US20020042620A1 - In vivo accessories for minimally invasive robotic surgery - Google Patents

Abstract

Surgical accessories are presented in vivo and used by surgical tools in the surgical site to perform additional tasks without the need to remove the tools from the surgical site for tool change or instrument loading. Examples of in vivo accessories include fastening accessories such as surgical clips for use with a clip applier, single working member accessories such as a blade which can be grasped and manipulated by a grasping tool for cutting, sheath accessories that fit over working members of a tool, flow tubes for providing suction or introducing a fluid into the surgical site, and a retraction member resiliently biased to retract a tissue to expose an area in the surgical site for treatment. The accessories can be introduced into the surgical site by a dedicated accessory introducer, or can be supported on the body of a surgical tool inserted into the surgical site and be manipulated using another surgical tool in the surgical site. The accessory introducer can be resiliently biased to bias the accessories toward a predetermined position in the surgical site.

Description

CROSS-REFERENCES TO RELATED APPLICATIONS
• This application claims benefit from U.S. Pat. application Ser. No. 09/478,953, filed on Jan. 7, 2000 which claims priority from U.S. Pat. application Ser. No. 09/453,978, filed Dec. 2, 1999, which issued as U.S. Pat. No. 6,309,397 on Oct. 30, 2001, the complete disclosures of which are incorporated herein by reference.[0001]
• This application is related to the following patents and patent applications, the full disclosures of which are incorporated herein by reference: PCT International application Ser. No. PCT/US98/19508, entitled “Robotic Apparatus”, filed on Sep. 18, 1998, U.S. application Ser. No. ______ (Attorney Docket No. 17516-003210), entitled “Surgical Robotic Tools, Data Architecture, and Use”, filed on Oct. 15, 1999; U.S. application Ser. No. 60/111,711, entitled “Image Shifting for a Telerobotic System”, filed on Dec. 8, 1998; U.S. application Ser. No. 09/378,173, entitled “Stereo Imaging System for Use in Telerobotic System“, filed on Aug. 20, 1999; U.S. application Ser. No. 09/398,507, entitled “Master Having Redundant Degrees of Freedom”, filed on Sep. 17, 1999, U.S. application Ser. No. 09/399,457, entitled “Cooperative Minimally Invasive Telesurgery System”, filed on Sep. 17, 1999; U.S. Provisional Application Serial No. 09/373,678, entitled “Camera Referenced Control in a Minimally Invasive Surgical Apparatus”, filed on Aug. 13, 1999; U.S. Provisional Application Serial No. 09/398,958, entitled “Surgical Tools for Use in Minimally Invasive Telesurgical Applications”, filed on Sep. 17, 1999; and U.S. Pat. No. 5,808,665, entitled “Endoscopic Surgical Instrument and Method for Use”, issued on Sep. 15, 1998.[0002]
BACKGROUND OF THE INVENTION
• Advances in minimally invasive surgical technology could dramatically increase the number of surgeries performed in a minimally invasive manner. Minimally invasive medical techniques are aimed at reducing the amount of extraneous tissue that is damaged during diagnostic or surgical procedures, thereby reducing patient recovery time, discomfort, and deleterious side effects. The average length of a hospital stay for a standard surgery may also be shortened significantly using minimally invasive surgical techniques. Thus, an increased adoption of minimally invasive techniques could save millions of hospital days, and millions of dollars annually in hospital residency costs alone. Patient recovery times, patient discomfort, surgical side effects, and time away from work may also be reduced with minimally invasive surgery.[0003]
• The most common form of minimally invasive surgery may be endoscopy. Probably the most common form of endoscopy is laparoscopy, which is minimally invasive inspection and surgery inside the abdominal cavity. In standard laparoscopic surgery, a patient's abdomen is insufflated with gas, and cannula sleeves are passed through small (approximately ½ inch) incisions to provide entry ports for laparoscopic surgical instruments. The laparoscopic surgical instruments generally include a laparoscope (for viewing the surgical field) and working tools. The working tools are similar to those used in conventional (open) surgery, except that the working end or end effector of each tool is separated from its handle by an extension tube. As used herein, the term “end effector”means the actual working part of the surgical instrument and can include clamps, graspers, scissors, staplers, and needle holders, for example. To perform surgical procedures, the surgeon passes these working tools or instruments through the cannula sleeves to an internal surgical site and manipulates them from outside the abdomen. The surgeon monitors the procedure by means of a monitor that displays an image of the surgical site taken from the laparoscope. Similar endoscopic techniques are employed in, e.g., arthroscopy, retroperitoneoscopy, pelviscopy, nephroscopy, cystoscopy, cisternoscopy, sinoscopy, hysteroscopy, urethroscopy and the like.[0004]
• There are many disadvantages relating to current minimally invasive surgical (MIS) technology. For example, existing MIS instruments deny the surgeon the flexibility of tool placement found in open surgery. Most current laparoscopic tools have rigid shafts, so that it can be difficult to approach the worksite through the small incision. Additionally, the length and construction of many endoscopic instruments reduces the surgeon's ability to feel forces exerted by tissues and organs on the end effector of the associated tool. The lack of dexterity and sensitivity of endoscopic tools is a major impediment to the expansion of minimally invasive surgery.[0005]
• Minimally invasive telesurgical robotic systems are being developed to increase a surgeon's dexterity when working within an internal surgical site, as well as to allow a surgeon to operate on a patient from a remote location. In a telesurgery system, the surgeon is often provided with an image of the surgical site at a computer workstation. While viewing a three-dimensional image of the surgical site on a suitable viewer or display, the surgeon performs the surgical procedures on the patient by manipulating master input or control devices of the workstation. The master controls the motion of a servomechanically operated surgical instrument. During the surgical procedure, the telesurgical system can provide mechanical actuation and control of a variety of surgical instruments or tools having end effectors such as, e.g., tissue graspers, needle drivers, or the like, that perform various functions for the surgeon, e.g., holding or driving a needle, grasping a blood vessel, or dissecting tissue, or the like, in response to manipulation of the master control devices.[0006]
• A typical surgery employs a number of different surgical instruments. When a different tool is desired during the surgical procedure, the surgical instrument is typically withdrawn from the surgical site so that it can be removed from its associated arm and replaced with an instrument bearing the desired end effector. The desired surgical instrument is then inserted into the surgical site.[0007]
• A surgical instrument may also be withdrawn from a surgical site for reasons other than to replace the end effector. For example, the loading of a clip in a clip applier used in affixing tissue typically occurs outside of the patient's body. Each time a new clip is desired, the clip applier is removed from the surgical site to load the clip and then reintroduced into the patient's body to apply the clip. Tool exchange and instrument loading for a robotic system takes time. Providing additional surgical instruments in the surgical site (and the typically associated need to make additional incisions in the patient's body) may be an undesirable alternative for any number of reasons, e.g., due to space constraints, increase in system complexities, and/or cost.[0008]
SUMMARY OF THE INVENTION
• The present invention is generally directed to robotic surgery methods, devices, and systems. The invention overcomes the problems and disadvantages of the prior art by providing surgical clips and/or other in vivo accessories at the surgical site. These in vivo accessories can be manipulated by robotic surgical tools in the site for performing different tasks. The accessories can be held by a dedicated accessory holder or support that is introduced into the surgical site through a separate opening. Alternatively, the accessories can be supported on the body of one of the surgical tools, and can be manipulated using another surgical tool in the surgical site. The surgical tools in the surgical site can use the accessories for performing a wide range of additional tasks without leaving the surgical site. In this way, the need to exchange tools and load instruments outside the surgical site is reduced, thereby minimizing “down time”.[0009]
• In accordance with an aspect of the present invention, a method of performing minimally invasive robotic surgery in a body cavity of a patient includes introducing at least one surgical accessory and a robotic surgical tool into the cavity. The surgical accessory is coupled with the robotic surgical tool inside the cavity after introducing the surgical accessory and the robotic surgical tool into the cavity. The surgical accessory may be decoupled from the robotic surgical tool inside the cavity.[0010]
• In some embodiments, the robotic surgical tool is used to grasp the surgical accessory inside the cavity of the patient. In other embodiments, the surgical accessory is mated with the robotic surgical tool to form a mated connection. The surgical accessory may be coupled with the robotic surgical tool by introducing a second robotic surgical tool into the cavity and using it to facilitate coupling of the surgical accessory with the first surgical tool.[0011]
• In certain preferred embodiments, the surgical accessory is introduced into the cavity supported by a surgical accessory support and the surgical accessory is removable from the surgical accessory support within the cavity. In a specific embodiment, the surgical accessory support includes a container. In another embodiment, the surgical accessory support includes a block having a material which deflects to releasably secure one or more surgical accessories therein. In yet another embodiment, the surgical support is provided on the body of another robotic surgical tool introduced into the cavity.[0012]
• In a specific embodiment, a cartridge is introduced into the cavity to provide a plurality of surgical clips. The surgical tool is a clip applier. The clips are sequentially loaded in the clip applier within the cavity and the loaded clips are affixed to a target tissue with the clip applier.[0013]
• In some embodiments, a portion of a master control device located remotely from the patient is actuated by a user to control the robotic surgical tool to grasp the surgical accessory. The robotic surgical tool may be instructed to continue to grasp the surgical accessory without requiring the user to continue to actuate the actuatable portion of the master control device.[0014]
• In accordance with another aspect of the invention, a method of performing minimally invasive robotic surgery in a body cavity of a patient includes introducing a robotic fastening tool and a surgical accessory support into the cavity. The surgical accessory support supports a plurality of fastening accessories. One of the fastening accessories is loaded in the robotic fastening tool inside the cavity. The loaded fastening accessory is affixed to a target tissue inside the cavity with the robotic fastening tool.[0015]
• In a specific embodiment, the robotic fastening tool is a clip applier and the fastening accessories include a plurality of surgical clips. The clips are supported on a clip cartridge or on the body of another robotic surgical tool introduced into the cavity.[0016]
• Another aspect of the present invention is directed to a robotic surgical system for effecting a predetermined treatment of a target tissue at an internal surgical site within a patient body. The system includes a surgical accessory adapted for effecting the treatment, and an accessory introducer having a proximal end and a distal end with an opening therebetween. The distal end of the introducer is insertable into the patient body so that the opening defines a first minimally invasive aperture. The surgical accessory is coupled with the distal end of the introducer and is passable through the opening to the internal surgical site. A robotic arm supports a surgical tool having an end effector suitable for insertion through a second minimally invasive aperture to the internal surgical site. The end effector is coupleable with the surgical accessory within the internal surgical site so that the robot arm can manipulate the surgical accessory to direct the treatment to the target tissue.[0017]
• In some embodiments, the accessory comprises a tool tip configured to be releasably coupled to an end effector working member of the surgical tool to form a tool tip for the end effector. In specific embodiment, the end effector comprises a pair of working members and the accessory comprises a pair of fingers movably supported on a collar which is configured to be releasably coupled with the surgical tool in a coupled position. The pair of fingers mate with the pair of working members to be movable by the pair of working members in the coupled position.[0018]
• Another aspect of the invention is directed to an apparatus for providing a surgical accessory in vivo through a wall of a patient body into an internal cavity of the patient body for effecting a desired treatment of a target tissue in the patient body. The apparatus includes a surgical accessory adapted for effecting the treatment and an accessory introducer having a proximal end and a distal end with an opening therebetween. The distal end of the introducer is insertable into the patient body so that the opening defines a first minimally invasive aperture. The surgical accessory is coupled with the distal end of the introducer and passable through the opening to the internal cavity. A resilient member is connected with the accessory introducer to resiliently bias the surgical accessory to a preset desired location within the internal cavity.[0019]
• In a specific embodiment, the accessory introducer includes a support member configured to be anchored to the wall of the patient body at the opening. A slidable member is coupled with the surgical accessory and is slidable relative to the support member. The resilient member includes a spring coupled between the support member and the slidable member.[0020]
• In accordance with another aspect of the invention, a method of performing minimally invasive robotic surgery in an internal cavity of a patient body includes supporting a portion of a target tissue with a first robotic surgical tool introduced into the internal cavity. The first robotic surgical tool is electrically conductive. The method further includes contacting another portion of the target tissue with an electrically conductive cautery member introduced into the internal cavity. The first robotic surgical tool and the cautery member are energized for coagulating the target tissue. In some embodiments, the first robotic surgical tool and the cautery member are energized by connecting them to opposite leads of a radiofrequency power source to form a bipolar system. In a specific embodiment, the cautery member is held by a second robotic surgical tool and electrically insulated therefrom.[0021]
• In accordance with yet another aspect of the invention, a robotic surgical system for performing a procedure on a body comprises a surgical tool having an end effector including at least two end effector members, the members capable of grasping an object. A master control device has an actuatable portion which is operatively connected to the surgical tool such that actuation of the portion causes the at least two end effector members to grasp the object. The system includes an input device for accepting an input from a user to cause the end effector members to continue to grasp without further actuation of the actuatable portion of the master control device.[0022]
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1A is a perspective view of an operator station of a telesurgical system in accordance with an embodiment of the invention;[0023]
• FIG. 1B is a perspective view of a cart or surgical station of the telesurgical system according to an embodiment of the invention, the cart of this particular embodiment carrying three robotically controlled arms, the movement of the arms being remotely controllable from the operator station shown in FIG. 1A;[0024]
• FIG. 2A is a side view of a robotic arm and surgical instrument assembly according to an embodiment of the invention;[0025]
• FIG. 2B is a perspective view of the robotic arm and surgical instrument assembly of FIG. 2A;[0026]
• FIG. 3 is a perspective view of a surgical instrument according to an embodiment of the invention;[0027]
• FIG. 4 is a schematic kinematic diagram corresponding to the side view of the robotic arm shown in FIG. 2A, and indicates the arm having been displaced from one position into another position;[0028]
• FIG. 5 is a perspective view of a wrist member and end effector of the surgical instrument shown in FIG. 3, the wrist member and end effector being movably mounted on a working end of a shaft of the surgical instrument;[0029]
• FIG. 6A is a perspective view of a hand held part or wrist gimbal of a master control device of the telesurgical system;[0030]
• FIG. 6B is a perspective view of an articulated arm portion of the master control device of the telesurgical system on which the wrist gimbal of FIG. 6A is mounted in use;[0031]
• FIG. 6C is a perspective view of the master control device showing the wrist gimbal of FIG. 6A mounted on the articulated arm portion of FIG. 6B;[0032]
• FIGS. 6D and 6E depict a preferred embodiment of the master control device shown in FIGS.[0033]6A-6C having a locking mechanism for locking the slave end effector into an actuated position;
• FIG. 7 is a perspective view of a clip applier end effector in accordance with the invention;[0034]
• FIG. 8 is an exploded view of the clip applier end effector shown in FIG. 7;[0035]
• FIG. 9 is a schematic view of a clip cartridge for supplying clips in vivo to a clip applier;[0036]
• FIG. 10 is a schematic view illustrating supply of clips in vivo by another surgical tool in the surgical site;[0037]
• FIG. 11 is a perspective view showing examples of different single working member accessories;[0038]
• FIG. 11A is a schematic view illustrating a way of performing electrocautery;[0039]
• FIG. 11B is a schematic view illustrating another way of performing electrocautery;[0040]
• FIG. 12 is a side view of forceps;[0041]
• FIG. 13 is a perspective view of a surgical accessory support block according to an embodiment of the invention;[0042]
• FIG. 14 is a perspective view of a surgical accessory container according to another embodiment of the invention;[0043]
• FIG. 15A is a perspective view of a surgical accessory support belt in a deflated state according to another embodiment of the invention;[0044]
• FIG. 15B is a perspective view of the surgical accessory support belt of FIG. 15A in an inflated state;[0045]
• FIG. 16 is an elevational view of a tool tip for a single working member end effector according to another embodiment of the invention;[0046]
• FIG. 17 is a perspective view of a pair of tool tips for a double working member end effector according to another embodiment of the invention;[0047]
• FIG. 18A is a perspective view of a dual tip tool glove for a double working member end effector according to another embodiment of the invention;[0048]
• FIG. 18B is a partial cross-sectional view of the dual tip tool glove assembled with the double working member end effector of FIG. 18A;[0049]
• FIG. 19 is an exploded perspective view of insulative or resilient sheaths for forceps;[0050]
• FIG. 20 is a schematic view illustrating manipulation of an in vivo flow tube by a grasping tool;[0051]
• FIG. 21 is a schematic view illustrating introduction of an in vivo flow tube into the surgical site using a needle; and[0052]
• FIG. 22 is a schematic view illustrating an in vivo retraction member.[0053]
DESCRIPTION OF THE SPECIFIC PREFERRED EMBODIMENTS
• As used herein, “end effector” refers to the actual working part that is manipulatable for effecting a predetermined treatment of a target tissue. For instance, some end effectors have a single working member such as a scalpel, a blade, or an electrode. Other end effectors have a pair of working members such as forceps, graspers, scissors, or clip appliers, for example.[0054]
• As used herein, the terms “surgical instrument”, “instrument”, “surgical tool”, or “tool” refer to a member having a working end which carries one or more end effectors to be introduced into a surgical site in a cavity of a patient, and is actuatable from outside the cavity to manipulate the end effector(s) for effecting a desired treatment of a target tissue in the surgical site. The instrument or tool typically includes a shaft carrying the end effector(s) at a distal end, and is preferably servomechanically actuated by a telesurgical system for performing functions such as holding or driving a needle, grasping a blood vessel, and dissecting tissue.[0055]
• As used herein, the terms “surgical accessory” and “accessory” refer to an assisting member that is introduced into the surgical site in the cavity of the patient to be used by an instrument or tool to perform a desired function in the surgical site.[0056]
• One type of accessory is loaded in a surgical instrument and applied by the surgical instrument to a target tissue. For instance, fastening accessories are adapted to be used with a fastening tool for fastening tissues and the like. An example is a clip for use with a clip applier which affixes or anchors the clip to a target tissue. Another example is a suture needle with suture material for use with a suturing tool.[0057]
• Another type of accessory is a single working member accessory such as a blade, a scalpel, a dissection finger, or an electrode, which does not require the more complex mechanisms for manipulating multiple working members such as forceps. For instance, a single working member accessory can be grasped by a tool having a pair of working members in a jaw-like arrangement, which is adapted for manipulating different single working member accessories and providing them with the desired degrees of freedom in movement to perform different treatments.[0058]
• The accessory may be a tool tip that is configured to be releasably coupled to an end effector working member of the surgical tool to form a tool tip for the end effector. For an end effector having a pair of working members, the accessory may include a pair of fingers movably supported on a collar which is configured to be releasably coupled with the end effector in a coupled position. The pair of fingers mate with the pair of working members to be movable by the pair of working members in the coupled position.[0059]
• The working members of a tool can be modified by sheath accessories. For instance, forceps on the working end of a tool can be fitted with insulating sheaths when desired to inhibit electric current leakage and prevent burning.[0060]
• Another example of an accessory is a flow tube introduced into the cavity of the patient for providing suction, introducing a gas or a liquid, or transporting other matters into or out of the cavity. Such a flow tube can be grasped by a grasping tool inside the cavity and moved to the desired location for treating a particular area of the patient's body.[0061]
• A retraction accessory includes a gripping portion such as a hook which can be manipulated by a grasping tool and used, e.g., to grip a tissue inside the surgical site. The retraction accessory is resiliently biased by a spring, preferably an adjustable spring, to move to a desired location, thereby retracting the tissue to expose an area in the surgical site for treatment. The retraction accessory preferably can be manipulated from inside or outside the body to further position tissue as desired, e.g., by providing a friction slide on the spring mechanism to adjust the spring preload. Further, a selection of springs of different tensions and spring constants may be provided to the surgeon depending upon the distances involved between the body wall and the tissue to be retracted.[0062]
• I. Exemplar Telesurgical System[0063]
• FIG. 1A shows an operator station or surgeon's[0064]console200 of a minimally invasive telesurgical system. Thestation200 includes aviewer202 where an image of a surgical site is displayed in use. Asupport204 is provided on which an operator, typically a surgeon, can rest his or her forearms while gripping two master controls (not shown in FIG. 1A), one in each hand. The master controls are positioned in aspace206 inwardly beyond thesupport204. When using thecontrol station200, the surgeon typically sits in a chair in front of thecontrol station200, positions his or her eyes in front of theviewer202 and grips the master controls one in each hand while resting his or her forearms on thesupport204.
• FIG. 1B shows a cart or[0065]surgical station300 of the telesurgical system. In use, thecart300 is positioned close to a patient requiring surgery and is then normally caused to remain stationary until a surgical procedure to be performed has been completed. Thecart300 typically has wheels or castors to render it mobile. Thestation200 is typically positioned remote from thecart300 and can be separated from thecart300 by a great distance, even miles away, but will typically be used within an operating room with thecart300.
• The[0066]cart300 typically carries three robotic arm assemblies. One of the robotic arm assemblies, indicated byreference numeral302, is arranged to hold animage capturing device304, e.g., an endoscope, or the like. Each of the twoother arm assemblies10 respectively, includes asurgical instrument14. Theendoscope304 has aviewing end306 at a remote end of an elongate shaft thereof. It will be appreciated that theendoscope304 has an elongate shaft to permit itsviewing end306 to be inserted through an entry port into an internal surgical site of a patient's body. Theendoscope304 is operatively connected to theviewer202 to display an image captured at itsviewing end306 on theviewer202. Eachrobotic arm assembly10 is normally operatively connected to one of the master controls. Thus, the movement of therobotic arm assemblies10 is controlled by manipulation of the master controls. Theinstruments14 of therobotic arm assemblies10 have end effectors that are mounted on wrist members which are pivotally mounted on distal ends of elongate shafts of theinstruments14, as is described in greater detail below. It will be appreciated that theinstruments14 have elongate shafts to permit the end effectors to be inserted through entry ports into the internal surgical site of a patient's body. Movement of the end effectors relative to the ends of the shafts of theinstruments14 is also controlled by the master controls.
• The[0067]robotic arms10,10,302 are mounted on acarriage97 by means of setupjoint arms95. Thecarriage97 can be adjusted selectively to vary its height relative to abase99 of thecart300, as indicated by arrows K. The setupjoint arms95 are arranged to enable the lateral positions and orientations of thearms10,10,302 to be varied relative to a vertically extendingcolumn93 of thecart300. Accordingly, the positions, orientations and heights of thearms10,10,302 can be adjusted to facilitate passing the elongate shafts of theinstruments14 and theendoscope304 through the entry ports to desired positions relative to the surgical site. When thesurgical instruments14 andendoscope304 are so positioned, the setupjoint arms95 andcarriage97 are typically locked in position.
• As shown in FIGS. 2A and 2B, each[0068]robotic arm assembly10 includes an articulatedrobotic arm12 and asurgical instrument14 mounted thereon. As best seen in FIG. 3, thesurgical instrument14 includes an elongate shaft14.1 and a wrist-like mechanism50 located at a working end of the shaft14.1. Ahousing53, arranged releasably to couple theinstrument14 to therobotic arm12, is located at an opposed end of the shaft14.1. The shaft14.1 is rotatably coupled to thehousing53 at55 to enable angular displacement of the shaft14.1 relative to thehousing53 as indicated by arrows H. In FIG. 2A, and when theinstrument14 is coupled or mounted on therobotic arm12, the shaft14.1 extends along an axis14.2. Theinstrument14 typically is releasably mounted on a carriage11, which can be driven to translate along alinear guide formation24 of thearm12 in the direction of arrows P.
• The[0069]robotic arm12 is typically mounted on a base or platform at an end of its associated setupjoint arm95 by a bracket or mountingplate16. Therobotic arm12 includes acradle18, anupper arm portion20, aforearm portion22, and theguide formation24. Thecradle18 is pivotally mounted on theplate16 in a gimbaled fashion to permit rocking movement of thecradle18 in the direction ofarrows26 about a pivot axis28 (FIG. 2B). Theupper arm portion20 includeslink members30,32 and theforearm portion22 includeslink members34,36. Thelink members30,32 are pivotally mounted on thecradle18 and are pivotally connected to thelink members34,36. Thelink members34,36 are pivotally connected to theguide formation24. The pivotal connections between thelink members30,32,34,36, thecradle18, and theguide formation24 are arranged to constrain therobotic arm12 to move in a specific manner.
• The movements of the[0070]robotic arm12 are illustrated schematically in FIG. 4. The solid lines schematically indicate one position of the robotic arm and the dashed lines indicate another possible position into which the arm can be displaced from the position indicated in solid lines.
• It will be understood that the axis[0071]14.2 along which the shaft14.1 of theinstrument14 extends when mounted on therobotic arm12 pivots about a pivot center orfulcrum49. Thus, irrespective of the movement of therobotic arm12, thepivot center49 normally remains in the same position relative to thestationary cart300 on which thearm12 is mounted. In use, thepivot center49 is positioned at a port of entry into a patient's body when an internal surgical procedure is to be performed. It will be appreciated that the shaft14.1 extends through such a port of entry, the wrist-like mechanism50 then being positioned inside the patient's body. Thus, the general position of themechanism50 relative to the surgical site in a patient's body can be changed by movement of thearm12. Since thepivot center49 is coincident with the port of entry, such movement of the arm does not excessively effect the surrounding tissue at the port of entry.
• As can best be seen in FIG. 4, the[0072]robotic arm12 provides three degrees of freedom of movement to thesurgical instrument14 when mounted thereon. These degrees of freedom of movement are firstly the gimbaled motion indicated byarrows26, pivoting or pitching movement as indicated byarrows27 and the linear displacement in the direction of arrows P. Movement of the arm as indicated byarrows26,27 and P is controlled by appropriately positioned actuators, e.g., electrical motors or the like, which respond to inputs from its associated master control to drive thearm12 to a desired position as dictated by movement of the master control. Appropriately positioned sensors, e.g., potentiometers, encoders, or the like, are provided on the arm and its associated setupjoint arm95 to enable a control system of the minimally invasive telesurgical system to determine joint positions, as described in greater detail below. The term “sensors” as used herein is to be interpreted widely to include any appropriate sensors such as positional sensors, velocity sensors, or the like. By causing therobotic arm12 selectively to displace from one position to another, the general position of the wrist-like mechanism50 at the surgical site can be varied during the performance of a surgical procedure.
• Referring now to the wrist-[0073]like mechanism50 of FIG. 5, the working end of the shaft14.1 is indicated at14.3. The wrist-like mechanism50 includes awrist member52. One end portion of thewrist member52 is pivotally mounted in a clevis17 on the end14.3 of the shaft14.1 by means of apivotal connection54. Thewrist member52 can pivot in the direction of arrows56 about thepivotal connection54. Anend effector58 is pivotally mounted on an opposed end of thewrist member52. Theend effector58 has two parts58.1,58.2 together defining a jaw-like arrangement.
• The end effector can be in the form of any desired surgical tool, e.g., having two members or fingers which pivot relative to each other, such as a clip applier for anchoring clips, scissors, two-fingered blunt dissection tools, forceps, pliers for use as needle drivers, or the like. Moreover, it can include a single working member, e.g., a scalpel, cautery electrode, or the like. When a different tool is desired during the surgical procedure, the[0074]tool14 is simply removed from its associated arm and replaced with an instrument bearing the desired end effector.
• In FIG. 5, the[0075]end effector58 is a grip applier. Theend effector58 is pivotally mounted in aclevis19 on an opposed end of thewrist member52, by means of apivotal connection60. The free ends11,13 of the parts58.1,58.2 are angularly displaceable about thepivotal connection60 toward and away from each other as indicated byarrows62,63. The members58.1,58.2 can be displaced angularly about thepivotal connection60 to change the orientation of theend effector58 as a whole, relative to thewrist member52. Thus, each part58.1,58.2 is angularly displaceable about thepivotal connection60 independently of the other, so that theend effector58, as a whole, is angularly displaceable about thepivotal connection60 as indicated in dashed lines in FIG. 5. Furthermore, the shaft14.1 is rotatably mounted on thehousing53 for rotation as indicated by thearrows59. Thus, theend effector58 has three degrees of freedom of movement relative to thearm12 in addition to actuation of the end effector members to, e.g., grip tissue, namely, rotation about the axis14.2 as indicated byarrows59, angular displacement as a whole about thepivot60 and angular displacement about thepivot54 as indicated by arrows56. By moving the end effector within its three degrees of freedom of movement, its orientation relative to the end14.3 of the shaft14.1 can selectively be varied. The movement of the end effector relative to the end14.3 of the shaft14.1 is controlled by appropriately positioned actuators, e.g., electrical motors, or the like, which respond to inputs from the associated master control to drive theend effector58 to a desired orientation as dictated by movement of the master control. Furthermore, appropriately positioned sensors, e.g., encoders, or potentiometers, or the like, are provided to permit the control system of the minimally invasive telesurgical system to determine joint positions.
• One of the master controls[0076]700 is shown in FIG. 6C. As seen in FIG. 6A, a hand held part orwrist gimbal699 of themaster control device700 has an articulated arm portion including a plurality of members orlinks702 connected together by pivotal connections or joints704. The surgeon grips thepart699 by positioning his or her thumb and index finger over apincher formation706. The surgeon's thumb and index finger are typically held on thepincher formation706 by straps (not shown) threaded throughslots710. When thepincher formation706 is squeezed between the thumb and index finger, the fingers or end effector elements of theend effector58 close. When the thumb and index finger are moved apart the fingers of theend effector58 move apart in sympathy with the moving apart of thepincher formation706. The joints of thepart699 are operatively connected to actuators, e.g., electric motors, or the like, to provide for, e.g., force feedback, gravity compensation, and/or the like. Furthermore, appropriately positioned sensors, e.g., encoders, or potentiometers, or the like, are positioned on each joint704 of thepart699, so as to enable joint positions of thepart699 to be determined by the control system.
• The[0077]part699 is typically mounted on an articulatedarm712 as indicated in FIG. 6B.Reference numeral4 in FIGS. 6A and 6B indicates the positions at which thepart699 and the articulatedarm712 are connected together. When connected together, thepart699 can displace angularly about an axis at4.
• The articulated[0078]arm712 includes a plurality oflinks714 connected together at pivotal connections or joints716. The articulatedarm712 further has appropriately positioned actuators, e.g., electric motors, or the like, to provide for, e.g., force feedback, gravity compensation, and/or the like. Furthermore, appropriately positioned sensors, e.g., encoders, or potentiometers, or the like, are positioned on thejoints716 so as to enable joint positions of the articulatedarm712 to be determined by the control system.
• To move the orientation of the[0079]end effector58 and/or its position along a translational path, the surgeon simply moves thepincher formation706 to cause theend effector58 to move to where he wants theend effector58 to be in the image viewed in theviewer202. Thus, the end effector position and/or orientation is caused to follow that of thepincher formation706.
• The[0080]master control devices700,700 are typically mounted on thestation200 through pivotal connections at717 as indicated in FIG. 6B. As mentioned above, to manipulate eachmaster control device700, the surgeon positions his or her thumb and index finger over thepincher formation706. Thepincher formation706 is positioned at a free end of thepart699 which in turn is mounted on a free end of the articulatedarm portion712.
• The electric motors and sensors associated with the[0081]robotic arms12 and thesurgical instruments14 mounted thereon, and the electric motors and sensors associated with themaster control devices700 are operatively linked in the control system. The control system typically includes at least one processor, typically a plurality of processors, for effecting control between master control device input and responsive robotic arm and surgical instrument output and for effecting control between robotic arm and surgical instrument input and responsive master control output in the case of, e.g., force feedback. An example of a suitable control system is described in U.S. application Ser. No. 09/373,678, entitled “Camera Referenced Control in a Minimally Invasive Surgical Apparatus”, filed on Aug. 13, 1999.
• II. In Vivo Accessories[0082]
• To minimize the need to remove tools from the surgical site for tool replacement or instrument loading, the present invention provides ways to present a variety of accessories in vivo. The surgeon can manipulate these in vivo accessories using tools already in the surgical site and adapt them for performing different functions without the need to remove the tools from the surgical site. A number of examples of in vivo accessories are provided herein below.[0083]
• A. Instrument Loading Accessories[0084]
• Certain instruments are used by loading accessories specifically adapted for use with the particular instruments to perform the intended tasks. For example, fastening accessories such as clips are specifically adapted for use with a clip applier. The clips are loaded in a clip applier which affixes or anchors the clips one at a time to a target tissue.[0085]
• FIGS. 7 and 8 show in greater detail the clip[0086]applier end effector58 for thetool14 of FIG. 5. The parts58.1,58.2 of theend effector58 are typically the same so as to keep production costs low. Accordingly, the parts58.1,58.2 each include an elongate finger portion or end effector element58.3. The finger portion58.3 is integrally formed with an end effector mounting formation in the form of, e.g., a pulley portion58.5. The pulley portion58.5 defines a circumferentially extending channel58.6 in which an elongate element in the form of, e.g., an activation cable, is carried, as described in greater detail herein below.
• The pulley portion[0087]58.5 includes an axially extending, centrally disposed hole58.7 through which a pivot pin of thepivotal connection60 extends. A generally circumferentially directed hole58.8 extends through a nape region of the finger portion58.3 and generally in register with the circumferentially extending channel58.6. The hole58.8 has a first portion58.9 and a second portion58.10 having a diameter greater than the first portion58.9. In use, the activation cable has a thickened portion along its length which seats in the hole portion58.10, the rest of the activation cable then extending along the channel58.6 in opposed directions. The thickened portion is crimped in its seated position in the hole portion58.10 so as to anchor the cable in the hole58.8. It will be appreciated that a greater force is necessary to clamp the free ends together when gripping an object therebetween, than that which is required to open the free ends11,13. Thus, the thickened portion of the cable is urged against an annular stepped surface between the hole portion58.9 and the hole portion58.10, when the free ends11,13 are urged into a closed condition. The part58.1,58.2 has an operatively inwardly directed face58.11 which rides against the face58.11 of the other one of the parts58.1,58.2.
• In use, a[0088]clip75, as indicated in FIG. 8, is positioned between the finger portions58.3. Opposed limbs75.1,75.2 of theclip75 are positioned in longitudinally extending recesses or seats58.13 in each of the finger portions58.1,58.2. It is important that the clip is securely seated in theclip applier58 until the clip applier is caused to anchor the clip in position. If theclip75 is not securely seated, theclip75 could become dislocated from theclip applier58. In such a case, valuable time could be lost in trying to find and recover theclip75 from the surgical site. To cause theclip75 to seat securely on theclipper pliers58, the portions58.158.2 are biased or urged in a closing direction so as to clamp theclip75 in the opposed seats or recesses58.13. The biasing or urging arrangement to cause such clamping of theclip75 in the seats58.13, as well as the mechanisms for operating the clipapplier end effector58, are discussed in detail in U.S. application Ser. No. 09/398,958, entitled “Surgical Tools for Use in Minimally Invasive Telesurgical Applications”, (Docket No. 17516-4410), filed on Sep. 17, 1999, the entirety of which is herein incorporated by reference. Alternatively, as described in the ′958 application, instead of being urged or biased towards each other, portions58.1 and58.2 can be constructed in such a way (with open-ended recesses58.13) as to open (e.g., against mechanical stops) to a predetermined angular position slightly less than the angle of the clips to be used. Thus, the natural resistance of the clip to deformation provides sufficient friction when loaded into the clip applier that a separate biasing means is unnecessary.
• Normally, in use, the clip applier having the[0089]end effector58 is removed from the surgical site, aclip75 is then positioned between the finger portions58.3, and then theend effector58 is reintroduced into the patient's body so as to apply or anchor theclip75 where required. To apply the clip, the master controls are manipulated to cause the clip applier to close so as to bend theclip75. When theclip75 has been applied, theend effector58 can again be opened and removed from the surgical site, anotherclip75 can then be positioned between the finger portions58.3, and the end effector can again be introduced to the surgical site to apply that clip and so on, until all the required clips have been applied or anchored in position. This process is time-consuming.
• In accordance with an embodiment of the present invention, the[0090]clips75 are introduced into thesurgical site77 in a cavity of a patient by a dedicated surgical accessory support in the form of acartridge76. Theend effector58 of the clip applier can be manipulated servomechanically or manually from outside the cavity to load aclip75 from thecartridge76 and affix theclip75 to a target tissue inside the cavity. Theend effector58 need not be removed from thesurgical site77 for loading theclip75 and reintroduced into thesurgical site77.
• In another embodiment shown in FIG. 10, the[0091]clips75 are supported on the shaft of anothertool81 having an end effector81.1 in a “piggyback” arrangement, thereby eliminating the need to open a separate port for introducing a dedicated accessory support into thesurgical site77. Cannula sleeves77.1 are typically provided through the wall77.2 of the patient's body for introducing the surgical tools and accessory support into thesurgical site77.
• As can be understood with reference to FIG. 10, releasably mounting a surgical accessory (such as clip[0092]75) to a robotically controlled structure (such as tool81) may facilitate mating of the accessory withtool14.Tool81 can be easily and accurately positioned in a field of view ofscope306 for loading theclip applier58.Tool14 and/ortool81 may be positioned and moved to accurately transferclip75 fromtool81 to clipapplier58 within the field of view from the scope using the robotic servomechanism to generate the desired clip loading forces, without having to verbally coordinate hand movements of two different persons.
• B. Single Working Member Accessories[0093]
• Another type of accessory is a single working member accessory such as a blade, a scalpel, a dissection finger, or an electrode, which does not require the more complex mechanisms for manipulating multiple working members such as forceps and clip appliers. For instance, the single working member accessory can be grasped by jaw-like working members such as forceps on a tool which can be used for manipulating different single working member accessories and providing them with the desired degrees of freedom of movement to perform different treatments on tissues in the surgical site.[0094]
• FIG. 11 shows examples of single working member accessories, including a cautery or[0095]electrosurgical hook118, acautery blade119, ascalpel120, and adissection finger121 or Kittner for blunt dissection. Another example of a single working member accessory is anelectrocautery electrode122 used to generate an electrical current at a surgical site so as to bum or seal, e.g., ruptured blood vessels. In use, the patient is earthed and a voltage is supplied to theelectrode122. An electricallyconductive cable124 is connected to theelectrode122. In use, thecable124 couples theelectrode122 to an appropriate electrical source outside the surgical site, preferably through an accessory body wall port. Theconductive cable124 is typically sheathed in an insulative material such as, e.g., TEFLON™. The electrode, in the form of a blade or hook, e.g., or other accessories may be dangled into the patient's body cavity through a body wall port by way of the cable and/or an associated spring mechanism, as disclosed in the context of FIGS. 16 and 18A. Grasping tool can be used to grasp one of the single working member accessories and manipulate its movement to treat the target tissue. Exemplary electrosurgical implements are disclosed in U.S. Application No. 09/ (Attorney Docket No. 17516-007200), entitled “Minimally Invasive Surgical Hook Apparatus & Method for Using Same”, filed on Oct. 8, 1999, the entirety of which is herein incorporated by reference.
• It will be appreciated that should the distance between the[0096]electrode122 and the patient be relatively great when a voltage is applied, current may jump from theelectrode122 to other conductive parts of the instrument. In such a case, current can be passed from the grasping tool to the patient along a path of least resistance, e.g., at the entry port coincident with the center of rotation49 (see FIGS. 2A and 2B). This may cause unnecessary burning at the entry port. One way of avoiding such current flow is to insulate theelectrode122 from the grasping tool so as to inhibit current leakage from theelectrode122 to the tool. Accordingly, the components of the grasping tool may be made of non-conductive material such as, e.g., ULTEM™ or VECTRAN™. The shaft of the tool is typically made entirely from a nonconductive material, or at least sheathed in such a material, to insulate the shaft from the patient, in particular in the region of the port of entry. The preferred nonconductive material for the shaft114.1 comprises an electrical grade fiberglass/vinyl ester composite material. A shaft of stainless steel or carbon fiber may be coated with, e.g., a nylon or parylene, such as Nylon-11 or Parylene C.
• FIG. 11A shows one way of performing electrocautery with superior safety and precision. The[0097]electrode122 is grasped by a grasping tool such asforceps125 having insulative components for making contact with theelectrode122. Alternatively, theelectrode22 can be partially sheathed in nonconductive material for making contact with the other tool. Anothertool127A is used to hold a tissue such as avessel129A. The portion of thetool127A in contact with thetissue129A is electrically conductive. Theelectrode122 is coupled with one lead of a bipolar system, while the graspingtool127A holding thetissue129A is coupled with the other lead of the bipolar system. Theelectrode122 is an active electrode and thetool127A is a passive electrode. The tissue disposed between the active and passive electrodes complete the electrical circuit of the bipolar system. When sufficient power is introduced, coagulation of the tissue between theelectrode122 and thetool127A occurs.
• In another embodiment shown in FIG. 11B, the[0098]tool127B is placed behind the target area of thetissue129B, while theelectrode122 approaches the target area from the front to define a specific coagulation zone. In both FIGS. 11A and 11B, the coagulation zone for thetissue129B is well-defined to provide safe, direct electrocauterization.
• FIG. 12 shows an example of a grasping[0099]tool having forceps110 for grasping and manipulating one of the single working member accessories inside the surgical site. Theforceps110 is mounted on a wrist mechanism similar to thewrist mechanism50. Theforceps110 has two working members110.1,110.2. The working members110.1,110.2 are slightly bent to define aspace112 between them. In use, it is difficult to provide force feedback to the master controls. Thus, it could happen that an organ, or tissue, or the like, can be grasped by forceps with too much force which may unnecessarily damage such organ or tissue. To inhibit this, thespace112 is provided. The members110.1,110.2 have a degree of resilience. Thus, when the forceps is used, the surgeon manipulating the master controls can obtain an indication of the force applied when grasping with theforceps110 by visually monitoring resilient deflection of the members110.1,110.2 relative to each other, all as described in U.S. application Ser. No. 09/398,958.
• The single working member accessories can be introduced into the surgical site in any suitable way. For instance, each accessory can be connected to a cable and inserted through an opening into the surgical site and be removed from the site by pulling on the cable from outside the patient's body. Alternatively, an accessory support can be used to introduce a plurality of accessories into the surgical site.[0100]
• FIG. 13 illustrates a surgical accessory support in the form of a[0101]block126 for holding the accessories such as thecautery blade119,scalpel120, anddissection finger121. Theblock126 is introduced through the cavity wall77.2 via a cannula sleeve77.1. Thesupport block126 in one embodiment is made of a foam material or the like which deflects to releasably secure the accessories therein. The accessories can be removed by the graspingtool110 inside the surgical site to perform a desired treatment and then returned to theblock126 after use. Theblock126 is particularly suitable for supporting sharp objects such as blades and scalpels.
• FIG. 14 shows a container or[0102]box130 as another embodiment of a surgical accessory support. Thebox130 extends through the cavity wall77.2 via a cannula sleeve77.1. Ahandle132 supports thebox130 in the surgical site from outside the patient's cavity. Thebox130 includes acompartment134 for housing accessories and a door136 which can be opened to allow access to the accessories, and be closed during transportation of the box136 into and out of the surgical site. A variety of mechanisms can be used to control movement of the door136. In the embodiment shown, acontrol rod138 is connected with the door136 and extends through the end of thehandle132. Thecontrol rod138 allows the operator to open the door136 by pushing therod138 toward thehandle132 and to close thedoor130 by pulling therod138 away from thehandle132. A physical or solenoid-activated latch might be included to lock the door in an open configuration during an operation, if desired. It is appreciated that other devices can be used for introducing the surgical accessories into the surgical site and supporting them therein.
• In another embodiment as shown in FIG. 15A, an inflatable tool belt or[0103]support730 can be used to holdaccessories732 such as needles, gauze, or blades, and can be inserted into the surgical site through a port with thetool belt730 in a deflated state. Theaccessories732 may be releasably attached to thetool belt730 in any suitable manner, such as the use of velcro or the like. After thetool belt730 has been inserted into the surgical site, it can be inflated in a manner similar to a balloon catheter to expose theaccessories732 so that they may be used in the surgical site, as illustrated in FIG. 15B. Theinflated tool belt730 provides support for theaccessories732 and may cause the accessories to stand in an erect position, making them more easily graspable by a grasping tool such asforceps110 or the like. Thetool belt730 can be deflated for retraction. A mechanism similar to those used for balloon catheters can be used for inflating and deflating thetool belt730.
• Single working member end effectors, such as a blade or a scalpel on a surgical tool can also be replaced inside the patient without removing the tool from the patient's body cavity. Mechanisms allowing such replacement include, e.g., a blade mounted on a pliable polymeric sleeve that fits snugly over a finger-like projection. For replacement, the tool is simply loosened and attached to an accessory belt of the type disclosed herein, and replaced with another single member tool having a similar sheath mounting structure. Alternative methods of mounting single member tools to the end of a robotic tool are disclosed in FIGS.[0104]17-19 of U.S. application Ser. No. 09/398,598, which is incorporated herein by reference in its entirety.
• C. Tool Tip Accessories[0105]
• FIG. 16 shows an example of a[0106]removable tool tip740 for a single workingmember end effector742 having a drivepulley744 connected with atool end746. Thetool tip740 is one of a plurality of tool tip accessories that can be introduced separately into the surgical tool so that theend effector742 can be fitted with different tool tips for performing different procedures as desired without having to leave the surgical site. Examples of tool tips include blades, scalpels, electrodes, and the like. Thetool tip740 and thetool end746 are configured to form a mating connection. Thetool tip740 can be grasped by a grasping tool and be snapped or wedged onto thetool end746. In the embodiment shown, thetool tip740 has aprotrusion747 that detachably fits into a slot or recess748 of thetool end746. To remove thetool tip740, the grasping tool can be used to grasp thetool tip740 and disengage it from thetool end746. It is understood that other detachable mechanisms may be used for connecting thetool tip740 with thetool end746 including, for example, cantilever-type snaps or the like.
• In FIG. 17, a double working[0107]member end effector750 has a pair of tool ends752 that can be fitted with twotool tips754 bymating protrusions757 of thetool tips754 withslots758 of the tool ends752. A pair of drive pulleys756 are connected with the tool ends752 to move thetool tips754 in a jaw-like arrangement. Thetool tips754 may include sets of forcep tips or other jaw-like working member tips of varying sizes or shapes.
• Another way to provide different tool tips for a double working member end effector is to use a dual[0108]tip tool glove760 as illustrated in FIGS. 18A and 18B. As shown in FIG. 18A, thetool glove760 includes a pair offingers762 that are pivotally attached to a tool glove support orcollar764. Thecollar764 is a hollow member configured to be placed over thewrist member766 of a double workingmember end effector768. Thewrist member766 supports a pair of drive pulleys770 that are connected to a pair of tool ends ornubs772. The tool nubs772 are inserted into a pair ofopenings774 of the pair offingers762 of thetool glove760 when thetool glove760 is joined with thewrist member766 in the attached position shown in FIG. 18B. Thepulleys770 are actuatable (typically by cables) to rotate thetool nubs772 which in turn cause thefingers762 to rotate and to move, e.g., in ajaw-like manner.
• The[0109]collar764 is configured to be releasably locked onto thewrist member766. As best seen in FIG. 18B, thecollar764 includes aspring retention ring776 which applies a resilient force to wrap around agroove778 on thewrist member766 to resiliently lock thecollar764 onto thewrist member766 in the attached position. Thespring retention ring776 is typically a metal ring held in a groove in thecollar764, and can split to expand in diameter and allow thecollar764 to be placed over thewrist member766. A grasping tool may be used to manipulate thetool glove760 for assembly with thewrist member766. When theretention ring776 reaches thegroove778 on thewrist member766, it contracts around thegroove778 from the split position, thereby releasably locking thecollar764 onto thewrist member766. To disconnect thetool glove760 from thewrist member766, a sufficient pulling force is applied to thetool glove760 via the grasping tool to overcome the resilient force of theretention ring776. It is appreciated that other releasable locking mechanisms may be used for locking thetool glove760 onto thewrist member766 of theend effector768. Further, thefingers762 of thetool glove760 may have other configurations.
• It has been found that when a surgeon uses a grasper to grab and hold an accessory tool for an extended period of time to perform surgery, in the manner previously described, the surgeon at some point may wish to relax his grip on the master control without the grasper losing its grip on the accessory tool. Further, the surgeon may wish to operate using the accessory tool without having to constantly grip the master control to actuate the grasper to grip the accessory. This ability to avoid constantly having to actuate two-member tools to close/grip is also desirable, e.g., during suturing, when the surgeon may need to exert a large gripping force on a needle while manipulating the needle to sew tissue. Such maneuvers sometimes can prove awkward and tiring to the surgeon's hands if too much gripping in involved over a long period of time. This problem is addressed by providing the surgeon with the ability to “lock” the graspers closed, after actuation, so that the graspers remain closed and gripping, e.g., a needle or accessory tool until the surgeon commands the graspers to do otherwise. Locking the two-membered tool in a closed/gripping position allows the surgeon to relax his gripping pressure on the master control after actuation of the tool. This functionality can be implemented in any number of ways, such as by the surgeon physically- or voice-activating a switch or button or latch on the master control while the tool is actuated, to instruct the system to maintain the tool's actuation until a further command is received, or by programming the control computer to detect when the operator intends to actuate the virtual locking function, e.g., by detecting a threshold closing force on the masters applied over a specific period of time, such as two seconds. Several threshold forces, corresponding to several different closing/locking forces might be provided as desired. Once the command is given, the computer would lock that particular tool into position and either maintain the particular force applied by the surgeon at the time the locking command was provided, or would maintain a maximum gripping force (depending upon how the system is configured) without further gripping force from the surgeon on the corresponding master control, until a further “unlock” command is given. Upon activation in this manner, the surgical system preferably would provide the surgeon with a perceivable indication that the tool was locked, e.g., through an audible sound, illumination of a locking light, illumination of an icon on the surgeon's console screen, etc. One example of a latch locking mechanism is shown in FIG. 6D. Sliding[0110]button703 inslot701 has two positions, as more clearly seen in FIG. 6E. When in a first position, latches705 and707 do not catch when thepincher formation706 is closed. When in a second position, however, latches705 and707, preferably made of a resilient metal such as spring steel (similar to the latching mechanism on the Castro-Viejo Needle Drivers made by Scanlan), do catch, thereby keeping the master locked into position and the slave end effector actuated until released. In this embodiment, the pincher formation remains in a closed profile. If desired, the end effector could be locked as described above while leaving the surgeon free to continue to manipulate the pincher formation as before—e.g., for comfort reasons—but without giving the surgeon the ability to further affect the actuation of the end effector until “unlocking” the mechanism.
• The tool is preferably unlocked in similar manner by a threshold outward force on the master actuation controls, or activation of a separate button or voice control. Upon unlocking, the surgeon would again be able to control the end effector as before, and preferably would be provided with an indication from the system that the unlock command had been received, such as another audible or visual signal or elimination of the previously illuminated icon.[0111]
• D. Sheath Accessories[0112]
• Sheath accessories can be used to modify the working members of a surgical tool. For instance, a pair of jaw-like working members such as forceps on the working end of a tool can be fitted with insulating sheaths or resilient sheaths when desired.[0113]
• FIG. 19 shows forcep[0114]sheaths140 configured to fit over working members110.1,110.2 offorceps110, forming a mated connection therewith. For insulation, theforcep sheaths140 are made of an insulative material such as rubber, VECTRAN™, ULTEM™, or the like. In an alternative embodiment, theforcep sheaths140 are made of a resilient material such as an elastomer for protecting tissues from damage caused by excessive pressure exerted by theforceps110. The surgeon can visually monitor the deformation of theresilient sheaths140 and adjust the gripping force accordingly. Thesheaths140 can be introduced into the surgical site by the container of FIG. 14, and be placed over theforceps110 while inside the body cavity using another grasping tool, for example.
• E. Other Accessories[0115]
• Another example of an accessory is a[0116]flow tube150 introduced into the cavity of the patient for providing suction, introducing a gas or a liquid, or transporting other matters into or out of the cavity, as shown in FIG. 20. Theflow tube150 can be grasped, for example, by a graspingtool having forceps110 inside the cavity and moved to the desired location for treating a particular area of the patient's body.
• In FIG. 20, the[0117]flow tube150 is inserted through the cavity wall77.2 of a patient into the cavity via atube support152. Theflow tube150 is typically flexible. Theflow tube150 includes anopening154 at a distal end. Theflow tube150 can be connected with a vacuum source to provide suction to draw out fluid or other matters from the cavity through theopening154, or an external source for introducing a fluid in the form of a liquid such as saline or a gas such as CO₂into the surgical site, or the like. In one embodiment, the flow through theopening154 of thetube150 can be modulated by adjusting the grip of the grasper on thetube150.
• To minimize interference with the manipulation of tools in the surgical site, the[0118]flow tube150 is advantageously resiliently biased by aspring156 to return to the location near thetube support152 at the aperture of the cavity wall77.2. Thespring156 compresses when thetube150 is pulled further into the surgical site and causes thetube150 to automatically return closer to the wall aperture when thetube150 is released by theforceps110. In this way, theflow tube150 stays clear of the remaining area of the surgical site. It is appreciated that other suitable resilient mechanisms may be employed, and that a similar resilient mechanism can be adapted for use with other accessory introducing devices.
• In some cases, the[0119]tube150 is sufficiently small that thetube support152 is no larger in cross-section than a typical hypodermic needle. FIG. 21 shows the use of ahollow needle158 for introducing theflow tube150 into theinternal cavity77. Apad159 is affixed to the external surface of the cavity wall77.2 of the patient. Thepad159 is typically made of a rubber or foam-like material, and may include a self-adhering surface for affixing to the external surface. Theneedle158 pierces through thepad159 and cavity wall77.2 carrying theflow tube150 through its core into thecavity77. In a specific embodiment, the needle is a small gauge Veress needle.
• Another example of an accessory is a[0120]retraction member160 introduced through the cavity wall77.2 of a patient via asupport housing162 for retracting tissue or the like, as illustrated in FIG. 22. The distal portion of thehousing162 which extends through the cavity wall77.2 is desirably small to minimize the size of the incision. In a specific embodiment, the distal portion of thehousing162 is as small as a12 gage needle. Theretraction member160 includes a gripping portion such as ahook164 or the like for securing atissue168 or other objects inside the cavity. Theretraction member160 is connected with apiston165 which is slidably disposed in thesupport housing162. Aspring166 biases thepiston165 away from the cavity wall77.2 and, as a result, biases theretraction member160 toward the distal portion of thesupport162 at the opening of the cavity wall77.2. Theretraction member160 can be grasped, for example, by a grasping tool inside the cavity to secure thetissue168 with thehook164. When theretraction member160 is released, the biasing force of thespring166 returns theretraction member160 to the position nearer the opening of the cavity wall77.2, thereby retracting thetarget tissue168 from its original location indicated at168A. The displacement of thetissue168 exposes the desired target area for treatment.
• The above-described arrangements of apparatus and methods are merely illustrative of applications of the principles of this invention and many other embodiments and modifications may be made without departing from the spirit and scope of the invention as defined in the claims. For instance, other telesurgical systems, e.g., without a remote center of motion, and surgical tools can be used to perform surgery with the in vivo accessories. The examples of surgical accessories and ways of presenting them in vivo are illustrative and not exhaustive. Additional illustrative examples of surgical accessories that can be provided in vivo in accordance with the present invention include various gauge needles and/or threads or sutures, gauze, and the like. The scope of the invention should, therefore, be determined not with reference to the above description, but instead should be determined with reference to the appended claims along with their full scope of equivalents.[0121]

Claims (50)

What is claimed is:

1. A method of performing minimally invasive robotic surgery in a body cavity of a patient, the method comprising:

introducing at least one surgical accessory into the cavity;

introducing a robotic surgical tool into the cavity; and

coupling the surgical accessory with the robotic surgical tool inside the cavity after introducing the surgical accessory and the robotic surgical tool into the cavity.

2. The method ofclaim 1 wherein the robotic surgical tool is manipulated by a servomechanism from outside the cavity to couple the robotic surgical tool with the surgical accessory inside the cavity.

3. The method ofclaim 2 wherein the robotic surgical tool is connected with a robot arm which is disposed outside the cavity and robotically controlled to manipulate the robotic surgical tool.

4. The method ofclaim 1 wherein the surgical accessory is coupled with the robotic surgical tool by grasping the surgical accessory with the robotic surgical tool.

5. The method ofclaim 1 wherein the surgical accessory is coupled with the robotic surgical tool by mating the surgical accessory with the robotic surgical tool to form a mated connection.

6. The method ofclaim 1 wherein the robotic surgical tool is a first robotic surgical tool, and wherein the surgical accessory is coupled with the first robotic surgical tool by introducing a second robotic surgical tool into the cavity and manipulating the surgical accessory with the second robotic surgical tool.

7. The method ofclaim 1 wherein the at least one surgical accessory is introduced into the cavity through a cannula.

8. The method ofclaim 1 wherein the at least one surgical accessory is introduced into the cavity supported by a surgical accessory support, and is removable from the surgical accessory support within the cavity.

9. The method ofclaim 8 wherein the surgical accessory support includes a container.

10. The method ofclaim 9 wherein the container includes a door, and wherein the method further comprises remotely manipulating the door between a closed position and an open position from outside the cavity.

11. The method ofclaim 8 wherein the surgical accessory support includes a block having a material which deflects to releasably secure one or more surgical accessories therein.

12. The method ofclaim 8 wherein the surgical accessory support is provided on the body of another robotic surgical tool introduced into the cavity.

13. The method ofclaim 8 wherein the surgical accessory support includes a cartridge releasably supporting a plurality of surgical accessories.

14. The method ofclaim 13 wherein the at least one surgical accessory includes a plurality of surgical clips supported on the cartridge, and wherein the robotic surgical tool comprises a clip applier, the method further comprising sequentially loading the surgical clips in the clip applier within the cavity and affixing the loaded clips to a target tissue with the clip applier.

15. The method ofclaim 1 wherein the at least one surgical accessory includes at least one of a scalpel, a blade, a dissection finger, an electrode, a clip, a tube, and a hook.

16. The method ofclaim 1 wherein the surgical accessory is introduced into the cavity through an opening in a cavity wall by connecting the surgical accessory with a distal portion of an extension line and inserting the surgical accessory and the distal portion of the extension line into the cavity through the cavity wall, the surgical accessory being movable between a first position close to the opening and a second position away from the opening.

17. The method ofclaim 16 wherein the surgical accessory is resiliently biased toward the first position.

18. The method ofclaim 1 further comprising decoupling the surgical accessory from the robotic surgical tool inside the cavity.

19. The method ofclaim 18 wherein the surgical accessory is supported by a surgical accessory support which is introduced into the cavity before the surgical accessory is coupled with the robotic surgical tool inside the cavity, and wherein the decoupled surgical accessory is returned to the surgical accessory support inside the cavity.

20. The method ofclaim 18 wherein a plurality of surgical accessories are introduced into the cavity, the method further comprising coupling another surgical accessory inside the cavity with the robotic surgical tool after the decoupling step.

21. The method ofclaim 1 wherein the surgical accessory comprises a tool tip which is releasably coupled with a working member of the robotic surgical tool to form a tool tip of the tool.

22. The method ofclaim 21 wherein the robotic surgical tool includes a pair of working members and a pair of tool tips are releasably coupled with the pair of working members of the robotic surgical tool to form tool tips of the tool.

23. The method ofclaim 1 wherein the surgical accessory comprises a sheath which is releasably coupled with the robotic surgical tool.

24. The method ofclaim 1 wherein the robotic surgical tool comprises a pair of working members, and wherein the surgical accessory comprises a pair of fingers movably supported on a collar which is releasably coupled with the robotic surgical tool in a coupled position, the pair of fingers mating with the pair of working members to be movable by the pair of working members in the coupled position.

25. The method ofclaim 1 further comprising:

manipulating the robotic surgical tool from outside the patient's body to position the surgical accessory within the body cavity; and

causing the surgical accessory to interact with a portion of the body cavity.

26. The method ofclaim 25 wherein the surgical accessory is caused to interact with a portion of the body cavity by a user actuating the accessory from outside the patient's body.

27. The method ofclaim 4 further comprising actuating a portion of a master control device located remotely from the patient by a user to control the robotic surgical tool to grasp the surgical accessory.

28. The method ofclaim 27 further comprising instructing the robotic surgical tool to continue to grasp the surgical accessory without requiring the user to continue to actuate the actuatable portion of the master control device.

29. A method of performing minimally invasive robotic surgery in a body cavity of a patient, the method comprising:

introducing a robotic fastening tool into the cavity;

introducing a surgical accessory support into the cavity, the surgical accessory support supporting a plurality of fastening accessories;

loading one of the fastening accessories in the robotic fastening tool inside the cavity; and

affixing the loaded fastening accessory to a target tissue inside the cavity with the robotic fastening tool.

30. The method ofclaim 29 wherein the robotic fastening tool is a clip applier, and the fastening accessories include a plurality of surgical clips.

31. The method ofclaim 30 wherein the surgical accessory support includes a clip cartridge.

32. The method ofclaim 31 wherein the clip cartridge is provided on the body of another robotic surgical tool introduced into the cavity.

33. A robotic surgical system for effecting a predetermined treatment of a target tissue at an internal surgical site within a patient body, the system comprising;

a surgical accessory adapted for effecting the treatment;

an accessory introducer having a proximal end and a distal end with an opening therebetween, the distal end of the introducer insertable into the patient body so that the opening defines a first minimally invasive aperture, the surgical accessory being coupled with the distal end of the introducer and passable through the opening to the internal surgical site; and

a robotic arm supporting a surgical tool, the surgical tool having an end effector suitable for insertion through a second minimally invasive aperture to the internal surgical site, the end effector coupleable with the surgical accessory within the internal surgical site so that the robot arm can manipulate the surgical accessory to direct the treatment to the target tissue.

34. The robotic surgical system ofclaim 33, wherein the accessory comprises a member selected from the group consisting of a scalpel, a blade, a dissection finger, an electrode, a clip, a tube, and a hook.

35. The robotic surgical system ofclaim 33 wherein the accessory introducer includes a block having a material which deflects to releasably secure the surgical accessory therein.

36. The robotic surgical system ofclaim 33 wherein the accessory introducer includes a container having a door and a mechanism coupled with the door for remotely moving the door between an open position and a closed position from outside the internal surgical site.

37. The robotic surgical system ofclaim 33 wherein the surgical accessory is a clip and the surgical tool is a clip applier.

38. The robotic surgical system ofclaim 33 further comprising means for resiliently biasing the surgical accessory toward the first minimally invasive aperture.

39. The robotic surgical system ofclaim 33 wherein the accessory introducer includes a container having a door openable by the surgical tool, the container containing one or more surgical accessories.

40. The robotic surgical system ofclaim 33 wherein the accessory comprises a tool tip configured to be releasably coupled to the end effector of the surgical tool to form a tool tip for the end effector.

41. The robotic surgical system ofclaim 33 wherein the end effector comprises a pair of working members and the accessory comprises a pair of fingers movably supported on a collar which is configured to be releasably coupled with the surgical tool in a coupled position, the pair of fingers mating with the pair of working members to be movable by the pair of working members in the coupled position.

42. An apparatus for providing a surgical accessory in vivo through a wall of a patient body into an internal cavity of the patient body for effecting a desired treatment of a target tissue in the patient body, the apparatus comprising:

a surgical accessory adapted for effecting the treatment;

an accessory introducer having a proximal end and a distal end with an opening therebetween, the distal end of the introducer insertable into the patient body so that the opening defines a first minimally invasive aperture, the surgical accessory being coupled with the distal end of the introducer and passable through the opening to the internal cavity; and

a resilient member connected with the accessory introducer to resiliently bias the surgical accessory to a preset desired location within the internal cavity.

43. The apparatus ofclaim 42 wherein the accessory introducer comprises a support member configured to be anchored to the wall of the patient body at the opening; and a slidable member coupled with the surgical accessory, the slidable member being slidable relative to the support member.

44. The apparatus ofclaim 43 wherein the resilient member comprises a spring coupled between the support member and the slidable member.

45. The apparatus ofclaim 42 wherein the accessory introducer comprises a needle portion for piercing through the wall of the patient body into the internal cavity, the needle portion including a hollow core for introducing the surgical accessory.

46. A method of performing minimally invasive robotic surgery in an internal cavity of a patient body, the method comprising:

supporting a portion of a target tissue with a first robotic surgical tool introduced into the internal cavity, the first robotic surgical tool being electrically conductive;

contacting another portion of the target tissue with an electrically conductive cautery member introduced into the internal cavity; and

energizing the first robotic surgical tool and the cautery member for coagulating the target tissue.

47. The method ofclaim 46 wherein the first robotic surgical tool and the cautery member are energized by connection to opposite leads of a radiofrequency power source to form a bipolar system.

48. The method ofclaim 46 wherein the cautery member is held by a second robotic surgical tool.

49. The method ofclaim 48 wherein the second robotic surgical tool is electrically insulated from the cautery member.

50. A robotic surgical system for performing a procedure on a body, the system comprising:

a surgical tool having an end effector comprising at least two end effector members, the members capable of grasping an object;

a master control device having an actuatable portion, the portion operatively connected to the surgical tool such that actuation of the portion causes the at least two end effector members to grasp the object; and

an input device for accepting an input from a user to cause the end effector members to continue to grasp without further actuation of the actuatable portion of the master control device.

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