the instrument systems in unison to perform the stitching action. In other words the computer controls the action of the needle end effector and hook end effector to perform the stitch such as a chain stitch.
- In the arrangement shown in FIGS. 3C and 3D the needle end effector is shown outside the lumen while the hook end effector is shown inside the lumen. In an alternate embodiment the positions of the instruments may be interchanged do the hook end effector is outside the lumen and the needle end effector is inside the lumen. The positioning between the end effectors can be controlled by sensing electromagnetic signals associated with sensors associated with each instrument system. The stitching sequences described can provide a variety of different stitch patterns. Inversion or eversion of sewed edges can be provided depending upon the particular surgical procedure being performed. For example, for cardiac procedures a slight inversion of the stitch is desired.
- FIG. 3E illustrates a surgical procedure in the stomach using dual instruments, a flexible instrument passing into the stomach and either a rigid or flexible instrument outside the stomach wall. FIG. 3F schematically shows the end of the sewing or suturing technique at the stomach wall. The
flexible instrument system 160A passes through theesophagus 167 entering initially through the patient's mouth. The outlet from the stomach is at theduodenum 168. This flexible instrument system is illustrated as having an operative segment O controlled by the surgeon in a telerobotic manner to control bending at that segment for guidance of thedistal end effector 160. Anoutside instrument system 150 is also illustrated which may be either a flexible or rigid instrument system. This is illustrated in FIG. 3E bysystem 150A carrying theend effector 150. In FIGS. 3E and 3F the end effectors may be the same as shown in FIGS. 3C and 3D used in performing a sewing or suturing operation. The instrument systems are controlled to perform the sewing or suturingaction forming stitches 170 as illustrated in FIG. 3F. This stitching action closes thehole 169. - FIGS. 3E and 3D illustrate a surgical procedure on the
stomach 165 particularly at thestomach wall 171. Anulcerated hole 169 is disclosed and it is the purpose of the instrument system shown to close up this hole by means of a sewing or suturing technique employing theinstrument systems - FIG. 3G shows still another technique that can be practiced with the instrument systems described herein. In FIG. 3G the same reference characters are used to identify similar components as previously described in connection with FIGS. 3C and 3D. In this instance an object is being stitched within the
body vessel 174. The object may be, for example, astent 173 that is being secure or re-secured within the vessel walls. For this purpose in FIG. 3G there is illustrated theinstrument systems instrument system 150A is flexible as it has to conform to the shape and contour of the inside of the vessel or lumen. Theinstrument systems respective end effectors stent 173, and further shows the instrument systems in action at the other end of the stent securing the other end thereof by means of the illustratedinstrument systems - In FIG. 3G the
instrument system 150A may enter the anatomy through a lumen from a natural body orifice, or percutaneously. Theinstrument system 160A may be positioned at the lumen via an incision at a convenient location proximal to the operative site. The stitching action may be direct surgeon controlled my manipulation at a master station or can be under automatic control. In FIG. 3G the securing may be for a newly placed object or can be used to repair an existing object. For example, the technique explained can be used for AAA stent failures. - Refer now to FIGS. 3H through 3J for an illustration of another surgical procedure that can be performed using the present inventive techniques. This example relates to the attachment of one vessel or
lumen 177 to another vessel orlumen 178. This is a technique that can be used, for example, in performing a cardiac by-pass. In the illustrated steps the same instrument systems may be employed as previously discussed in connection with earlier embodiments that are described herein. This may include both flexible and rigid systems. Furthermore it is noted in this particular procedure that more than two instrument systems are employed. For example, refer to FIG. 31 where three instrument systems are shown, two positioned within respective lumens and one positioned outside the lumens. - FIG. 3H shows the lumen or
vessel 178 to which the vessel orlumen 177 is to be attached. This illustrates the first step in the procedure of positioning thelumen 177 by means of theinstrument system 180 that is disposed within thelumen 177. Theinstrument system 180 may carry aballoon 181 for example, that is inflated to hold thelumen 177 in place. Theinstrument system 180 may then be advanced to position thelumen 177 toward the position illustrated in FIG. 31. The control of movement of theinstrument system 180 may be by means of surgeon control from a master station input device. In this procedure, as well as other procedures described herein a viewing endoscope is used to assist in the positioning of instrument systems. - FIG. 3I now shows the next step in the procedure of attaching the tapered end of the
vessel 177 to the side wall of thevessel 178. For this purpose there is provided the previously describedinstrument systems vessel 177 to attach it to the side wall of thevessel 178. This sewing or suturing step is performed with the use and control of theend effectors instrument system 180 may be kept in place during this step to hold the vessel orlumen 177 against the vessel orlumen 178 to assure accurate attachment. At least parts of the procedures may be performed automatically, particularly the sewing or suturing technique. - After the step illustrated in FIG. 3I is completed then an opening is to be cut in the sidewall of
lumen 178 to allow fluid flow between lumens. This is illustrated in FIG. 3J where additional instrument systems are now employed. Oneinstrument system 182 may carry a cutting blade to perform the opening of the sidewall in thelumen 178. In theother lumen 178 there is disposed theinstrument system 183 that carries aballoon 184 that is meant to hold the sidewall in place as the cutting operation is performed. For the purpose of illustration only one balloon id shown in FIG. 3J, however, instead a pair of balloons may be used, one positioned on either side of the opening so that there is no interference between the cutting instrument and the supporting balloons. - Refer now to another use of the concepts of the invention illustrated in FIG. 3K.
- This illustrates a surgical procedure that is performed in the
bladder 185. FIG. 3K shows oneinstrument system 160A passing through theurethra 188 into the interior of the bladder. This is theinstrument system 160A carrying theneedle end effector 160. FIG. 3K also illustrates theother instrument system 150A carrying thehooked end effector 150. Both of these instrument systems are shown in relative proximity to each other and can be used to perform any one of a number of different procedures. For example, the instrument systems may be used to close the sphincter at the base of theureter tube 186 that couples to thekidney 187. - FIG. 3L is a further illustration of the use of the instrument systems of the invention in closing the sphincter leading into the
stomach 190 at the gastro-esophageol juncture. This is a procedure that is useable to reduce acid reflux that can occur in some patients. By reducing the size of the port at that point acids from the stomach are impeded from backing up into the esophagus. Thus, in FIG. 3L theaforementioned instrument systems area 192 illustrated in FIG. 3L. Theinstrument system 150A carries thehook end effector 150 while theinstrument system 160A carries theneedle end effector 160. Both the instrument systems may be operated in the same manner as described previously in connection with other procedures that have been described herein. - FIG. 4 is an exploded perspective view of another version of the cable drive mechanism and tool. FIG. 5 is a top plan view of the rigid instrument insert itself. FIG. 4 is an exploded perspective view of the cable drive mechanism and instrument illustrating the de-coupling concepts at the slave station S. A section of the surgical tabletop T which supports the
rigid post 19 is shown. Thedrive unit 8 is supported from the side of the tabletop by an L-shapedbrace 210 that carries an attachingmember 212. Thebrace 210 is suitably secured to the table T. Thedrive unit 8 is secured to the attachingmember 212 by means of aclamp 214. Similarly, therigid support rod 19 is secured to the attachingmember 212 by means of anotherclamping mechanism 216. - Also in FIG. 4 the
instrument 14 is shown detached from (or not yet attached to) supportpost 19 atbracket 25. Theinstrument 14 along withcables lightweight housing section 856 provide a relatively small and lightweight decoupleable slave unit that is readily manually engageable (insertable) into the patient at theguide tube 24. - After insertion, the instrument assembly, with attached
cables housing 856, is attached to thesupport post 19 by means of theknob 26 engaging a threaded hole inbase 452 ofadapter 15. At the other end of thesupport post 19,bracket 216 has a knob 213 that is tightened when thesupport rod 19 is in the desired position. Thesupport rod 19, at itsvertical arm 19A, essentially moves up and down through theclamp 216. Similarly, the mountingbracket 25 can move along thehorizontal arm 19B of the support rod to be secured at different positions therealong. Afurther clamp 214 supports and enables thedrive unit 8 to be moved to different positions along the attachingmember 212. FIG. 4 also shows thecoupler 230 which is pivotally coupled frombase piece 234 by means of thepivot pin 232. Thecoupler 230 is for engaging with and supporting the proximal end of theinstrument insert 16. - The
first housing section 855 also carries oppositely disposed thumb screws 875 (see FIG. 4). These may be threaded throughflanges 876. When loosened, these set screws enable thesecond housing section 856 to engage with thefirst housing section 855. For this purpose, there is provided aslot 878 illustrated in FIG. 4. Once thesecond housing section 856 is engaged with thefirst housing section 855, then the thumb screws 875 may be tightened to hold the two housing sections together, at the same time facilitating engagement between thecoupler disks 862 and the coupler spindles 860. - As illustrated in FIG. 4, the two
housing sections first housing section 855 that contains the motors 800. Thefirst housing section 855, as described previously, contains the motors 800 and theircorresponding coupler disks 862. In FIG. 4, thesecond housing section 856 primarily accommodates and supports the coupler spindles 860 and the cabling extending from each of the spindles to the cable bundles 21 and 22 depicted in FIG. 4. - FIG. 4 also shows details of the adaptor including the
carriage 226 supported onrails 224. Thecarriage 226 holds thebase piece 234 that, in turn, supports the instrument insert. Thecoupler 230 of the adaptor provides mechanical drive to the instrument insert. The carriage and rails are pivoted at 225 to provide one degree of freedom, while the in and out motion of the carriage provides another degree of freedom to the instrument. - As shown in FIG. 5, each wheel of the
instrument coupler 300 has twocables 376 that are affixed to the wheel and wrapped about opposite sides at its base. The lower cable rides over one of the idler pulleys or capstans (e.g., capstan 34), which routes the cables toward the center of theinstrument stem 301. It is desirable to maintain the cables near the center of the instrument stem. The closer the cables are to the central axis of the stem, the less disturbance motion on the cables when the insert stem is rotated. The cables may then be routed through fixed-length plastic tubes that are affixed to the proximal end of thestem section 301 and the distal end of thestem section 302. The tubes maintain constant length pathways for the cables as they move within the instrument stem. - The
instrument coupler 300 is also provided with aregistration slot 350 at its distal end. Theslot 350 engages with a registration pin 352 supported between the bars 270 and 272 ofbase piece 234. Thecoupler 300 is also provided with aclamping slot 355 on its proximal end for accommodating the threaded portion of the clamping knob 327 (on adapter coupler 230). Theknob 327 affirmatively engages and interconnects thecouplers - In operation, once the surgeon has selected a
particular instrument insert 16, it is inserted into theadapter 15. Theproximal stem 301, having thedistal stem 302 and thetool 18 at the distal end, extend through theadapter guide tube 24. FIG. 4 shows thetool 18 extending out of theguide tube 24 when thesurgical instrument 16 is fully inserted into theadaptor 15. When it is fully inserted, thetab 281 on theaxial wheel 306 engages with the mating detent 280 in pulley 279. Also, theregistration slot 350 engages with the registration pin 352. Then thecoupler 230 is pivoted over thebase 300 of theinstrument insert 16. As this pivoting occurs, the respective wheels of thecoupler 230 and thecoupler 300 interengage so that drive can occur from thecoupler 230 to theinsert 16. Theknob 327 is secured down so that the twocouplers - FIG. 6 is a perspective view of one embodiment of the
flexible instrument system 500 illustrated in FIG. 1. FIG. 7 is an enlarged detailed perspective view of the end effector that may be used with the flexible instrument system. FIG. 1 depictsflexible instrument system 500 supported fromsupport bracket 502, which extends to the operating table. Usually the support bracket is supported from the side of the operating table and may be adjustable in position relative to the operating table, to disposesystem 500 in a convenient position over or relative to the patient. In one embodiment,bracket 502 is secured to the operating table at one end. The other end ofbracket 502 supports the entire flexible instrument by means of a two-piece structure similar to that described in copending U.S. Provisional Applications Serial No. 60/279,087 filed Mar. 27, 2001 the entire teachings of which are concorporated herein by reference. A knob may be provided onsupport base 504, not shown in FIG. 1. Once thesupport base 504 is fixed to thesupport bracket 502, then the flexible instrument system is maintained in a fixed position atbase 504, providing a stable and steady structure during the medical procedure. Like the rigid system in FIG. 1,system 500 can be positioned at an acute angle with respect to the operating table or can be arranged at other convenient positions depending upon the surgical procedure being performed. -
Flexible instrument system 500 illustrated in FIG. 6 comprisesflexible instrument 510 having ashaft 528 extending to mechanicallydrivable mechanism 526, which interlocks with base (or receiver) 506.Base 506 is supported oncarriage 508.Carriage 508, in turn, is adapted for linear translation and supported byelongated rails Rails end piece 516 which provides further support.Support base 504 terminatesrails Carriage 508 includes bearings orbushings 509 that support the carriage fromrails -
Flexible instrument system 500 employs two separate cable bundles for mechanically driving the flexible instrument alongrails carriage control module 520, receives a first pair ofcables 518.Pulley 521 also receives a second set of cables, which runs throughcarriage 508 to afurther pulley 522 supported byend piece 516. The second set of cables controls the translational motion ofcarriage 508 and terminates atpoint 519. - FIG. 6 also shows a set of
cables 524 for driving control elements, e.g. pulleys withinreceiver 506. These control elements move the shaft and the tool in several degrees-of-freedom. Arrow J1 indicates the linear translation viamodule 520. Rotational arrow J2 indicates rotation offlexible shaft 528 offlexible instrument 510 about the inner axis parallel with the shaft length. Arrow J3 represents the flexing or bending offlexible shaft 528 at controlledflexible segment 530. In this embodiment,flexible segment 530 is positioned directlyadjacent tool 534 at the distal end ofshaft 528. Arrow J4 represents the pivot action of a wrist joint, which linkstool 534 toshaft 528, aboutaxis 532. In this embodiment,tool 534 is exemplified as a grasper, and arrows J5 and J6 represent the opening and closing actions of the tool jaws. Motions indicated by arrows J2-J6 are controlled from cabling 524 originating atreceiver 506. - FIG. 7 provides an enlarged perspective view of the distal end of
shaft 528 includingflexible segment 530 andtool 534. Thesegment 530 corresponds to thesection 500B illustrated in FIG. 3, while theend effector 534 corresponds to theend effector 500A illustrated in FIG. 3.Tool 534 comprises upper grip orjaw 602 and lower grip orjaw 603, both supported fromlink 601.Base 600 is affixed to or integral withflexible shaft 528.Link 601 is rotatably connected to base 600 aboutaxis 532. A pivot pin may be provided for this connection. Upper andlower jaws axis 536 and again, a pivot pin can provide this connection. - FIG. 7 shows eight cables at538 extending through the hollow inside of
shaft 528 for control oftool 534 andflexible segment 530. Two of these cables operate the bend offlexible segment 530, two cables operate one of thejaws 602, two cables operate the other of thejaws 603 and the last two cables operate the wrist action about theaxis 532. All of these cables travel through thehollow shaft 528 and through appropriate holes inflexible segment 530e.g. wire 525, as well as holes inbase 600. Each of these pairs of cables operates in concert to open and close jaws, pivot about the wrist, and bendflexible segment 530. - One pair of cables travels through
shaft 528 and through appropriate holes in thebase 600, wrapping around a curved surface of thelink 601 and then attaching to the link. Tension on this pair of cables rotates thelink 601 along with the upper and lower grips orjaws axis 532. - Two other pairs of cables also extend through the
shaft 528 and through holes in the base and then pass between fixedposts 612. These posts constrain the cables to pass substantially throughaxis 532, which defines rotation oflink 601. This construction essentially allows free rotation oflink 601 with minimal length changes in the cables passing tojaws cables actuating jaws link 601 and are not effected by any rotation oflink 601. Cables controlling jaw movement terminate onjaws jaws axis 536. A similar set of cables is present on the under-side of the link 601 (not shown). Each of thejaws link 601, may be constructed of metal. Alternatively, link 601 may be constructed of a hard plastic material.Base 600 may also be constructed of a plastic material and may be integral withshaft 528. - Bending of
flexible segment 530 is provided via diametricallydisposed slots 662, which define spacedribs 664.Flexible segment 530 also has alongitudinally extending wall 665 through which cabling may extend, particularly for the operation of the tool. One of the pairs of cables ofbundle 538 controllingflexible segment 530 terminates wherebase 600 intercouples withshaft 528. This pair of cables works in concert to cause bending as indicated by arrow J3, i.e. in a direction orthogonal to the pivoting provided atwrist axis 532. Theflexible segment 530 may also be provided with additional degrees of freedom by controlling bending in two axes, direction J3 that is illustrated and a direction orthogonal thereto. - FIGS. 8, 9 and10 show different embodiments that can be used with either instrument but that are illustrated, in particular, for the rigid instrument system. FIG. 8 illustrates the construction of one form of a tool. FIG. 8 is a perspective view. The
tool 18 is comprised of four members including abase 600, link 601, upper grip orjaw 602 and lower grip orjaw 603. Thebase 600 is affixed to the flexible stem section 302 (see FIG. 5). The flexible stem may be constructed of a ribbed plastic. This flexible section is used so that the instrument will readily bend through the curved part of theguide tube 24. - The
link 601 is rotatably connected to the base 600 aboutaxis 604. FIG. 8 illustrates apivot pin 620 ataxis 604. The upper andlower jaws pivot pin 624 to thelink 601 aboutaxis 605, whereaxis 605 is essentially perpendicular toaxis 604. - Six cables606-611 actuate the four members 600-603 of the tool. Cable 606 travels through the insert stem (section 302) and through a hole in the
base 600, wraps around curved surface 626 onlink 601, and then attaches onlink 601 at 630. Tension on cable 606 rotates thelink 601, and attached upper andlower grips axis 604.Cable 607 provides the opposing action to cable 606, and goes through the same routing pathway, but on the opposite sides of the insert.Cable 607 may also attach to link 601 generally at 630. -
Cables stem base 600. Thecables fixed posts 612. These posts constrain the cables to pass substantially through theaxis 604, which defines rotation of thelink 601. This construction essentially allows free rotation of thelink 601 with minimal length changes in cables 608-611. In other words, the cables 608-611, which actuate thejaws link 601.Cables jaws cables jaws axis 605. Finally, as shown in FIG. 8, thecables cables cables jaws jaws - Reference is now made to FIG. 9. FIG. 9 is a side elevation view of a needle driver version of end effector. This embodiment employs an over-center camming arrangement so that the jaw is not only closed, but is done so at a forced closure.
- In FIG. 9, similar reference characters are employed with respect to the embodiment of FIG.8. Thus, there is provided a
base 600, alink 601, anupper jaw 650 and alower jaw 652. Thebase 600 is affixed to theflexible stem section 302. Cabling 608-611 operate the end jaws.Linkages - FIG. 10 is a perspective view of an embodiment of a flexible or bendable wrist just proximal to the tool. FIG. 10 illustrates the manner in which the previously disclosed tools may be used with a flexible or bendable segment of the instrument shaft, whether used with a rigid shaft body or a flexible shaft body or combinations thereof. One of the advantages is that only a single cable needs to be coupled to the tool for actuation thereof. The pitch and yaw of the tool is controlled at the
flexible section 100 shown in FIG. 10. This arrangement also lends itself to making the tool disposable or at the very least detachable from the instrument body such as for substitution of another tool. Because the construction becomes more simplified at the tip of the instrument, it makes it possible to construct a tool that is readily detachable from the instrument. - In FIG. 10 there is disclosed one embodiment of a tool, illustrated in conjunction with a flexible shaft or tube having a remotely controllable bending or flexing
section 100. The medical instrument may comprise an elongated shaft, such asshaft section 110, having proximal and distal ends; and a tool, such asgraspers flexible section 100. In order to provide the pitch and yaw action at the tool, the bending or flexingsection 100 is constructed so as to have orthogonal bending by using four cables separated at 90° intervals and by using a center support with ribs and slots about the entire periphery. Refer to theribs 112 that define correspondingslots 114. The ribs define at each of their centers acenter support passage 118 that has extending therethrough the cable 136. Thebending section 100 is at the end oftube section 110. Thesection 110 may be flexible itself, may be smooth as shown, or may be fluted. - The
bending section 100 has alternatingridges 120 to provide universal bending. This version enables bending in orthogonal directions by means of fourcables cables 106 and 107 provides flexing in one degree-of-freedom while an added orthogonal degree-of-freedom is provided by operation ofcables 116 and 117. Each of thecables distal end wall 119 of theflexible section 100. - The
bending section 100, as indicated previously, includes a series of spacedribs 112 disposed, in parallel, with the plane of each rib extending orthogonal to the longitudinal axis of thesection 100. At the proximal end of the bendable section an end rib connects to theshaft section 110, while at the distal end there is provided thedistal end wall 119 that supports the ends of the cables. Each of theribs 112 are held in spaced relationship by means of the alternatingridges 120. As depicted in FIG. 10 these ribs are identified as horizontal ribs 120A, alternating with vertical ribs 120B. This structure has been found to provide excellent support at the center passage for the actuating cable 136, while also providing enhanced flexibility in orthogonal directions of bending or flexing. - The
grippers pivot pin 135 that extends along a pivot axis. These grippers may be supported inlink 140. Refer to the exploded perspective view of FIG. 10 showing thepin 135, andgrippers pin 135 may be supported at its ends in opposite sides oflink 140. - Reference is now made to FIGS. 11-14 for an illustration of different end effector devices that can be used with the instrument systems described herein. FIG. 11 shows a
clip applier 410. FIG. 12 shows a cuttingjaw 420. FIG. 13 shows adevice 430 for applying a solution or agent to an operative site. FIG. 14 shows asyringe type device 440 useable as an end effector. - The surgical robotic system, as illustrated in FIGS. 15-17, although preferably used to perform minimally invasive surgery, may also be used to perform other procedures as well, such as open or endoscopic surgical procedure. FIG. 15 is a perspective view at the slave station of the system of FIG. 1 illustrating the interchangeable instrument concepts as applied in a dual instrument system. FIG. 16 is a cross-sectional view through the storage chamber and as taken along line16-16 of FIG. 15. FIG. 17 is a longitudinal cross-sectional view, as taken along line 17-17 of FIG. 15, and showing both a stored articulating instrument and a stored fluid dispensing.
- Reference is now made to FIG. 15 which is a perspective view illustrating the
instrument 14 and theadaptor 15 at the slave station S. This instrument system is secured in the manner illustrated in FIG. 1 to therigid post 502 that supports the surgical instrument by way of a mounting bracket. FIG. 15 also shows several cables that may be separated into five sets for controlling different motions and actions at the slave station. These are individual cables of theaforementioned bundles support yoke 220 that is secured to the mounting bracket 31, thepivot piece 222, andsupport rails 224 for thecarriage 226. The rails are supported inend pieces end piece 241 attached to thepivot piece 222. Thepivot piece 222 pivots relative to thesupport yoke 220 aboutpivot pin 225. Abase piece 234 is supported under thecarriage 226 by means of thesupport post 228. Thesupport post 228 in essence supports the entire instrument assembly, including theadaptor 15 and theinstrument 14. - As indicated previously, the
support yoke 220 is supported in a fixed position from the mounting bracket 31. Thesupport yoke 220 may be considered as having anupper leg 236 and alower leg 238. In theopening 239 between theselegs pivot piece 222. Cabling extends into thesupport yoke 220. This is illustrated in FIG. 15 by thecable set 501. Associated with thepivot piece 222 and thecarriage 226 are pulleys (not shown) that receive the cabling for control of two degrees-of-freedom. This control from the cable set 501 includes pivoting of the entire instrument assembly about thepivot pin 225. This action pivots theguide tube 24 essentially in a single plane. This pivoting is preferably about an incision of the patient which is placed directly under, and in line with, thepivot pin 225. Other cables ofset 501 control thecarriage 226 in a linear path in the direction of thearrow 227. See also thecables 229 extending between thecarriage 226 and theend pieces tube 24 back and forth in the direction of the operative site OS. Incidentally, in FIG. 15 the instrument is in its fully advanced state with the tool at the operative site OS. - The
base piece 234 is the main support for the interchangeable instrument apparatus of the invention. Thebase piece 234 supports theguide tube 24, theinstrument storage chamber 540, and theinstrument driver 550. Theinstrument driver 550 is supported from another carriage, depicted in FIGS. 15 and 17 as thecarriage 552, and that, in turn, is supported for translation on the carriage rails 554. Therails 554 are supported at opposite ends atend pieces other carriage 226. Asupport post 560 interconnects thecarriage 552 with theinstrument driver housing 570. - With further reference to FIG. 15, and as mentioned previously, there are a number of cable sets from
bundles guide tube 24. Cable set 505 controls thecarriage 552, and, in turn, the extending and retracting of the instrument driver for instrument exchange. Cable set 507 controls rotation of the instrument through rotation of the instrument driver. Finally, cable set 509 controls the tool via the instrument driver and instrument. There is also one other set of control cables not specifically illustrated in FIG. 15 that controls theindexing motor 565, to be discussed in further detail later. - FIG. 17 shows a cross-sectional view through the interchangeable instrument portion of the overall instrument system. This clearly illustrates the internal cable and pulley arrangement for the various motion controls. There is a
pulley 301 driven from the cable set 503 that controls rotation of theguide tube 24. There is also apulley 303 driven fromcable set 505, along with acompanion pulley 305 that provides control for thecarriage 552. FIG. 17 also illustrates anotherpulley 307 driven fromcable set 507, and for controlling the rotation of theinstrument driver 550, and, in turn, the selected instrument. - FIG. 17 illustrates the
guide tube 24 supported from thebase piece 234. Theguide tube 24 is hollow, has a curved distal end as illustrated in FIG. 15, and is adapted to receive the individual instruments or work sections 541 (articulating) or 590 (fluid-filled) disposed in theinstrument storage chamber 540, as well as theinstrument driver 550. Refer to FIG. 17 for an illustration of the instrument and instrument driver positioned in theguide tube 24. FIG. 17 shows theinstrument driver 550 in its rest or disengaged position. Theproximal end 24A of theguide tube 24 is supported in thebase piece 234 by means of a pair ofbearings 235 so that theguide tube 24 is free to rotate in thebase piece 234. This rotation is controlled from thepulley 237 which is secured to the outer surface of theguide tube 24 by means of aset screw 231. Thepulley 237 is controlled to rotate by means of thecabling 310 that intercouples thepulleys cabling 503. Thus, by means of the cable and pulley arrangement, and by means of the rotational support of theguide tube 24, the rotational position of theguide tube 24 is controlled fromcable set 503. Of course, this controlled rotation is effected from the master station via the controller 9, as depicted in the system view of FIG. 1, and as a function of the movements made by the surgeon at theuser interface 15. - As indicated before the
proximal end 24A of theguide tube 24 is supported from thebase piece 234. The distal end of theguide tube 24, which is adapted to extend through the patient incision, is disposed at the operative site OS illustrated about theinstrument member 20 in FIG. 15, and where a medical or surgical procedure is to be performed. In the system shown in FIG. 15 the distal end of theguide tube 24 is curved at 24B. In this way by rotating theguide tube 24 about its longitudinal axis there is provided a further degree-of-freedom so as to place the distal end of the instrument at any position in three-dimensional space. The rotation of theguide tube 24 enables an orbiting of the instrument end about the axis of theguide tube 24. Theguide tube 24 is preferably rigid and constructed of a metal such as aluminum. - FIG. 17 also illustrates a cross-section of the
instrument storage chamber 540 including thestorage magazine 549, and showing two of the sixinstrument passages 542 in thestorage magazine 549. The instrument storage chamber may also be referred to herein as an instrument retainer. In FIG. 17 one of thefluid retaining instruments 590 is about to be engaged by theinstrument driver 550. The other articulatingtype instrument 541 is in place (storage or rest position) in theinstrument storage chamber 540, and out of the path of theinstrument driver 550. Theinstrument 541 carries a gripper tool, but other instruments may also be carried such as a scissors. Because these instruments are adapted to pass to theguide tube 24 and be positioned at thedistal end 24B thereof, the body 548 of each instrument is flexible so as to be able to curve with the curvature of theguide tube 24. - Although reference is made herein to the separate instrument and instrument driver, such as illustrated in FIG. 17, once they are engaged they function as a single piece instrument member. Accordingly reference is also made herein to the
instrument driver 550 as a “driver section” of the overall one piece instrument member, and theinstrument - The
carriage 552 illustrated in FIG. 17 is moved linearly by thecables 555 that extend betweenpulleys carriage 552. The carriage movement is controlled fromcable set 505. It is the movement of thecarriage 552 that drives the instrument driver (driver section) 550. Theinstrument driver 550, in its rest or disengaged position, is supported between theinstrument driver housing 570 and thewall 562 that is used for support of theinstrument storage chamber 540. Theinstrument magazine 549 is rotationally supported by means of the axle orshaft 547, with the use of bushings or bearings, not shown. This support is betweenwalls - FIG. 17 shows the very
distal end 525 of the instrument driver (transporter) 550 supported atwall 562. In the rest position of theinstrument driver 550 the driver is out of engagement with the instruments and themagazine 549, thus permitting rotation of theinstrument storage chamber 540. Theproximal end 526 of theinstrument driver 550 is supported at theinstrument driver housing 570. It may be rotationally supported by means of abushing 527. Theinstrument driver 550 is supported for rotation, but rotation is only enabled once the driver has engaged the instrument and preferably is at the operative site. The rotation of theinstrument driver 550 is controlled fromcable set 507 by way of thepulley 307. - In FIG. 15 the cable set509 is illustrated as controlling the instrument motions including tool actuation. These cables control a series of pulleys shown in FIG. 17 as
pulleys 529. As indicted in FIG. 17 these pulleys control cabling that extends through the instrument driver and the instrument for control of instrument and tool motions when articulating type tools are selected. The cables that are controlled from these pulleys may control three degrees-of-freedom of the instrument, including pivoting at the wrist and two for gripper action. The same engagement arrangement can be used in this second embodiment of the invention including the mating hook arrangement, interlocked atinterface 559 when the instrument driver and instrument are engaged. - In one version of the invention a rotating member may be used for control of actuating rods. In the illustrated embodiment of the invention a different arrangement is used that includes a lead screw type of mechanism. This
mechanism 591 is illustrated in FIG. 17 next to thepulleys 529. This mechanism includes a drive nut 593 having an internal threaded passage for receiving theactuating rod 592. Theactuating rod 592 also has a threaded outer surface and further includes an elongated slot or keyway 594. An anti-rotation key 595 is fixed in position and is adapted to be received in the keyway 594. This engagement between the key 595 and theactuating rod 592, prevents rotation of theactuating rod 592. However, the threaded engagement between the drive nut 593 and the outer threads of theactuating rod 592 enable linear (screw advance) translation of theactuating rod 592. This linear translation of the actuating rod initiates dispensing from the fluid-filled instrument by actuating the instrument member piston. - The drive nut593 is journaled to the
housing 570, but is free to rotate relative to the housing. A bearing 596 is provided to enable rotation of the drive nut 593 relative to thehousing 570. The cable set 511 couples about the drive nut 593 to cause rotation thereof. Because the key 595 is fixed in position, then theactuating rod 592 can only move linearly in the direction of the arrow 597. The linear translation of theactuating rod 592 is transferred, via thedriver 550, to the actuating rod of the instrument member. This action is, in turn, transferred to the dispensing piston of thesyringe member 590. For further details refer to the pending applications referred to before and incorporated by reference herein. - FIG. 17 shows one fluid-filled
instrument 590. The cable control via the cable set 511 can provide precise movement of theactuating rod 592 so that all or any portion of the liquid in the dispensing member can be ejected at the appropriate body site. If less than all the liquid is ejected then the instrument can be returned to the storage magazine in readiness for a subsequent use. By keeping track of the degrees of rotation of the drive nut 593, one can ascertain how much of the liquid has been dispensed and how much remains in the syringe member. - FIG. 18 is schematic diagram of the catheter system of the present invention as deployed through the urethra for a surgical procedure in the bladder. FIG. 18 provides a schematic cross-sectional diagram illustrating a surgical procedure where catheter K1 enters a natural body orifice, such as the urethra for carrying out procedures in, for example, the bladder. In FIG. 18 catheter K1 is shown extending into bladder B1. In this example, the computer controlled segment, identified as operative, bendable or flexible segment O in FIG. 18, is positioned at a more proximal section of catheter K1. Bladder B1, being an open cavity, does not have lumens leading from the urethra that would naturally guide a catheter towards any particular operative site. Upon entering bladder B1, catheter K1 can bend in any direction including the direction of the operative site. In this embodiment, because of the more proximal positioning of operative segment O, a surgeon can controllably bend the distal end of catheter K towards the operative site. In the embodiment shown in FIG. 18, the distal end of the catheter, labeled P1, can be rigid or be “passively” flexible, i.e. made of a flexible material and not necessarily controlled for flexure under remote computer control. FIG. 18 also shows another instrument system preferably a rigid instrument system including an instrument C extending through an incision D. The instrument shaft carries an end effector C1 that may be a set of jaws. Similarly, the bendable instrument K1 may carry an end effector C2. These instruments are coordinated in their action so that they can operate together in performing a surgical procedure. Refer also to the previous discussion regarding FIG. 3K.
- Refer now to FIG. 19 for added details of the bladder procedure referenced in FIGS. 3K and 18. This drawing also shows the cross-section through the wall WI of the bladder B1, illustrating the ureter tube T1 that extends through the muscle wall to the kidney. This also shows an inside instrument system I1 with a corresponding end effector, as well as an outside instrument system I2 that likewise carries an end effector. These end effectors may be for sewing or for other purposes depending upon the particular procedure that is to be performed. The inside instrument system is usually flexible, while the outside instrument system may be either flexible or rigid.
- Reference to a rigid instrument system usually refers to an instrument in which there is a shaft that is primarily rigid and usually meant for insertion into the patient through a small incision such as a laparoscopic incision. However, rigid instruments may also be used to some extent within a natural body orifice. Flexible shaft instruments may be used through a natural body orifice, by percutaneous entry, through an incision or by other means for entry into the patient.
- FIG. 20 shows still another instrument system that may be used for suturing, sewing or other surgical procedures in a body cavity or vessel such as in the
cavity 193 illustrated. Theinstrument system 194 uses a single instrument arrangement that actually has two or more work areas. By way of example in FIG. 20 there is, at the very distal end of theinstrument system 194, anactive work element 195. This may be the same as theinstrument end effector 160 illustrated in FIG. 3K or may be a set of jaws. In addition to theactive work element 195 the instrument system is also provided with anintermediate work element 197. This is another end effector that is adapted to cooperate with theend effector 195 in performing a surgical procedure. For sewing theend effector 197 may be a hook end effector previously described, or it may be an anvil construction. The end effectors shown in FIG. 20 may also be of other types such as, but not limited to, graspers, needle drivers, cauterizing tools, scalpels, etc. The instrument system shown in FIG. 20 is simple in construction using only a single controlled instrument member. Preferably the shaft of the instrument system is curved back upon itself as illustrated at 198 in FIG. 20. This construction enables the one instrument system to be used for performing a complete surgical procedure such as passing a suture through a fold of tissue as illustrated in FIG. 20. - Another concept relates to arthroscopic procedures, but could also apply to other medical procedures. This relates to the use of a single flexible instrument that might be used in, for example, a knee operation through a single entry point, rather than present instrumentation that uses multiple instruments and associated multiple incisions. The procedures described herein are also advantageous in that they can be carried out without requiring open incisions, thus lessening recovery times.
- The following are some of the additional features that characterize these inventions and relating to the use of multiple instruments, particularly multiple instruments of different types and adapted for different locations of access to anatomic parts of the body.
- (A) The use of instruments intralumenally minimizes the number of incisions that have to be made in a particular procedure.
- (B) The intralumenal instrument can be used as a “locator” to assist in locating the extralumenal instrument. For example, one can locate the coronary vessel (often hidden by fat and muscle, and not on the heart surface) for anastomosis by means of the intralumenal instrument.
- (C) Provides for multiple instruments in a small space. For example, in bowel anastomosis/resection two instruments may be used intralumenally and one used extralumenally.
- (D) Provides for internal and external control of a surgical procedure. For example, in the repair of a failed AAA stent (see FIG. 3G), the intralumenal instrument stabilizes the stent, bringing the loose stent against the vessel wall, while the extralumenal instrument performs an anchoring through the vessel wall.
- (E) In all of the above the instruments are preferably computer controllable from a master station with an input device and in coordination with each other. For that purpose the instruments are provided with sensors so each knows the position of the other, and their accurate manipulation can thus be controlled.
- (F) The control of operations described herein such as sewing or suturing techniques employs algorithms when operation is substantially totally computer controlled. These algorithms can control such parameters as stitch patterns, stitch tension, stitch spacing, tightness and precision of the stitching.
- While this invention has been particularly shown and described with references to preferred embodiments thereof, it will be understood by those skilled in the art that various changes in form and details may be made therein without departing from the scope of the invention encompassed by the appended claims.
Claims (41)
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US20070250072A1 (en) | 2007-10-25 |
US20080177281A1 (en) | 2008-07-24 |
US20070239186A1 (en) | 2007-10-11 |
US20070239178A1 (en) | 2007-10-11 |
US20070250097A1 (en) | 2007-10-25 |
US7959557B2 (en) | 2011-06-14 |
US20070232855A1 (en) | 2007-10-04 |
US20070238924A1 (en) | 2007-10-11 |
US8671950B2 (en) | 2014-03-18 |
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