US20050107663A1 - Endoluminal tool deployment system - Google Patents

Abstract

Systems, devices and methods are provided for endoscopic procedures involving tissue manipulations beyond the capabilities of traditional endoscopic instruments. Embodiments of the systems include an elongated main body having a scope therethrough and at least one steerable tool arm which extends from the distal end of the main body. In preferred embodiments, the system includes two tool arms, each arm steerable to form a curve laterally outward which then bends laterally inward so that the arms form an angular shape. In addition, end effectors extend from the distal ends of each tool arm for use in manipulation of tissue. The angular shape brings the end effectors together in view of the scope for cooperative movements which are continuously visible by the surgeon. In addition, the tool arms may be steerable in any additional direction and may be rotateable to allow grasping, elevation and more complex manipulation of tissue.

Description

CROSS-REFERENCES TO RELATED APPLICATIONS
• The present application is a continuation of U.S. patent application Ser. No. 10/346,709 (Attorney Docket No. 021496-000100US), filed Jan. 15, 2003, the full disclosure of which is incorporated herein by reference.
BACKGROUND OF THE INVENTION
• The present invention relates generally to medical devices, systems and methods. More particularly, the present invention relates to devices, systems and methods for use in endoscopic or laparoscopic procedures.
• Endoscopy is a form of minimally invasive procedure wherein the interior of the body is accessed and visualized through an orifice in the body, such as the esophagus or rectum. Such access allows a surgeon or physician to view and/or treat internal portions of the orifice or internal tissues or organs which are accessible through the orifice. These procedures may be for diagnostic purposes, such as visual inspection or the removal of a tissue sample for biopsy, or the procedure may be used for treatment purposes, such as the removal of a polyp or tumor or the restructuring of tissue. While these procedures can be done using regular open surgery, endoscopy usually involves less pain, less risk, less scarring, and faster recovery of the patient.
• Endoscopy is typically performed with the use of an endoscope, a small circular tube containing optical components. Traditional endoscopes comprise a small diameter “snake-like” insertion tube having a distal end which is inserted into the orifice to the desired internal location. Fiber optics extend through the insertion tube and terminate at the distal end to allow axial viewing from the distal end. Images of the internal location near the distal end of the endoscope are transmitted to a video monitor for the physician to view. A control handle allows the endoscopist to control the direction of the scope and in some cases, permits the actuation of air, water and suction utilities that may be required for the endoscopy procedure.
• Since endoscopes may be used to perform a treatment at an internal location, some endoscopes are equipped with a lumen through which a surgical instrument or tool may be passed. Generally, the lumen extends through the length of the insertion tube to the distal end so that the end effector of the inserted instrument protrudes from the distal end in the axial direction. Thus, the instrument is directed in parallel to the fiber optics so that the end effector is positioned along the line of view.
• Such endoscopes have a number of constraints which limit their usefulness in performing diagnostic and surgical procedures. To begin, surgical instruments and tools are inserted axially through a working lumen in the endoscope. And, most of these endoscopes only allow axial and rotational movement of the tool beyond the distal end. This helps to maintain positioning of the tool within the field of view of the endoscope which is also directed axially. However, this limits the variety and complexity of procedures that may be performed. For example, procedures which involve tissue approximation pose great difficulty since only one portion of tissue may be grasped at a time and lateral, rather than axial, movement may be required. Although steering of an axially inserted tool may be possible near the distal end, such steering typically positions the end effector of the tool out of the field of view of the axially directed scope.
• A similar minimally invasive procedure which overcomes some of these constraints is laparoscopy. In laparoscopy, the interior of the body is accessed and visualized through a small incision. When accessing the abdomen, the incision is usually made in the navel. Laparoscopy was initially used by gynecologists to diagnose and treat conditions relating to the female reproductive organs: uterus, fallopian tubes, and ovaries. It is now used for a wider range of procedures, including operations that in the past required open surgery, such as removal of the appendix (appendectomy) and gallbladder removal (cholecystectomy). Laparoscopy is performed with a device which allows the surgeon or physician to view and/or treat internal tissues or organs which are accessible through the incision. This device is the same or similar to an endoscope, sometimes referred to as a laparoscope. The device comprises a small diameter insertion tube having a distal end which is inserted into the incision to the desired internal location. Fiber optics extend through the insertion tube and terminate at the distal end to allow axial viewing from the distal end. Images of the internal location near the distal end are transmitted to a video monitor for the physician to view. Sometimes, access through an incision creates a shorter, straighter and more direct access path than through an orifice. Therefore, some laparoscopes may have a shorter and stiffer insertion tube than some endoscopes.
• Although laparoscopes suffer from many of the same limitations as endoscopes, laparoscopy allows additional surgical instruments and tools to be inserted through separate incisions to perform procedures. Proper location of the incisions can allow instruments to be positioned in various directions. Therefore, movement and viewing is not limited to the axis of the laparoscope and simultaneous viewing of the tissues and the instruments may be more readily achieved during the procedure. However, these additional benefits are achieved at the cost of increased invasiveness. Access paths must be created for the instruments with the use of trocars requiring general anesthesia, risk of complications and infection, and increased overall recovery time for the access paths to heal. In addition, access may be difficult or contraindicated in some patients, particularly in the morbidly obese.
• Thus, it would be desired to provide an improved methods, devices and systems to perform minimally invasive procedures. Particularly, methods, devices and systems which would provide the benefits of endoscopy, such as lower invasiveness and access to deeply internal locations, with the benefits of laparoscopy, such as the use of multiple instruments with movement and viewing along various axes. The devices and systems would be reliable, convenient and easy to use with improved outcomes for patients due to reduction in invasiveness and therefore risk, cost and recovery time. At least some of these objectives will be met by the invention described hereinafter.
BRIEF SUMMARY OF THE INVENTION
• The present invention provides systems, devices and methods for endoscopic procedures involving tissue manipulations beyond the capabilities of traditional endoscopic instruments. Embodiments of the systems include an elongated main body having a scope therethrough and at least one steerable tool arm which extends from the distal end of the main body. In preferred embodiments, the system includes two tool arms, each arm steerable to form a curve laterally outward which then bends laterally inward so that the arms form a an angular or boomerang shape. In addition, end effectors extend from the distal ends of each arm for use in manipulation of tissue. The angular shape brings the end effectors together in view of the scope for cooperative movements which are continuously visible by the surgeon through the scope. In addition, the tool arms may be steerable in any additional direction and may be rotateable to allow grasping, pulling, tugging, elevation and more complex manipulation of tissue. Thus, the systems and devices of the present invention provide many of the capabilities of open surgery or laparoscopic surgery with an endoscopic approach.
• In a first aspect of the present invention, the tool arm(s) comprise a shaft having a proximal end and a deflectable or steerable distal end. In some embodiments, the steerable distal end will be laterally stabilized so that the distal end may be steered, i.e. bent or manipulated, within a plane but will resist deflection outside of the plane during use. The steering plane will generally be parallel to a central axis of the scope but may be rotated by rotation of the tool arm. In this way, the arm(s) will maintain stable positioning within the field of view of the scope and will resist accidental deflection outside of the field. It may be appreciated that the tool arm may also be translated axially within the stabilized plane while maintaining viewing within the field.
• A preferred structure for achieving lateral stability comprises a plurality of adjacent links. Usually, the links are pivotally attached by hinged structures. In some embodiments, the hinged structures comprise pivot pins which are disposed parallel to one another and generally transverse to the stabilized plane in which the arm may be steered. In other embodiments, the hinged structures comprise male and female bearing surfaces which define axes, wherein the axes are disposed in parallel to limit deflection of the distal section to within the plane. A variety of other structures are also available to provide lateral stability, such as deployment frames, various shaped linkages connected by reinforcements or pullwires, and slotted tubes, to name a few.
• Typically, the distal end includes at least two steerable sections, wherein a distal-most steerable section includes a tip section which curves in a first direction and wherein an intermediate steerable section includes a base which curves in the opposite direction, where both curves are in the stabilized plane. In some embodiments, the tip section curve has a radius which is greater than that of the curve of the base. To achieved such curvatures, the adjacent links may be shaped to allow substantially continuous deflection. Or, the adjacent links may be shaped so that the steerable distal end is deflectable to form a predetermined curvature wherein the arm is then restricted from further deflection.
• Means for selectively deflecting the distal section of the tool arm(s) often comprise at least one pullwire or one pushwire. Such pull or pushwires may be present in any quantity and arrangement. The means for selectively deflecting the distal section can further include at least one spring which is configured to straighten the distal section in opposition to the pullwire or pushwire.
• In some embodiments, the tool arm includes an end effector disposed at its distal end. A wide variety of end effectors may be used depending on the procedure or tissue manipulations which are desired. For example, end effectors may include but are not limited to knives, needles, sutures, staplers, fasteners, clippers, electrosurgical or hemostatic cutters and coagulators, laser welders, cryosurgery instruments, secondary scopes, forceps, lasers hooks, tongs, graspers, retractors, probes, clamps, scissors, tissue approximation devices and suction applicators. Alternatively, the tool arm may include a tool deployment lumen through which a tool having an end effector may be passed. In these embodiments, the tool arm may include a steering cuff arranged for passage of the tool therethrough so that manipulation of the tool within the steering cuff steers the distal end of the tool arm. Thus, in either case, manipulation of the end effector and the tool arm may be interconnected.
• In another aspect of the present invention, the elongated main body has a distal end, a proximal end, and an arm guide lumen extending through at least a distal section of the elongated main body. In preferred embodiments, the elongated main body has a viewing scope lumen extending therethrough and terminating in the distal tip. The arm guide lumens and the viewing scope lumen may be arranged in any suitable fashion within the main body. For example, when the elongated main body has a second arm guide lumen, the distal terminations of the two arm guide lumens and the one viewing scope lumen may be arranged in a generally triangular pattern on the distal tip of the main body. Alternatively, the lumens may be aligned, wherein the viewing scope lumen is disposed between the arm guide lumens.
• Typically, at least the distal section of the elongated main body is steerable. In some embodiments, the elongated main body comprises a first section and a second section disposed proximally of the first section, and the first and second sections are independently lockable. Thus, the first section may be lockable while the second section remains steerable. Such steering may be achieved with means for selectively deflecting the second section within at least a single plane. This may include retroflexion wherein the distal end of the main body is directed toward the proximal end. In some embodiments, the distal section of the elongated main body comprises a plurality of adjacent links to allow for such steering.
• Typically, at least the distal section of the elongated main body has a generally cylindrical exterior wherein the arm guide lumen does not extend out of the cylindrical exterior. And, the arm guide lumen terminates at a distal tip of the elongated main body so that the tool arm advances through the distal tip. Likewise, as mentioned previously, the elongated main body typically has a viewing scope lumen extending therethrough and terminating in the distal tip.
• In yet another aspect of the present invention, the tool arms may have a distal end which is steerable by a variety of mechanisms. For example, the distal end may be comprised of a flexible tube having at least one pullwire attached thereto so that manipulation of the at least one pullwire deflects the steerable distal end. Or, the tool arm may have a steerable distal end which comprises a flexible tube having shape memory material so that emergence of the steerable distal end from the distal tip of the main body allows deflection of the steerable distal end to a shape memory position. Or, the tool arm may further comprise a deployment frame extending from the distal tip of the main body, the frame comprising at least two supports each attached to one of the at least two tool arms so that manipulation of the deployment frame deflects the attached tool arms.
• In an additional embodiment of the present invention, the endoluminal tool deployment system may be comprised of an elongated main body having a distal end, a proximal end, and at least two arm guide lumens extending over or through at least a distal section of the elongated main body, wherein said arm guide lumens extend filly to a distal tip of the main body, and at least two tool arms adapted to extend through the arm guide lumens of the elongated main body, said tool arms emerging from the distal tip of the main body.
• In still another aspect of the present invention, the endoluminal tool deployment system comprises an elongated main body having a distal end, a proximal end, and an arm guide lumen extending through at least a distal section of the elongated main body, wherein at least the distal section comprises a plurality of adjacent links. The system further includes a means for selectively deflecting the distal section within at least a single plane, and at least one tool arm adapted to extend through the arm guide lumen of the elongated main body.
• In a further aspect of the present invention, a method is provided for deploying one or more tools in an anatomical space. In a preferred embodiment, the method comprises introducing a distal end of a main body to said anatomical space, advancing a tool arm from a tool deployment lumen in said main body into said anatomical space, deflecting and positioning the tool arm to locate a distal tip thereof adjacent to a target location within the anatomical space, wherein a distal section of the arm is curved and laterally stabilized in a single plane, and advancing a tool through a lumen of the tool arm to the target location.
• In some embodiments, deflecting and position comprises tensioning a plurality of adjacent hinged links within the distal section of the tool arm. The adjacent hinged links may be joined by hinge pins which are disposed perpendicularly to the single plane such that the pins stabilize the distal section and inhibit deflection outside of the single plane. The method may further comprise viewing the target location through a viewing scope disposed in the main body, wherein the tool arm extends axially from a distal tip of the main body from a location adjacent to the viewing scope.
• Other objects and advantages of the present invention will become apparent from the detailed description to follow, together with the accompanying drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 illustrates an embodiment of a system of the present invention.
• FIG. 2 illustrates the system ofFIG. 1 in an assembled arrangement.
• FIG. 2A depicts the cross-section of the system ofFIG. 2, andFIG. 2B depicts an alternative cross-section.
• FIGS. 3A-3D,4-6 illustrate possible movements of the steerable distal ends of the tool arms.
• FIGS. 7A-7B illustrate the use of an embodiment of the system to perform a mucosectomy.
• FIGS. 8A-8C illustrate an embodiment of the main body in a variety of positions.
• FIG. 9A shows an embodiment of the shaft of the main body comprised of a multiplicity of nestable elements, andFIG. 9B provides an exploded view of these elements.
• FIGS. 9C-9E provide cross-sectional views of various nestable elements.
• FIG. 10A provides an exploded view of nestable elements having a pullwire extending through their centers andFIG. 10B provides a cross-sectional view one of the nestable elements.
• FIG. 10C illustrates the nestable elements ofFIG. 10A with the inclusion of liners andFIG. 10D provides a cross-sectional view of one of the nestable elements.
• FIG. 11 illustrates an embodiment of a tool arm.
• FIGS. 12A-12B,13A-13B,14 illustrate embodiments of adjacent links disposed at the distal end of a tool arm.
• FIG. 15 illustrates examples of possible deflections or movements of an embodiment of the tool arm.
• FIGS. 16A-16B illustrate another embodiment of a tool arm comprising a plurality of adjacent links.
• FIGS.17,17A-17C illustrate an embodiment of a tool arm which is steerable to a predetermined arrangement.
• FIGS. 18A-18B illustrate the creation of distinct curvatures achieved by separate pullwires.
• FIG. 19 illustrates two tool arms steered to a predetermined arrangement.
• FIG. 20 illustrates an embodiment including both links which are steerable to a predetermined arrangement and links which are unrestrictedly steerable.
• FIGS. 21 A-21B illustrate an embodiment of a tool arm comprised of a slotted tube.
• FIGS. 21C-21D illustrate an embodiment of a tool arm comprised of a tube wherein a pullwire is positioned on the outside of the tube.
• FIGS. 21E-21F illustrate an embodiment of a tool arm comprised of a polymer wall co-extruded with shape memory material.
• FIGS. 21G-21H illustrate a mechanism for steering the tool arms including a deployment frame.
• FIGS. 22A-22B,23,24 illustrate embodiments of the shaft of the main body.
• FIGS. 25A-25B provide a view of the proximal end of an embodiment of the main body wherein two tool arms are present, each including a steering cuff.
• FIGS.26,27A-27B,28A-28B illustrate embodiments of a steering cuff.
• FIGS.29,29A-29D illustrate embodiments of a tool having an end effector in the form of various types of scissors.
• FIG. 30 illustrates an embodiment of the tool having an end effector in the form of gator toothed graspers.
• FIG. 31 illustrates an embodiment of the tool having an end effector in the form of an articulatable grasper.
• FIGS. 32-36 illustrate embodiments of the tool having end effectors in the form of various shaped retractors.
• FIGS. 37A-37B illustrate grasping hooks inserted through auxiliary lumens in the main body andFIG. 37C illustrates a fixation device which may be deployed by the tool arms when such grasping hooks are used in a plication procedure.
• FIGS. 38, 39,40A-40B illustrate alternative tools passed through auxiliary lumens in the main body.
• FIG. 41 illustrates a tool passed through an arm guide lumen for use in conjunction with a tool arm.
• FIG. 42 illustrates an arm used to cleanse a portion of the main body, particularly the scope lens.
DETAILED DESCRIPTION OF THE INVENTION
• I. Overview
• An embodiment of asystem2 of the present invention is illustrated inFIG. 1. Thesystem2 includes an elongatedmain body10 having aproximal end12 and adistal end14 terminating in adistal tip16. Themain body10 is used to access an internal target location within a patient's body. Typically, thedistal end14 is passed through a body orifice and one or more naturally occurring body lumens to the target location, such as in endoscopy, while theproximal end12 remains outside of the body. Therefore, themain body10 has a deflectable and/orsteerable shaft20, either due to choice of material or design of theshaft20 to include links, hinges, coils or other similar structures to allow deflection. Thus, FIG. I illustrates themain body10 in a deflected position wherein thebody10 includes curvatures. Such deflection and/or steering may be useful in traversing body lumens to the target location and is achievable by manipulation of ahandle22 near theproximal end12. It may be appreciated, however, that thesystem2 may be used in laparoscopic procedures wherein such deflection and/or steering may be less utilized for placement of themain body10. In either case, rigidization of some or all theshaft20 may be desired, for example to provide a stable visualization platform. Therefore, portions of theshaft20 of themain body10 are lockable to maintain a desired shape and provide rigidity, either due to choice of material or design of theshaft20 to include locking mechanisms, as will be described in later sections.
• Themain body10 also includes at least onearm guide lumen26 which extends over or through at least a distal section of themain body10, typically along the majority of the length of thebody10 as shown. Here inFIG. 1, twoarm guide lumens26 are shown, each extending from a position along theshaft20 near theproximal end12 to thedistal tip16. In addition, themain body10 includes ascope lumen24 which extends through theshaft20 to thedistal tip16.
• Thesystem2 also includes at least onetool arm30, two are shown inFIG. 1, eacharm30 of which is insertable through a separatearm guide lumen26 as indicated by dashed line. Eachtool arm30 has aproximal end32, adistal end34 and ashaft36 therebetween. Thedistal end34 is steerable, such as by manipulation of adjacent links as schematically indicated. Such steerability may be controlled by asteering cuff35 which is part of theproximal end32. Theshaft36 is typically flexible or deflectable to allow deflection of the surroundingmain body shaft20. Eachtool arm30 additionally includes atool deployment lumen38 therethrough.
• In this embodiment, thesystem2 also includes at least onetool40, two are shown inFIG. 1. Eachtool40 includes adistal end42, aproximal end44 and anelongate shaft46 therebetween to allow passage through thetool deployment lumen38 of thearm30. Eachtool40 has anend effector48 disposed at thedistal end42 and optionally ahandle50 at theproximal end44 for manipulation of theend effector48 from outside the body. Thetool40 is advanced so that theend effector48 emerges from thedistal end34 of thearm30.
• FIG. 2 illustrates thesystem2 ofFIG. 1 in an assembled arrangement. Here, thetool arms30 are shown inserted through thearm guide lumens26 of themain body shaft20. The steerable distal ends34 of thearms30 protrude from thedistal end14 of themain body10 and the proximal ends32 of thearms30 protrude from theproximal end12 of themain body10. As shown, the steering cuffs35 are located at the proximal ends32 of thearms30. In addition, thetools40 are shown inserted through thetool deployment lumens38 so that theend effectors48 extend beyond the steerable distal ends34 of thearms34. Likewise, the proximal ends44 of thetools40 withhandles50 are shown protruding from the steering cuffs35. Movement of thetools40 against the steering cuffs35 will actuate steering of the distal ends34 of thearms30, as will be described in later sections.
• FIG. 2A provides a cross-sectional view ofsystem2 ofFIG. 2. Since theshaft20 of themain body10 has a generally cylindrical exterior in this embodiment, the cross-section of theshaft20 has a circular shape. It may be appreciated that cylindrical shafts may alternatively have an elliptical, oval or oblong cross-section. Theshaft20 has an outer diameter in the range of about 5 to 25 mm, preferably approximately 14 mm. Theshaft20 has awall21 with a thickness in the range of about 0.5 to 5 mm, preferably about 2-3 mm, defining an innercentral lumen23. Within thewall21 lies various pushwires orpullwires96, hereinafter referred to as pullwires, for steering themain body10 which may be present in a variety of quantities and arrangements. Alternatively, thepullwires96 may be present within thecentral lumen23. At least onearm guide lumen26, two are shown, extend through thecentral lumen23. Eacharm guide lumen26 has an inner diameter in the range of about 0.5 to 5 mm, preferably about 4 mm. Positioned within thelumens26 are theshafts36 of thetool arms30. And, likewise, positioned within theshafts36 are thetools40.FIG. 2A also illustrates thescope lumen24 which has an inner diameter in the range of about 2 to 10 mm, preferably about 4 mm. In this embodiment, the twoarm guide lumens26 and thescope lumen24 are arranged in a generally triangular pattern which is maintained to thedistal tip16, however any suitable arrangement may be used which allows viewing of the tool arms, particularly the end effectors, by the scope. For example,FIG. 2B illustrates a cross-section of an embodiment wherein theshaft20 has an oval shape and thearm guide lumens26 and thescope lumen24 are generally aligned. Here, thescope lumen24 is disposed between thearm guide lumens26 to facilitate viewing of thetool arms30.. Also illustrated inFIGS. 2A and 2B are additional lumens which may be used for various needs. For example, an irrigation/suction lumen60, aninsufflation lumen56 and anauxiliary lumen58 may be present, each having an inner diameter in the range of about 0.5 to 5 mm, preferably about 2 mm. Theauxiliary lumen58 may be utilized for a variety of uses, such as insertion of additional tools, such as a macerator, a grasping tool, a cutting tool or a light source, to name a few, for use in conjunction with the end effectors present at the distal ends of thearms30 or the distal ends of thetools40 inserted through thearms30.
• FIGS. 3A-3D illustrate a series of movements of the steerable distal ends34 of thetool arms30. This series serves only as an example, as a multitude of movements may be achieved by the distal ends34 independently or together.FIG. 3A illustrates thedistal tip16 of themain body10. Thescope lumen24 is shown along with twoarm guide lumens26 terminating at thedistal tip16 and forming a triangular pattern as illustrated inFIG. 2A.FIG. 3B illustrates the advancement of the distal ends34 of thetool arms30 through thearm guide lumens26 so that thearms30 extend beyond thedistal tip16.FIGS. 3C-3D illustrate deflection of thearms30 to a preferred arrangement.FIG. 3C illustrates deflection of thearms30 laterally outward. This is achieved by curvature in the outward direction near thebase64 of the steerabledistal end34.FIG. 3D illustrates deflection of thetip section66 of thedistal end34 laterally inward achieved by curvature in the inward direction so that eacharm30 forms a hook shape. By facing thetip sections66 of thearms30 toward each other as shown, thetip sections66 are positioned directly in the path of thescope lumen24. Therefore, when ascope28 is positioned within thescope lumen24, thetip sections66 of thetool arms30 and anytools40 advanced therethrough, will be visible through thescope28. InFIGS. 3C-3D, deflection of thearms30 is achieved with the use ofadjacent links62 in the areas of desired curvature. Embodiments ofsuch links62 and other mechanisms of deflection will be discussed in later sections. Further, the deflection ofFIGS. 3A-3D are shown to be within a single plane. However, various embodiments include deflection in multiple planes. Likewise, thearms30 are shown to be deflected simultaneously inFIGS. 3A-3D, however thearms30 may be deflected selectively or independently.
• FIGS. 4-6 illustrate additional possible movements of thetool arms30. For example,FIG. 4 illustrates axial movement of thetool arms30. Eachtool arm30 can independently move distally or proximally, such as by sliding within thetool deployment lumen38, as indicated by arrows. Such movement maintains thearms30 within the same plane yet allows more diversity of movement and therefore surgical manipulations.FIG. 5 illustrates rotational movement of thetool arms30. Eachtool arm30 can independently rotate, such as by rotation of thearm30 within thetool deployment lumen38, as indicated by circular arrow. Such rotation moves thearm30 through a variety of planes. By combining axial, lateral and rotational movement, thearms30, and therefore thetools40 positioned therethrough, may be manipulated through a wide variety of positions in one or more planes.
• FIG. 6 illustrates further articulation of thetool arms30. In some embodiments, thearms30 are deflectable to form a predetermined arrangement, such as illustrated inFIG. 3D. Typically, when forming the predetermined arrangement, thearms30 are steerable up until the formation of the predetermined arrangement wherein thearms30 are then restricted from further deflection. In other embodiments, the arms are deflectable to a variety of positions and are not limited by a predetermined arrangement. Such an embodiment is illustrated inFIG. 6 wherein thearms30 articulate so that thetip sections66 curl inwardly toward thedistal tip16 of themain body10. Again, thetip sections66 are positioned in front of thescope lumen24 andscope28 for viewing. Typically, the tip sections66aare positioned on opposite sides of acentral axis31 of thescope28, wherein the field of view (indicated by arrow29) spans up to approximately 140 degrees, approximately 70 degrees on each side of thecentral axis31. In addition, the depth of field is typically in the range of approximately 1-10 cm.
• As mentioned previously, the endoluminaltool deployment system2 of the present invention may be used to access a various internal tissues or organs to perform a wide variety of surgical procedures.FIGS. 7A-7B illustrate the use of an embodiment of thesystem2 to perform a mucosectomy, or removal of a portion of the mucosa and/or submucosa of the stomach.FIG. 7A illustrates advancement of themain body10 through the esophagus E to the stomach S. Themain body10 is then steered to a desired position within the stomach S and the stomach mucosa M is visualized through thescope28 at thedistal tip16. Referring toFIG. 7B, thetool arms30 are then advanced through themain body10 and articulated. As mentioned,tools40 may be advanced through thetool arms30 or anend effector48 may be disposed at the distal end of eacharm30. Here, agrasper80 is disposed at the distal end of onearm30 and a cutter81 is disposed at the distal end of theother arm30. Thegrasper80 is used to grasp a portion of the mucosa M. The grasped portion of mucosa M can then be elevated by rotation or manipulation of thetool arm30. This allows safe resection of the portion of mucosa M by cutting with the use of thecutter82, as shown. Manipulation and resection of the tissue is visualized throughout the procedure through thescope28 which is aligned with thetip sections66, and therefore endeffectors48.
• It may be appreciated that the systems, methods and devices of the present invention are applicable to diagnostic and surgical procedures in any location within a body, particularly any natural or artificially created body cavity. Such locations may be disposed within the gastrointestinal tract, urology tract, peritoneal cavity, cardiovascular system, respiratory system, trachea, sinus cavity, female reproductive system and spinal canal, to name a few. Access to these locations may be achieved through any body lumen or through solid tissue. For example, the stomach may be accessed through an esophageal approach, the heart through a port access approach, the rectum through a rectal approach, the uterus through a vaginal approach, the spinal column through a port access approach and the abdomen through a port access approach.
• A variety of procedures may be performed with the systems and devices of the present invention. The following procedures are intended to provide suggestions for use and are by no means considered to limit such usage: Laryngoscopy, Rhinoscopy, Pharyngoscopy, Bronchoscopy, Sigmoidoscopy (examination of the sigmoid colon, the sigmoid colon is the portion that connects the descending colon to the rectum; primarily for diagnostic purposes, however a biopsy procedure and trans anal micro surgery may be performed for removing tumors), Colonoscopy (examination of colon; for the removal of polyps and tumors or for biopsy), and Esophagogastroduodenoscopy (EGD) which enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain.
• In addition, endoscopic retrograde cholangiopancreatography (ERCP) may be achieved which enables the surgeon to diagnose disease in the liver, gallbladder, bile ducts, and pancreas. In combination with this process endoscopic sphincterotomy can be done for facilitating ductal stone removal. ERCP may be important for identification of abnormalities in the pancreatic and biliary ductal system. Other treatments include Cholecystectomy (removal of diseased gallbladder), CBD exploration (for common bile duct stones), appendicectomy.(removal of diseased appendix), hernia repair TAP, TEPP and other (all kinds of hernia), fundoplication and HISS procedures (for gastro esophageal reflux disease), repair of duodenal perforation, gastrostomy for palliative management of late stage upper G.I.T. carcinoma), selective vagotomy (for peptic ulcer disease), splenectomy (removal of diseased spleen), gastric restrictive and malabsorbtive procedures (for morbid obesity), upper and lower G.I. endoscopies (diagnostic as well as therapeutic endoscopies), pyloroplastic procedures (for children's congenital deformities), colostomy, colectomy, adrenalectomy (removal of adrenal gland for pheochromocytoma), liver biopsy, gastrojejunostomy, subtotal liver resection, gastrectomy, small intestine partial resections (for infarction or stenosis or obstruction), adhesions removal, treatment of rectum prolaps, Heller's Myotomy, devascularization in portal hypertension, attaching a device to a tissue wall and local drug delivery to name a few.
• II. Main Body
• As mentioned previously, thesystem2 of the present invention includes an elongatedmain body10 having aproximal end12 and adistal end14 terminating in adistal tip16. An embodiment of themain body10 is illustrated inFIG. 8A in a straight configuration. However, themain body10 is used to access an internal target location within a patient's body so themain body10 has a deflectable and/orsteerable shaft20. Thus,FIG. 8B illustrates themain body10 having various curvatures in its deflected or steered state. In preferred embodiments, themain body10 is steerable so that themain body10 may be advanced through unsupported anatomy and directed to desired locations within hollow body cavities. In some embodiments, themain body10 includes afirst section90 which is proximal to asecond section92, as indicated inFIG. 8B. Although bothsections90,92 are steerable, thefirst section90 may be locked in place while thesecond section92 is further articulated. This is illustrated inFIG. 8C, wherein thefirst section90 is shown in a locked position unchanged fromFIG. 8B and thesecond section92 is shown in various retroflexed positions. In retroflexion, thesecond section92 is curved or curled laterally outwardly so that thedistal tip16 is directed toward theproximal end12 of themain body10. Optionally, thesecond section92 may also be locked, either in retroflexion or in any other position.
• Steering and locking may be achieved by any suitable mechanisms. In some embodiments, theshaft20 comprises a multiplicity ofnestable elements260, as illustrated inFIG. 9A.FIG. 9B provides an exploded view of thenestable elements260 ofFIG. 9A. Here it can be seen that theelements260 are disposed so that adistal surface262 of oneelement260 coacts with aproximal surface264 of an adjacent element. Each of thenestable elements260 includes one or morepullwire lumens98 through which pullwires96 pass. Thepullwires96 are used to hold theelements260 in nesting alignment and to provide steering and locking. Thepullwires98 preferably are made from a superelastic material, e.g. nickel titanium alloy, to provide flexibility, kink-resistance and smooth movement of thepullwires96 through thepullwire lumens98. Alternatively, thepullwires96 may be made from braided stainless steel, a single stainless steel wire, poly-para-phenylene terephthalamide (such as Kevlar®), a high tensile strength monofilament thread, combinations thereof or any suitable materials.
• Generally, theadjacent surfaces262,264 are contoured to mate so that when thepullwires96 are relaxed, surfaces262,264 can rotate relative to one another. This allows theshaft20 to form curvatures throughout its length in any direction. Eachpullwire96 is fixed at its distal end to aspecific element260 along theshaft20 or to thedistal tip16. When tension is applied to aspecific pullwire96, a curvature forms in theshaft20 proximal to the fixation point, thus steering theshaft20. Thepullwires96 may be arranged in various patterns to achieve steering in various directions. For example,FIG. 9C is a cross-sectional view of theshaft20 in thefirst section90 ofFIG. 8B. Here, eight pullwires96 (fourpullwires96aand fourpullwires96b) are shown passing through thewall21. Fourpullwires96aterminate at the distal end of thefirst section90 and are used to steer thefirst section90. Since the pullwires96aare equidistantly positioned, applying tension to the pullwires96a,either individually or in combination, steers thefirst section90 in any desired direction. Thefirst section90 may be locked in place by holding the tension in the pullwires96ausing any suitable mechanisms. For example, tension may be applied to thepullwires96 simultaneously until theelements260 are compressed to a state in which they are locked by friction wherein the tension is held.
• FIG. 9D is a cross-sectional view of theshaft20 in thesecond section92 ofFIG. 8B. Here, fourpullwires96bare shown passing through thewall21. Thesepullwires96bextended through thefirst section90, as indicated inFIG. 9C, and terminate near thedistal tip16. Since thepullwires96bare equidistantly positioned, applying tension to thepullwires96b,either individually or in combination, steers thesecond section92 in any desired direction. Since thepullwires96balso pass through thefirst section90, such steering may also effect the curvature in thefirst section90 when the first section is not locked. However, such effects are minimal, may be counteracted or compensated for by steering in thefirst section90, and may be avoided by locking. Thesecond section92 may be also be locked in place by holding the tension in thepullwires96busing any suitable mechanisms.
• In this embodiment, thewall21 extends continuously from theproximal end12 to thedistal end14 with the first andsecond sections90,92 determined by the termination points of thepullwires96 which extend therethrough. Alternatively, the first andsection sections90,92 may be comprised of separate shafts which are coaxially positioned adjacent to one another.
• In the embodiment illustrated inFIG. 9B, thenestable elements260 have acentral lumen23 which passes through the length of themain body10. Instruments or tools may be passed through thislumen23, as indicated inFIGS. 9C-9D, or tubes may be present within thelumen23 through which instruments or tools may be passed. In preferred embodiments, thenestable elements260 have holes formed therein so that lumens are formed by alignment of the holes when theelements260 are stacked. For example,FIG. 9E provides a cross-sectional view of anestable element260 illustrating the holes formed therein which serve as lumens. As shown, ascope lumen24,arm guide lumens26, andauxiliary lumens58 extend through the center of theelement260 whilepullwire lumens98 are located around the periphery. It may be appreciated thatpullwire lumens98 may also extend through the center of theelement260. For example,FIG. 10A illustrates an embodiment having a pullwire96 which extends through the center of the stackednestable elements260.FIG. 10A provides an exploded view of thenestable elements260 wherein theelements260 are disposed so that adistal surface262 of oneelement260 coacts with aproximal surface264 of an adjacent element. As shown, each of thenestable elements260 includes apullwire lumen98 through its center.FIG. 10B provides a cross-sectional view of anestable element260 ofFIG. 10A. As shown, thenestable element260 includes a lockingpullwire lumen98chaving a pullwire96ctherethrough in the center of theelement260 surrounded by various other lumens, such as ascope lumen24,arm guide lumens26,auxiliary lumen58 and variouspullwire lumens98 used for steering. Once theelements260 are positioned in a desired arrangement, theshaft20 may be locked in place by thecentral pullwire96c.Applying tension to thepullwire96ccompresses theelements260 to a state in which they are locked by friction wherein the tension is held.
• In addition,liners266 may be passed through any of the lumens of the stackednestable elements260.Such liners266 form create a continuous lumen connecting the lumen holes of thenestable elements260.FIG. 10C illustrates thenestable elements260 ofFIG. 10A with the inclusion ofliners266 passing through, for example, thearm guide lumens26. Likewise,FIG. 10D provides a cross-sectional view of anestable element260 ofFIG. 10C. Here,liners266 are shown positioned through thenestable element260 forminglumens24,26,58 therethrough. It may also be appreciated thatliners266 may extend throughpullwire lumens98 as well. Theliners266 may be coated on their luminal surface with a hydrophilic coating for reducing friction or theliners266 may be comprised of a lubricious polymer such as Teflon®, fluoroethylene polymer (FEP) or the like.
• It may be appreciated that theshaft20 of themain body10 may have any structure suitable for delivering thetool arms30 to the desired location within the body. Exemplary embodiments of such structures are described above and provided in co-pending U.S. patent application Ser. No. 10/281,462 filed Oct. 25, 2002, which is a continuation in part of U.S. patent application Ser. Nos. 10/173,203, 10/173,227, 10/173,238 and 10/173,220, all of which were filed on Jun. 13, 2002 and herein incorporated by reference for all purposes. Also of interest and incorporated by reference for all purposes are co-pending U.S. patent application Ser. Nos. 10/281,461 and 10/281,426 each filed on Oct. 25, 2002. In addition, it may be appreciated that themain body10 may be comprised of a traditional endoscope or laparoscope through which one ormore tool arms30 may be passed. Exemplary embodiments of traditional endoscopes are provided in U.S. Pat. Nos. 3,948,251; 4,036,218; 4,201,198; 4,224,929; 4,988,171; 5,020,539; 5,035,231; 5,068,719; 5,170,775; 5,172,225; 5,187,572; and 5,196,928, all of which are herein incorporated by reference for all purposes.
• III. Tool Arms
• As mentioned previously,system2 also includes at least onetool arm30, eacharm30 of which is insertable through a separatearm guide lumen26 in themain body10. As shown inFIG. 11, eachtool arm30 has aproximal end32, adistal end34 and ashaft36 therebetween. Thedistal end34 is steerable, such as by manipulation ofadjacent links62 as schematically indicated. Such steerability may optionally be controlled by asteering cuff35, disposed within theproximal end32. Eachtool arm30 additionally includes atool deployment lumen38 therethrough.
• A. Distal End
• FIGS. 12A-12B illustrate an embodiment ofadjacent links62 disposed at thedistal end34 to allow steerability of thearm30. Here, links62 are pivotally connected byhinge structures100. As shown inFIG. 12A, thelinks62 are shaped so that connection by thehinge structures100 createsgaps102 between thelinks62 directly opposite to thehinge structures100. Apullwire96 is shown extending through thelinks62 and terminating at afixation point104. Referring now toFIG. 12B, retraction of thepullwire96 draws thelinks62 together, minimizing thegaps102 between thelinks62. Due to the shape and arrangement of thelinks62, this movement creates a curve in thearm30 as shown. Thedistal end34 may be steered to have any curvature between substantially straight and a maximum curvature wherein thegaps102 are completely closed or another limiting feature is established. In some embodiments, up to360 degree curvature of thedistal end34 is possible. Thedistal end34 may be returned to a straightened position by advancement of thepullwire96 or by the presence of a spring which will straighten thedistal end34 by recoil force.
• FIGS. 13A-13B illustrate a similar embodiment ofadjacent links62 disposed at thedistal end34 to allow steerability of thearm30. Again, links62 are pivotally connected byhinge structures100. However, as shown inFIG. 13A, thelinks62 are shaped so that connection by thehinge structures100 createsgaps102 between thelinks62 on both sides of thehinge structures100. Apullwire96 is shown extending through thelinks62 and terminating at afixation point104. Referring now toFIG. 13B, retraction of thepullwire96 draws thelinks62 together, minimizing thegaps102 between thelinks62 along thepullwire96 and maximizing thegaps102 on the opposite side of thehinge structures100. Due to this shape and arrangement of thelinks62, this movement creates a curve in thearm30 as shown. Thedistal end34 may also be returned to a straightened position by advancement of thepullwire96 or by the presence of a spring which will straighten thedistal end34 by recoil force. However, in this embodiment, thedistal end34 may be deflected or curved in the opposite direction by continued advancement of thepullwire96. Advancement of thepullwire96 minimizes thegaps102 on the opposite side of thehinge structures100 causing a curvature in the opposite direction. Likewise, a spring may be present to straighten thedistal end34 from a curvature in this opposite direction.
• FIG. 14 illustrates an embodiment similar to the embodiment illustrated inFIG. 13A-13B. Thelinks62 are shown pivotally connected byhinge structures100. Here thehinge structures100 comprise pivot pins106 which are arranged in parallel to limit deflection to a single plane. In some embodiments, the hinge structures comprise male and female bearing surfaces which define axes, wherein the axes are disposed in parallel to limit deflection of the distal section to within the single plane. Thelinks62 are shaped so that connection by the pivot pins106 createsgaps102 between thelinks62. Closure of thegaps102 on one side of the pivot pins106 simultaneously opens gaps on the other side of thepins106.FIG. 14 also illustrates anend effector48 of atool40 which has been advanced through thetool deployment lumen38 of thearm30.
• FIG. 15 illustrates examples of possible deflections or movements of thetool arms30. Here, twoarms30 are shown emerging from thedistal tip16 of the elongatedmain body10. Thedistal end34 of eacharm30 is steerable and comprised of a plurality ofadjacent links62. Thearm30 on the left is shown steered to a position wherein thetip section66 is curled inwardly forming an almost complete circular shape. In contrast, thearm30 on the right is shown steered to a position wherein thetip section66 is deflected slightly inwardly forming an arc shape. Thus, thearms30 may be independently steerable to varying degrees of curvature. Preferably, thearms30 are steerable inwardly to perform surgical procedures in cooperation and to maintain visibility through the centrally located scope.
• FIGS. 16A-16B illustrate another embodiment of atool arm30 comprising a plurality ofadjacent links62. Here, thelinks62 are comprised ofdisks110 having faces which are angled to formgaps102 between thedisks110 when thedisks110 are stacked. Thedisks110 are connected by one or more wires orribbons112. In this embodiment, illustrated inFIG. 16B, tworibbons112 are present, each at diametrically opposite positions within the wall of each of the stackeddisks110 so that the angled faces are aligned between theribbons112. Theribbons112 may be embedded in the wall, co-molded with the stacked disks or simply advanced through a lumen in the wall. Theribbons112 maintain relative position of thedisks110 and stabilize the steerabledistal end34 to be deflectable in only a single plane. Also shown inFIG. 16B,lumens114 are present between theribbons112 for positioningpullwires96 therethrough. Thepullwires96 pass through the angled portions of thedisks110 so that application of tension to apullwire96 draws the angled faces of thedisks110 together to close thegaps102 therebetween. This in turn widens the diametricallyopposite gaps102 creating curvature in the stack.
• As mentioned previously, in some embodiments, thearms30 are deflectable to form a predetermined arrangement, such as previously illustrated inFIG. 3D. Typically, when forming the predetermined arrangement, thearms30 are steerable up until the formation of the predetermined arrangement wherein thearms30 are then restricted from further deflection.FIG. 17 illustrates an embodiment of such anarm30 comprising a plurality ofadjacent links62 wherein thearm30 is steerable to a predetermined arrangement. As shown, thedistal end34 comprises a base64 which deflects thedistal end34 outwardly and atip section66 which deflects inwardly. Between thebase64 andtip section66 lies aspacer68 which is rigid. Thespacer68 may be considered a larger elongate link or simply a straight section. Usage ofsuch spacers68 is optional and may be used to create specific predetermined arrangements.FIG. 17A is an enlarged view of thetip section66 which illustrates the shapes of thelinks62 which are pivotally connected byhinge structures100 formed into thelinks62.Gaps102 are present on opposite sides of thestructures100 to allow curvature of thedistal end34. The size of thegaps102 will vary due to varying sizes and shapes of thelinks64 so that closure of thegaps102 forms a specific curvature. This is most easily seen inFIGS. 17B-17C.FIG. 17B illustrateslinks62 of the base64 having varying shapes to creategaps102 of varying size. As shown, apullwire96 extends through thelinks62 along thegaps102. Applying tension to thepullwire96 draws thelinks62 together to close thegaps102 and to form a predetermined curve as inFIG. 17C.
• The predetermined arrangement ofFIG. 17 includes curvatures in opposite directions, the base64 curving laterally outwardly and thetip section66 curving laterally inwardly. These distinct curvatures may be achieved byseparate pullwires96. For example, as shown inFIG. 18A, afirst pullwire97amay be positioned along one side of thetool arm30 terminating at afixation point104alocated midway along thedistal end34. Thelinks62 which lie proximally of thisfixation point104aform thebase64. Asecond pullwire97bmay be positioned along the opposite side of thearm30 terminating at afixation point104blocated at the tip of thedistal end34. Generally, thelinks62 which lie between thefixation point104aand thefixation point104bform thetip section66. Referring now toFIG. 18B, by applying tension to thefirst pullwire97a,the base curves laterally outwardly, and by applying tension to thesecond pullwire97b,the tip section curves laterally inwardly.
• FIG. 19 illustrates twotool arms30 which are steered to a predetermined arrangement. Such steering is achieved with the use ofpullwires96 as illustrated inFIGS. 18A-18B. Fixation points104bare visible while fixation points104aare hidden within thearms30. As shown, thelinks62 are varied in size and shape to form this arrangement when tension is applied to thepullwires96. For example, thelinks62 are generally larger thought thebases64 and smaller through thetip sections66. Further, this embodiment includesstabilizers120 which pass through thearms30 for stability.
• In some embodiments, the steerabledistal end34 includes both types of links, links which are steerable to a predetermined arrangement and links which are unrestrictedly steerable. For example,FIG. 20 illustrates an embodiment wherein thebase64 is comprised oflinks62 which are appropriately shaped and sized to deflect laterally outwardly to form a predetermined arrangement. Such deflection is achieved with a pullwire which is hidden from view and terminates midway along thedistal end34. In this embodiment, thetip section66 is comprised oflinks62 which are appropriately sized and shape to deflect laterally inwardly in an unrestricted fashion. Thelinks62 of thetip section66 are hinged together bypivot pins106 to provide support throughout the unrestricted movement. In addition, atool40 having anend effector48 is shown passed through thetool deployment lumen38 in thearm30. Also shown inFIG. 20, thearms30 are rotated to lie in different planes, a feature which has been described in previous sections.
• It may be appreciated that the embodiments which include links may have any number of links. For example, the steerabledistal end34 may have twolinks62 which are hinged together by ahinge structure100. In this example, theshaft36 would direct thefirst link62 in a first direction and thehinge structure100 would turn thedistal tip16 towards a second direction. The addition ofmore linkages62 would create a smoother curve and/or allow multiple curves throughout the steerabledistal end34.
• Although the previous embodiments of thetool arms30 have been comprised of a plurality of adjacent links, it may be appreciated that thearms30 may be comprised of material in any suitable form. For example, eacharm30 may be comprised of a polymeric tube which has been pre-shaped, such as by heat setting, to form a desired curvature. The polymeric tube is comprised of a material which is sufficiently flexible to allow straightening of the curve for delivery through thearm guide lumen26 and adequately flexible to allow recoiling of thearm30 to form the desired curvature upon emergence from thelumen30.
• In another embodiment, eacharm30 is comprised of a slotted tube, as illustrated inFIGS. 21A-21B. Referring toFIG. 21A, atube130 has a series ofslots132 along its length. In this embodiment, theslots132 are present along one side of thetube130 however, it may be appreciated that theslots132 may be present on both sides of the tube or along any portion of the tube which is desired to deflect. Referring back toFIG. 21A, thepullwire96 is positioned within the tube along theslots132 and fixed to thetube130 at afixation point104. By applying tension to thepullwire96, thetube130 is deflected toward thepullwire96 as shown inFIG. 21B. The presence of theslots132 allows thetube130 to be comprised of a relatively rigid or thick material while deflecting and curving with minimal buckling or impedance by thetube130. It may be appreciated that thetube130 ofFIGS. 21A-21B may alternatively be a solid-walled tube without slots comprised of a thinner or more flexible material which itself allows deflection and curvature with minimal buckling or impedance. Further, each of the following embodiments illustratingvarious tool arms30 may be comprised of solid-walled or slotted tubes, or any other suitable tube construction.
• FIGS. 21C-21D illustrate an embodiment of thearm30 comprised of atube130 wherein apullwire96 is positioned on the outside of thetube130 and fixed to thetube130 at afixation point104. By applying tension to thepullwire96, thetube130 is deflected toward thepullwire96 as shown inFIG. 21D. Since thepullwire96 is disposed outside of thetube130, thepullwire96 forms a tether to thefixation point104 and does not follow along the surface of thetube130.
• FIGS. 21E-21F illustrate an embodiment of thearm30 comprised of a polymer wall co-extruded with shape memory material, such as nitinol wire.FIG. 21E illustrates thearm30 in a straightened position, wherein thearm30 is passed through thearm guide lumen26, and a curved position, wherein thearm30 recoils to a shape-memory curve.FIG. 21F provides a cross-sectional view of thearm30 ofFIG. 21E illustrating shape-memory material280 distributed within the wall of thearm30.
• FIGS. 21G-21H illustrate an alternative mechanism for steering thetool arms30. Referring toFIG. 21G, theshaft20 of themain body10 is illustrated having a pair oftool arms30 extending therefrom. Surrounding thearms30 lies adeployment frame290. Theframe290 is comprised of a semi-rigid or rigid material, such as stainless steel wire, which provides sufficient strength to apply force to thearms30. Theframe290 comprises at least twosupports292, each extending from thedistal tip16 of theshaft20 and connecting at apeak294. Eachsupport292 attaches to atool arm30 at anattachment point296. Theframe290 also includes anactuation support298 extending from thedistal tip16 to thepeak294. Thearms30 and supports292,298 advance from thedistal tip16 of themain body10 to a desired location in the body in a straight configuration as illustrated inFIG. 21G. Referring toFIG. 21H, application of tension to theactuation support298 draws thepeak294 toward thedistal tip16 causing thesupports292 to bow or bend outward drawing the attachedarms30 outward. Likewise, thesupports292 may include hinges wherein thesupports292 would bend at the hinge. AlthoughFIG. 21H illustrates thearms30 bending at the attachment points296, it may be appreciated that thearms30 may bend at any location. Such bending directs thetool deployment lumens38 toward each other to facilitate coordination of tools passed therethrough. Movement of thepeak294 proximally and distally varies the curvature of thearms30 and provides steering. Theframe290 also serves to create a working space, restricting surrounding tissue from encroaching on thearms30 andtools40.
• In most embodiments, the distal ends of the tool arms are lockable to maintain a deflected position. Such locking may be achieved by any suitable mechanisms. When the tool arm is steerable by manipulation of pullwires or pushwires, the wires may be held in place to lock the distal end in a desired position. In embodiments comprising a multiplicity of nestable elements through which pullwires pass, the pullwires are typically used to hold the elements in nesting alignment and to provide steering and locking. By applying tension to the pullwires simultaneously, the elements may be compressed to a state in which they are locked by friction wherein the tension is held. Other locking mechanism may also be used. Further, the tool arms may be locked rotationally and axially within the main body to maintain positioning of the tool arm in relation to the main body.
• B. Shaft
• As described previously, theshaft36 of thetool arm30 passes though themain body10. In embodiments wherein themain body10 is deflectable, theshaft36 is also deflectable. However, although it is desired that theshaft36 be laterally deflectable, it is also desired that theshaft36 maintain axial rigidity. Any suitable construction may be used, including a braid reinforced torqueable tube. Additional embodiments are described below.
• FIGS. 22A-22B illustrate embodiments of theshaft36 comprising acoil140. Here, illustrated inFIG. 22A, the turns of thecoil140 lie adjacent to each other to prevent axial movement and maintain axial rigidity. However, the coil configuration allows deflection of theshaft36 as shown inFIG. 22B.
• In another embodiment, illustrated inFIG. 23, theshaft36 comprises a plurality ofadjacent linkages150. Here, eachlinkage150 includes a pair of protrudingstructures152 on its face and a pair ofnotches154 on its base. The protrudingstructures152 andnotches154 are both arc shaped so that the protrudingstructures152 of onelinkage150 rotateably interfit with thenotches154 of an adjacentlystacked linkage150. By alternating the position of the pairs of protrudingstructures152 andnotches154 as shown inFIG. 23, theshaft36 is flexible in both lateral bending directions while maintaining stiffness axially and in torsion. Also shown are flaredlumens158 which pass through the protrudingstructures152 and the wall of theshaft36. Flaring allows for a rod or wire passed therethrough to move within thelumen158 as alinkage150 rotates over the protrudingstructure152. Roundpullwire lumens156 pass through thenotches154 and the wall of theshaft36 as shown. The rod or wire holds thelinkages150 in a stacked configuration and optionally may be used to steer theshaft36.
• In another embodiment, illustrated inFIG. 24, theshaft36 comprises a plurality ofadjacent linkages160 which are also stacked to provide lateral deflection while maintaining axial rigidity. Here, eachlinkage160 includes a pair of protrudingstructures162 on its face and a pair ofnotches164 on its base. The protrudingstructures162 andnotches164 are both arc shaped so that the protrudingstructures162 of onelinkage160 rotateably interfit with thenotches164 of an adjacentlystacked linkage160. By alternating the position of the pairs of protrudingstructures162 andnotches164 as shown inFIG. 24, theshaft36 is flexible in both lateral bending directions while maintaining stiffness axially and in torsion. In this embodiment, thelinkages150 include acentral lumen166 through which a rod or wire is passed. The rod or wire is used to hold thelinkages60 in the stacked configuration.
• C Proximal End
• Theproximal end32 of thetool arm30 may simply terminate in an endpiece or connector for passage of atool40 through itstool deployment lumen38. However, theproximal end32 may optionally include asteering cuff35 for steering thetool arm30, particularly for steering itsdistal end34.
• FIG. 25A illustrates an embodiment of theproximal end12 of themain body10 wherein twotool arms30 are present, each inserted through anarm guide lumen26 in theshaft20 of themain body10. As shown, eachtool arm30 includes asteering cuff35 which remains outside of themain body10 and thetool deployment lumen38 is accessible through thesteering cuff35.FIG. 25B illustrates an alternative embodiment of theproximal end12 wherein twotool arms30 are present, each inserted through anarm guide lumen26 through thehandle22 of themain body10. Again, eachtool arm30 includes asteering cuff35 which remains outside of themain body10 and thetool deployment lumen38 is accessible through thesteering cuff35. This embodiment also includes alocking mechanism170 on eacharm30. Thelocking mechanism170 can be manipulated, such as by turning alever172 shown inFIG. 25B, to lock thedistal end34 or thetool arm30 in a steered or deflected position.
• FIG. 26 illustrates an embodiment of asteering cuff35 disposed at theproximal end32 of atool arm30 wherein atool40 is passed therethrough. In this embodiment, thetool arm30 includes four pullwires96 (three are visible inFIG. 26) which are equidistantly positioned around the perimeter of theshaft36. Thepullwires96 are used to steer thedistal end34 of thearm30 as previously described. As shown, thetool40 has adistal end42 with anend effector48 which emerges from thedistal end34 of thearm30. Likewise, thetool40 has aproximal end44 which emerges from thesteering cuff35. In this embodiment, thesteering cuff35 has a funnel shape wherein one end is attached to at least thepullwires96 and typically additionally to thearm30 itself. Deflection of theproximal end44 of thetool40, indicated byangular arrow180, presses theproximal end44 against thesteering cuff35 which rotates thesteering cuff35 to a deflected position, indicated by dashed line. Such rotation applies tension to pullwires96 diametrically opposite to the deflected position as indicated byarrows182. Such tension steers thedistal end34 of thearm30. Thus, manipulation of thetool40 within thesteering cuff35 can be used to steer thedistal end34 of thearm30.
• FIGS. 27A-27B andFIGS. 28A-28B illustrate another embodiment of asteering cuff35. Here, thesteering cuff35 has a sphere shape and is disposed at theproximal end32 of thetool arm30. Thetool40 is passed through alumen184 in the sphere shapedcuff35 so that thedistal end42 of the tool emerges from thedistal end34 of thearm30 and theproximal end44 remains outside of thecuff35 as shown. In this embodiment, thetool arm30 includes four pullwires96 (three are visible) which are equidistantly positioned around the perimeter of theshaft36. Thepullwires96 are used to steer thedistal end34 of thearm30 as previously described.FIG. 27A illustrates thepullwires96 emerging from theshaft36 of thearm30 and attached to the surface of the sphere shapedcuff35. Likewise,FIG. 27B provides a similar view, however in this case thearm30 is cutaway to reveal thepullwires96 extending through lumens in theshaft36 and thetool40 extending through thetool deployment lumen38.FIG. 28A illustrates the embodiment in the straight position. Deflection of theproximal end44 of thetool40, indicated byangular arrow180, presses theproximal end44 against thesteering cuff35 which rotates thesteering cuff35 to a deflected position, as shown inFIG. 28B. Such rotation applies tension to pullwires96 diametrically opposite to the deflected position as indicated byarrow182. Such tension steers thedistal end34 of thearm30. Thus, manipulation of thetool40 within thesteering cuff35 can be used to steer thedistal end34 of thearm30.
• It may be appreciated that the embodiments of thesteering cuff35 depicted inFIG. 26 andFIGS. 27A-27B,28A-28B may include any number ofpullwires96 for any desired level of steerability. For example, in each embodiment, twopullwires96 may be present disposed on opposite sides of thesteering cuff35 for movement of the steerabledistal end34 of anarm30 in a single plane. This would be the case for laterally stabilizedarms30.
• IV. Tool
• As mentioned previously, thesystem2 also includes at least onetool40. In some embodiments, thetool40 may simply comprises anend effector48 positioned at the distal end of thetool arm30 wherein theend effector48 is operated by manipulation of mechanisms which extend through thearm30. In other embodiments, eachtool40 includes adistal end42, aproximal end44 and anelongate shaft46 therebetween to allow passage through thetool deployment lumen38 of thearm30. Theshaft46 is typically desired to be a torque-stable tube comprised of any suitable material, such as a braid or coil-reinforced extrusion. In these embodiments, eachtool40 has anend effector48 disposed at thedistal end42 and optionally ahandle50 at theproximal end44 for manipulation of theend effector48 from outside the body. Thus, thetool40 is advanced so that theend effector48 emerges from thedistal end34 of thearm30.
• A wide variety ofend effectors48 may be used depending on the procedure or tissue manipulations which are desired. For example,end effectors48 may include but are not limited to knives, needles, sutures, staplers, fasteners, clippers, electrosurgical or hemostatic cutters and coagulators, laser welders, cryosurgery instruments, secondary scopes, forceps, lasers hooks, tongs, graspers, retractors, probes, clamps, scissors, tissue approximation devices and suction applicators.
• FIG. 29 illustrates an embodiment of atool40 having anend effector48 in the form ofscissors200. Scissors are one of the oldest surgical instruments used by surgeons. Scissors are used to perform many tasks in open surgical procedure but its use in minimal access surgery requires greater skill. As shown, thescissors200 includes twoblades202, afulcrum204 andforce applicators206. The cutting force of thescissors200 works on the law of lever. The force applied on theblade202 can be calculated by length of theforce applicators206 and force applied on theapplicators206. Thescissors200 of thetool40 do not apply the exact law of lever because of the cylinder action of thelong shaft46, but the design ofapplicators206 helps in the amplification of force by lever action. When theblades202 of thescissors200 close, its sharp edges grind against each other and any tissue which comes between the blades of scissors will be cut.
• Thescissors200 ofFIG. 29 provide an example of straight scissors wherein the blades are straight. This is a widely used instrument for mechanical dissection in laparoscopic surgery. Other types of scissors includecurved scissors214, illustrated inFIG. 29A, wherein theblade202 of thescissors214 is slightly curved. In some cases curvedscissors214 are preferred because the curvature of theblade202 of this scissors creates additional angles of manipulation and may provide a better view through the scope. Other types of scissors includeserrated scissors216 whereinserrated edges218 prevent the tissue from slipping out of theblades202. This may be useful in cutting a slippery tissue or ligature. Still other types of scissors includehook scissors220 which encircle a tissue structure before cutting. Since the tissue is held between its hooked blades, there is minimal chance of slipping. Thehook scissor220 is especially useful for cutting secured ducts or arteries. Likewise, the cutting of nerve bundles in neurectomy becomes may benefit from the use ofhook scissors220.Hook scissors220 are also helpful in partial cutting of cystic ducts for intra-operative cholangiography. Further, additional types of scissors includemicrotip scissors222. One of the main advantages ofmicrotip scissors222 is to cut ducts partially for facilitating cannulation. Likewise, thisscissor222 may be used for cutting the cystic duct for performing intra-operative cholangiogram. Exploration of small ducts like common bile duct is very helpful withmicrotip scissors222 due to its fine small blades.Fine microtip scissors222 are also available in curved form.
• FIG. 30 illustrates an embodiment of atool40 having anend effector48 in the form of gatortoothed graspers230. Thesegraspers230 have reverse angledteeth232 which are capable of providing an aggressive grip on tissue. In addition, thegraspers230 are cupped to allow tissue to herniated when the tissue is compressed. Thus, thegraspers230 may be useful for pelviscopy and handling fibrous ovaries and uterine tissue.
• FIG. 31 illustrates an embodiment of atool40 having anend effector48 in the form of anarticulatable grasper236. Thegrasper236 includes anarticulation section238 betweengrasper jaws240 and theshaft46. This allows thegrasper236 to articulate in an additional degree of freedom relative totool arm30.
• Embodiments of thetool40 having anend effector48 may be in the form of various shaped retractors. Examples of such retractors include anangled retractor242, (FIG. 32), hooked retractors244 (FIG. 33-34), a triangular retractor246 (FIG. 35), and a circular retractor (FIG. 36), to name a few. Each retractor is flexible and allows for manipulation of organs and tissue structures.
• V. Auxiliary Lumens
• As mentioned previously, lumens in addition to thescope lumen24 and arm guidelumens26 may be present within themain body10 and may be consideredauxiliary lumens58.Such lumens58 may be used for any purpose, such as irrigation, suction, insufflation, macerating, illuminating, grasping, or cutting to name a few, and are typically used in conjunction with thearms30 and/ortools40 inserted through thearms30 or positioned at the ends of thearms30.
• In one embodiment, illustrated inFIG. 37A, graspinghooks310 are inserted through a single auxiliary lumen or through separate auxiliary lumens58 (shown) in theshaft20. The grasping hooks310 may be comprised of any suitable material, such as shape memory wire or shapeable polymer, that allows a hook shape to be formed once thehooks310 have emerged from thedistal tip16. In addition, thehooks310 may have a pointed or sharp tip to assist in grasping or piercing tissue. Referring toFIG. 37B, the graspinghooks310 may be used to grasp a portion of tissue T to create a plication or fold. Thetool arms30 may then be extended on opposite sides of the folded tissue T to deploy afixation device312 which will hold the plication in place.FIG. 37C illustrates such afixation device312 comprising atie314 passing through the tissue T withanchors316 positioned on either side of the plication. Thetie314 may be comprised of a suture, wire or rod, for example, and theanchors316 may be comprised of knots, disks or expandable umbrellas, to name a few. Such plication procedures may be used for treating gastroesophageal reflux disease (GERD).
• Alternatively, other tools may be passed throughauxiliary lumens58 for similar or other purposes. For example, a corkscrew device320 (FIG. 38) or a grasper claw322 (FIG. 39) may be passed through anauxiliary lumen58 for grasping tissue T. Or, tissue T may be grasped with a suction device.FIG. 40A illustrates a suction device324 in an undeployed configuration. The suction device324 comprises adeployment sleeve328 which houses anexpandable funnel326. Withdrawal of thedeployment sleeve328 releases thefunnel326 allowing thefunnel326 to self-expand, as shown inFIG. 40B. The increased surface area of thefunnel326 allows for adequate suction for grasping tissue T and holding the tissue T within thefunnel326.
• It may be appreciated thattools40 may alternatively be passed through anarm guide lumen26 for use in conjunction with atool arm30 passed through anotherarm guide lumen26. For example, as illustrated inFIG. 41, amacerator336 may be passed through anarm guide lumen26 for maceration of tissue T or a blood clot while atool arm30 is used for irrigation and aspiration. Themacerator336 macerates the tissue T to form small particles which may be more readily aspirated. Further, irrigation through thearm30 may be used to cleanse portions of the device. For example, as illustrated inFIG. 42, thearm30 may be steered to face thescope28 allowing irrigation to cleanse thescope28 thus improving viewing.
• Although the foregoing invention has been described in some detail by way of illustration and example, for purposes of clarity of understanding, it will be obvious that various alternatives, modifications and equivalents may be used and the above description should not be taken as limiting in scope of the invention which is defined by the appended claims.

Claims (30)

1. An apparatus for use with an endoscope, comprising:

an elongated main body configured to surround an endoscope, the elongated main body having a lumen extending therethrough and adapted for positioning adjacent to the surrounded endoscope, wherein the lumen is adapted to move relative to the surrounded endoscope and extend beyond a distal tip of the surrounded endoscope; and

at least one controllable member disposed along the elongated main body, wherein the at least one controllable member is adjacent to the lumen extending beyond the distal tip of the endoscope and includes a wire member adapted to manipulate the at least one controllable member.

2. The apparatus ofclaim 1, wherein the at least one controllable member comprises a distal end effector adapted to manipulate tissue.

3. The apparatus ofclaim 1, further comprising a second controllable member disposed along the elongated main body.

4. The apparatus ofclaim 1, further comprising a stiffened structure adapted to support the at least one controllable member.

5. The apparatus ofclaim 4, wherein the stiffened structure comprises a frame attached to the at least one controllable member.

6. The apparatus ofclaim 4, wherein the stiffened structure is comprised of a semi-rigid or rigid material.

7. The apparatus ofclaim 4, wherein the stiffened structure is adapted to actuate the at least one controllable member.

8. The apparatus ofclaim 1, further comprising a shape memory wire adapted to move the at least one controllable member to a preset curve when the at least one controllable member is extended beyond the lumen.

9. The apparatus ofclaim 1, further comprising at least one cable extending through the elongated main body extending from a proximal end to a distal end of the elongated main body.

10. The apparatus ofclaim 9, wherein manipulation of the cable at the proximal end deflects the distal end of the elongated main body.

11. The apparatus ofclaim 9, wherein the cable is eccentrically attached to the elongated main body.

12. The apparatus ofclaim 1, wherein the at least one controllable member is longitudinally movable relative to the elongate main body.

13. A system for use with an endoscope, comprising:

an endoscope;

an elongated main body configured to surround the endoscope, the elongated main body having a lumen extending therethrough and adapted for positioning adjacent to the surrounded endoscope, wherein the lumen is adapted to move relative to the surrounded endoscope and extend beyond a distal tip of the surrounded endoscope; and

at least two controllable members disposed along the elongated main body, wherein the controllable members are adjacent to the lumen extending beyond the distal tip of the endoscope and each controllable member includes a wire member adapted to manipulate the member.

14. The system ofclaim 13, wherein each controllable member comprises a distal end effector adapted to manipulate tissue.

15. The system ofclaim 13, further comprising a stiffened structure adapted to support the controllable members.

16. The system ofclaim 15, wherein the stiffened structure comprises a frame attached to the controllable members.

17. The system ofclaim 15, wherein the stiffened structure is comprised of a semi-rigid or rigid material.

18. The system ofclaim 15, wherein the stiffened structure is adapted to actuate the controllable members.

19. The system ofclaim 13, further comprising a shape memory wire adapted to move the controllable members to a preset curve when controllable members are extended beyond the lumen.

20. The system ofclaim 13, comprising a plurality of cables extending through the elongated main body extending from a proximal end to a distal end of the elongated main body.

21. The system ofclaim 20, wherein manipulation of the cables at the proximal end deflects the distal end of the elongated main body.

22. The system ofclaim 20, wherein the cables are eccentrically attached to the elongated main body.

23. The system ofclaim 13, wherein the controllable members are longitudinally movable relative to the elongate main body.

24. A method of deploying an endoscopic device, comprising:

maneuvering an endoscopic device through a body cavity within a patient, the endoscopic device having an elongated main body configured to surround an endoscope;

extending a distal end of a lumen, which extends through the elongated main body, beyond a distal tip of the endoscope; and

articulating at least one controllable member disposed along the elongated main body by manipulating a wire member connected to the at least one controllable member, which is adjacent to the lumen extending beyond the distal tip of the endoscope.

25. The method ofclaim 24, wherein maneuvering an endoscopic device comprises inserting the endoscopic device into the patient.

26. The method ofclaim 24, wherein maneuvering an endoscopic device comprises articulating the distal end of the lumen.

27. The method ofclaim 24, wherein articulating at least one controllable member comprises articulating an end effector disposed on a distal portion of the at least one controllable member.

28. The method ofclaim 27, wherein articulating an end effector comprises manipulating tissue via the end effector.

29. The method ofclaim 24, wherein manipulating the wire member comprises manipulating a proximal end of the wire member.

30. The method ofclaim 24, wherein articulating at least one controllable member comprises moving the at least one controllable member longitudinally relative to the elongate main body.

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