Surgical system

专利摘要:
curved cannula and robotic manipulator. the present invention relates to a robotic surgical system configured with rigid curved cannulas that extend through the same opening in a patient's body. surgical instruments with passively flexible shafts extend through curved cannulas. the cannulas are oriented to direct the instruments to a surgical site. various portal features that support the curved cannulas within the single opening are described. cannula support accessories are described that support the cannulas during insertion into the single opening and mounting on robotic manipulators. a teleoperation control system is described that moves the curved cannulas and their associated instruments in a way that allows a surgeon to experience intuitive control.
公开号:BR112012006641B1
申请号:R112012006641-2
申请日:2010-08-27
公开日:2020-01-07
发明作者:Giuseppe Maria Prisco；Samuel Kwok Wai Au；Craig R. Gerbi；Theodore W. Rogers；John Ryan Steger；Charles E. Swinehart
申请人:Intuitive Surgical Operations, Inc.；
IPC主号:

专利说明:

SURGICAL MA.
CROSS REFERENCE TO RELATED APPLICATIONS [001] This application claims the benefit of the Patent Application
North American Provisional No. 61 / 245,171 (filed September 23, 2009) (which describes Curved Cannula), which is incorporated herein by reference.
BACKGROUND
1. Field of the Invention [002] The present invention relates to minimally invasive surgery, more particularly, to minimally invasive surgical systems, and, even more particularly, to minimally invasive robotic surgical systems that work through a single point of entry into the patient's body.
2. Technique [003] Benefits of minimally invasive surgery are well known, and they include less trauma to the patient, less blood loss, and faster recovery times when compared to traditional open incision surgery. In addition, the use of robotic surgical systems (for example, teleoperated robotic systems that provide telepresence) is known, such as the da Vinci® Surgical System, manufactured by Intuitive Surgical, Inc., Sunnyvale, California. Such robotic surgical systems can allow a surgeon to operate with intuitive control and greater precision, when compared to minimally invasive manual surgeries.
[004] To additionally reduce trauma to the patient and to retain the benefits of robotic surgical systems, surgeons began to perform a surgical procedure to investigate or treat a patient's condition through a single incision through
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2/65 of the skin. In some instances, such single portal access surgeries were performed with hand instruments or with existing robotic surgical systems. What is desired, therefore, is improved equipment and methods that allow surgeons to perform surgeries more efficiently through single portal access, as compared to the use of existing equipment and methods. It is also desired to be able to easily modify the existing robotic surgical systems that are typically used for multiple incision (multiple port) surgeries to perform such surgeries via single portal access.
SUMMARY [005] In one aspect, a surgical system includes a robotic manipulator, a curved cannula, and an instrument with a passively flexible shaft that extends through the curved cannula. The robotic manipulator moves the curved cannula around a remote center of movement that is placed in an opening in a patient's body (for example, an incision, a natural orifice) so that the curved cannula provides an angle of triangulation for the surgical instrument at the surgical site. In one implementation, an endoscope and two such curved cannulas with distal ends oriented to a surgical site from different angles are used so that the effective triangulation of the instrument is achieved, which allows the surgeon to effectively work on the surgical site and visualize the same.
[006] In another aspect, the curved cannula includes a straight section and an adjacent curved section. A robotic manipulator mounting bracket is attached to the straight section. A second straight section can be attached to the opposite end of the curved section to facilitate alignment of a passively flexible surgical instrument that extends out of the distal end of the cannula towards a surgical site.
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3/65 [007] In another aspect, a surgical instrument includes a passively flexible shaft and a surgical end effector coupled to the distal end of the shaft. The flexible axis extends through a curved cannula, and a distal section of the flexible axis extends cantilevered beyond a distal end of the curved cannula. The distal section of the flexible shaft is sufficiently rigid to provide effective surgical action at the surgical site, but it is flexible enough to allow it to be inserted and removed through the curved cannula. In some respects, the stiffness of the distal shaft section of the instrument is greater than the stiffness of the shaft section that remains in the curved section of the cannula during a surgical procedure.
[008] In another aspect, a characteristic of a surgical portal is a single body that includes channels between its upper and lower surfaces. The channels are angled in opposite directions to retain the straight sections of the curved cannulas at a desired angle. The body is flexible enough to allow the curved cannulas to move around remote centers of movement that are usually located within the channels. In some respects, the portal feature also includes a channel for an endoscope cannula and / or one or more auxiliary channels. The channels can include multiple seals.
[009] In another aspect, a second portal feature is described which includes an upper funnel portion and a lower tongue. Channels for surgical instruments, such as curved cannulas, are defined in a section of a narrower part that connects the funnel portion and the tongue. In one aspect, this second portal feature is used for surgeries that require instruments to enter the patient's body at a relatively small (acute) angle, because the portal feature helps prevent unnecessary tension between the instruments and the patient's body and vice versa.
[0010] In another aspect, mounting accessories are described
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4/65 cannula. These accessories support the cannulas for insertion and for fitting in their associated robotic manipulators. In one aspect, an accessory includes arms that hold an endoscope cannula and a curved instrument cannula. In another aspect, an accessory is configured as a cap that retains the distal ends of an endoscope and a curved cannula. The cap is pointed to facilitate insertion into the opening in the patient.
[0011] In another aspect, a control system for a robotic surgical system with a curved cannula is described. The control system uses kinematic data associated with the curved cannula. To provide an intuitive control experience for the surgeon, the control system commands a robotic manipulator to move the curved cannula and its instrument in response to the surgeon's input on a master manipulator, as if the instrument is positioned along a straight axis extending from the distal end of the curved cannula, usually tangent to the distal end of the curved section of the cannula.
BRIEF DESCRIPTION OF THE DRAWINGS [0012] Figure 1A is a front elevation view of a patient's car in a robotic surgical system.
[0013] Figure 1B is a front elevation view of a surgeon's console in a robotic surgical system.
[0014] Figure 1C is a front elevation view of a viewing car in a robotic surgical system.
[0015] Figure 2A is a side elevation view of an instrument arm.
[0016] Figure 2B is a perspective view of a manipulator with an assembled instrument.
[0017] Figure 2C is a side elevation view of a portion of a camera arm with a camera mounted.
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5/65 [0018] Figure 3 is a diagrammatic view of multiple cannulas and associated instruments inserted through a body wall in order to reach a surgical site.
[0019] Figure 4A is a schematic view of a portion of a patient's robotic manipulator that supports and moves a combination of curved cannula and passively flexible surgical instrument.
[0020] Figure 4B is a schematic view showing a second robotic patient manipulator that supports and moves a second combination of curved cannula and passively flexible surgical instrument, added to the view in Figure 4A.
[0021] Figure 4C is a schematic view showing a telescopic camera handler holding an endoscope, added to the view in Figure 4B.
[0022] Figure 5 is a diagrammatic view of a flexible instrument.
[0023] Figure 6 is a bottom view of a force transmission mechanism.
[0024] Figure 7 is a diagrammatic side view of a distal portion of a surgical instrument.
[0025] Figure 8 is a cut-away perspective view of a portion of an instrument axis.
[0026] Figure 9 is a cut-away perspective view of a portion of another instrument axis.
[0027] Figure 10 is a diagrammatic view of a curved cannula.
[0028] Figure 10A is a diagrammatic view of a key alignment feature.
[0029] Figures 11A and 11B illustrate cannula orientations.
[0030] Figures 12A, 12B and 12C are diagrammatic views showing an instrument axis that runs through various cannula configurations and extends from these.
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6/65 [0031] Figure 13 is a schematic view illustrating another combination of curved cannula and flexible instrument.
[0032] Figure 14A is a diagrammatic plan view of a portal feature.
[0033] Figure 14B is a diagrammatic perspective view of a portal feature.
[0034] Figure 15A is a diagrammatic cross-sectional view taken on a cutting line in Figure 14A.
[0035] Figure 15B shows a detail of a seal shown in Figure 15A.
[0036] Figure 15C is a diagrammatic cross-sectional view taken on another cut line in Figure 14A.
[0037] Figure 15D is a diagrammatic cross-sectional view that illustrates an electrically conductive layer in a portal feature.
[0038] Figure 16A is a diagrammatic view of several skin and fascia incisions.
[0039] Figure 16B is a cross sectional view in diagrammatic perspective of another portal feature.
[0040] Figures 17A and 17B are diagrammatic views of yet another portal feature.
[0041] Figures 18A and 18B are diagrammatic views of yet another portal feature.
[0042] Figure 19A is a perspective view of a cannula insertion / stabilization accessory.
[0043] Figure 19B is another perspective view of a cannula insertion / stabilization accessory.
[0044] Figure 19C is a diagrammatic perspective view of a cannula stabilization accessory.
[0045] Figures 20A-20D are diagrammatic views that illustrate
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7/65 another way to insert cannulas.
[0046] Figure 21 is a diagrammatic view of a curved cannula and several reference axes.
[0047] Figure 22 is a diagrammatic view of a curved cannula and the distal end of a flexible instrument with associated fiber optic tension sensors.
[0048] Figure 23 is a diagrammatic view of a control system architecture.
DETAILED DESCRIPTION [0049] This description and the accompanying drawings that illustrate aspects and embodiments of the invention should not be taken as limiting - the claims define the protected invention. Various mechanical, compositional, structural, electrical and operational changes can be made without departing from the spirit and scope of this description and the claims. In some examples, well-known circuits, structures and techniques have not been shown or described in detail in order not to obscure the invention. Similar numbers in two or more figures represent the same or similar elements.
[0050] Additionally, the terminology of this description is not intended to limit the invention. For example, spatially relative terms - such as under, below, lower, above, upper, proximal, distal, and the like - can be used to describe the relationship of an element or feature to another element or feature, as illustrated in the figures. These spatially relative terms are intended to cover different positions (that is, locations) and orientations (that is, rotational settings) of a device in use or operation in addition to the position and orientation shown in the figures. For example, if a device in the figures is turned upside down, the elements described as below or under other elements can be found in the figure 870190087467, 05/09/2019, p. 10/76
8/65 tos or features would then be above or over other elements or features. Thus, the example term below can cover both positions and orientations from above and below. A device can be otherwise oriented (rotated 90 degrees or in other orientations) and the spatially relative descriptors used here interpreted accordingly. Likewise, descriptions of movement along and around the various axes include various positions and special orientations of the device. In addition, the singular forms one and one are intended to include plural forms as well, unless the context indicates otherwise. And, the terms comprise, comprising, include, and the like specify the presence of certain features, steps, operations, elements, and / or components, but do not prevent the presence or addition of one or more features, steps, operations, elements, components and / or groups. The components described as coupled can be electrically or mechanically coupled directly, or they can be indirectly coupled through one or more intermediate components.
[0051] Elements described in detail with reference to an embodiment can, whenever practical, be included in other embodiments in which they are not specifically shown or described. For example, if an element is described in detail with reference to an embodiment and is not described with reference to a second embodiment, the element may, however, be claimed as included in the second embodiment.
[0052] The flexible term in association with a mechanical structure or component must be widely constructed. In essence, the term indicates that the structure or component can be repeatedly folded and restored to its original shape without damage. Many rigid objects have a slight inherent resilient sinuousness due to
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9/65 material properties, although such objects are not considered flexible as the term is used here. A flexible mechanical structure can have infinite degrees of freedom (DOF's). Examples of such structures include foldable closed tubes (formed, for example, from NITINOL, polymer, soft rubber, and the like), helical spiral springs, etc., which can be bent into several simple and composite curves, usually without significant transverse deformation. Other flexible mechanical structures can approach such a piece of infinite degree of freedom with the use of a series of strictly spaced components that are similar to vertebrae in a winding arrangement. In such a vertebral arrangement, each component is a short link in a kinematic chain, and mobile mechanical constraints (for example, pin joint, bilboque, live joint, and the like) between each link may allow one (for example, tilt) or two (for example, tilt and yaw) degrees of relative freedom of movement between links. A short flexible structure can serve, and be modeled, as a single mechanical constraint (joint) that provides one or more degrees of freedom between two links in a kinematic chain, although the flexible structure itself can be a kinematic chain formed of several coupled links . Those skilled in the art will understand that the flexibility of a component can be expressed in terms of its stiffness.
[0053] In this description, a flexible mechanical component or structure can be either active or passively flexible. An actively flexible part can be bent using forces inherently associated with the part itself. For example, one or more tendons can be directed along the length of the piece and displaced from the longitudinal axis of the piece so that tension on one or more tendons causes the piece to be bent. Other ways to actively fold an actively flexible part include,
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10/65 without limitation, the use of pneumatic or hydraulic force, gears, electroactive polymer, and the like. A passively flexible part is bent using a force external to the part. An example of a passively flexible part with inherent rigidity is a plastic rod or a resilient rubber tube. An actively flexible part, when not driven by its inherently associated forces, can be passively flexible. A single component can be formed from one or more passively flexible portions in series.
[0054] Aspects of the invention are described primarily in terms of an implementation that uses a da Vinci® Surgical System (specifically, an IS3000 Model, marketed as a da Vinci® Si ™ HD ™ Surgical System), manufactured by Intuitive Surgical, Inc., from Sunnyvale, California. Those skilled in the art will understand, however, that the aspects of the invention described here can be realized and implemented in a variety of ways, including robotic and non-robotic embodiments and implementations. Implementations on da Vinci® Surgical Systems (eg, Model IS3000, Model IS2000, marketed as the da Vinci® S ™ HD ™ Surgical System) are merely exemplary and should not be considered to limit the scope of the aspects of the invention described on here.
[0055] Figures 1A, 1B and 1C are seen in frontal elevation of three main components of a teleoperated robotic surgical system for minimally invasive surgery. These three components are interconnected in order to allow a surgeon, with the assistance of a surgical team, to perform diagnostic and corrective surgical procedures on a patient.
[0056] Figure 1A is a front elevation view of the patient's car component 100 of the da Vinci® Surgical System. The patient's car includes a base 102 that rests on the floor, a replacement tower 870190087467, from 09/05/2019, p. 13/76
11/65 size 104 which is mounted on base 102, and several arms that support surgical tools (which include a stereoscopic endoscope). As shown in Figure 1A, arms 106a, 106b are instrument arms that hold and move the surgical instruments used to manipulate tissue, and arm 108 is a camera arm that supports and moves the endoscope. Figure 1A also shows an optional third instrument arm 106c which is supported on the rear side of the support tower 104, and which can be positioned either on the left side or on the right side of the patient's car, as needed, to conduct a procedure. surgical. Figure 1A additionally shows interchangeable surgical instruments 110a, 110b,
110c mounted on instrument arms 106a, 106b, 106c, and shows endoscope 112 mounted on camera arm 108. The arms are discussed in more detail below. Those skilled in the art will appreciate that the arms that support the instruments and the camera can also be supported by a base platform (fixed or movable) mounted on a ceiling or wall, or, in some instances, on another piece of equipment in the operating room (for example, the operating table). Likewise, they will appreciate that two or more separate bases can be used (for example, a base supporting each arm).
[0057] Figure 1B is a front elevation view of a component of the 120 surgeon console of the da Vinci® Surgical System. The surgeon's console is equipped with master tool manipulators (MTM's) of multiple degrees of freedom left and right 122a, 122b, which are kinematic chains that are used to control surgical tools (which include the endoscope and various cannulas). The surgeon grips a clamping assembly 124a, 124b on each master tool handler 122, typically with his thumb and index finger, and can move the clamping assembly to several
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12/65 positions and guidelines. When a tool control mode is selected, each master tool manipulator 122 will be coupled to control a corresponding instrument arm 106 for patient carriage 100. For example, left master tool manipulator 122a can be coupled to the instrument arm control 106b and instrument 110a, and the right master tool manipulator 122b can be coupled to instrument control arm 106b and instrument 110b. If the third instrument arm 106c is used during a surgical procedure and is positioned on the left side, then the left master tool manipulator 122a can be switched between control arm 106a and instrument 110a for control arm 106c and the instrument 110c. Likewise, if the third instrument arm 106c is used during a surgical procedure and is positioned on the right side, then the right master tool manipulator 122a can be switched between control arm 106b and instrument 100b for the control arm. control 106c and instrument 110c. In some examples, control assignments between master tool handlers 122a, 122b and the arm 106a / instrument 110a combination and the arm 106b / instrument 110b combination can also be exchanged. This can be done, for example, if the endoscope is rotated 180 degrees, so that the instrument moving in the endoscope's field of view appears to be on the same side as the master tool manipulator that the surgeon is moving. The clamping assembly is typically used to operate a surgical terminal operator provided with a claw (e.g., scissors, grip retractor, needle driver, and the like) at the distal end of an instrument 110.
[0058] The surgeon console 120 also includes a stereoscopic image display system 126. Images on the left side
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13/65 of and on the right side captured by the stereoscopic endoscope 112 are output on the corresponding left and right monitors, which the surgeon perceives as a three-dimensional image on the video screen 126. In an advantageous configuration, the master tool manipulators 122 are positioned below from the video screen 126 so that the images of the surgical tools shown on the glass appear to be co-located with the surgeon's hands below the image. This feature allows the surgeon to intuitively control the various surgical tools in the three-dimensional image, as if he were looking directly at his hands. Consequently, the servo control of the master tool manipulator of the associated instrument arm and the instrument is based on the endoscopic image reference frame.
[0059] The endoscopic image reference frame will also be used, if the master tool manipulators are switched to a camera control mode. In the da Vinci® Surgical System, if the camera control mode is selected, the surgeon can move the distal end of the endoscope by moving one or both of the master tool handlers together (portions of the two master tool handlers can be servo mechanically coupled so that the two master tool manipulator portions appear to move each other as a unit). The surgeon can then intuitively move (for example, pan, tilt, zoom) the stereoscopic image displayed by moving the master tool handlers as if holding the image in their hands.
[0060] The surgeon's console 120 is typically located in the same operating room as the patient's car 100, although it is positioned so that the surgeon who operates the console is out of the sterile field. One or more assistants typically assist the surgeon
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14/65 in working within the surgical field (for example, to change tools in the patient's car, to perform manual retraction, etc.). Consequently, the surgeon operates remotely from the sterile field, so the console can be located in a room or building separate from the operating room. In some implementations, two 120 consoles (either co-located or remote from each other) can be networked together so that two surgeons can view and control the tools at the surgical site.
[0061] Figure 1C is a front elevation view of a visualization car component 140 of the da Vinci® Surgical System. The display car 140 houses the central electronic data processing unit of the surgical system 142 and the visualization equipment 144. The central electronic data processing unit includes much of the data processing used to operate the surgical system. In several other implementations, however, electronic data processing can be distributed on the surgeon's console and the patient's car. The viewing equipment includes camera control units for the left and right image capture functions of the 112 stereoscopic endoscope. The viewing equipment also includes lighting equipment (eg, Xenon lamp) that provides illumination for the image formation of the surgical site. As shown in Figure 1C, the viewing car includes an optional 609.6 mm (24 inch) touch screen monitor 146, which can be mounted anywhere else, such as on patient car 100. The viewing car 140 additionally includes space 148 for auxiliary surgical equipment, such as electrosurgical units and insufflators. The patient's car and the surgeon's console are connected via fiber optic communications links to the visualization car so that three components together act as a single minimally invasive surgical system telePetition 870190087467, from 05/09/2019, p. 17/76
15/65 operated that provides an intuitive telepresence for the surgeon. And, as mentioned above, a second surgeon console can be included so that a second surgeon can, for example, control the work of the first surgeon.
[0062] Figure 2A is a side elevation view of an illustrative instrument arm 106. Sterile garments and associated mechanisms that are normally used during surgery are omitted for the sake of clarity. The arm is formed by a series of links and junctions that couple the links together. The arm is divided into two parts. The first portion is the configured portion 202, in which non-energized junctions couple the links. The second portion is the energized robotic manipulator 204 (patient manipulator (PSM) that supports and moves the surgical instrument). During use, the configured portion 202 is moved to place the manipulator portion 204 in the proper position to perform the desired surgical task. The joints of the configured portion are then locked (for example, with brake mechanisms) to prevent this arm portion from moving.
[0063] Figure 2B is a perspective view of the patient manipulator 204 with an illustrative instrument 110 mounted. Patient manipulator 204 includes a yaw servo actuator 206, a tilt servo actuator 208, and an insertion and withdrawal (I / O) actuator 210. An illustrative surgical instrument 110 is shown mounted on an instrument mounting carriage 212. An illustrative straight cannula 214 is shown mounted on the cannula holder 216. The axis 218 of the instrument 110 extends through the cannula 214. Patient manipulator 204 is mechanically limited so that he moves the instrument 110 around a center stationary motion remote 220 located along the axis of the instrument. The yaw actuator 206 provides yaw movement 222 around the center
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16/65 remote 220, tilt actuator 208 provides tilt movement 224 around remote center 220, and I / O actuator 210 provides insertion and withdrawal movement 226 through remote center 220. Configured portion 202 is typically positioned to place the remote center of movement 220 in the incision in the patient's body wall during surgery and to allow sufficient yaw and tilt movement to be available to perform the particular surgical task. Those skilled in the art will understand that movement around a remote movement center can also be limited solely by the use of software, rather than by a physical constraint defined by a mechanical assembly.
[0064] Corresponding force transmission discs in the assembly carton 212 and in the force transmission assembly of the instrument 230 couple actuating forces of the actuators 232 on the patient manipulator 204 to move the various parts of the instrument 110 in order to position, orient and operate the instrument terminal operator 234. Such driving forces can typically rotate the instrument axis 218 (thus providing another degree of freedom through the remote center), operate a piston 236 that provides degrees of freedom of yaw and tilt, and operate a moving part or clamping claws of various terminal operators (for example, scissors, grippers, electrocautery hooks, retractors, etc.).
[0065] Figure 2C is a side elevation view of a portion of a camera arm 108 with an illustrative camera 112 mounted. Similar to instrument arm 106, camera arm 108 includes a configured portion 240 and a manipulator portion 242 (endoscopic camera manipulator, (ECM). Endoscopic camera manipulator 242 is configured similarly to patient manipulator 204 and includes a yaw motion actuator 244, a tilt motion actuator 246, and a motion actuator
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17/65
I / O 248. Endoscope 112 is mounted on cart assembly 250 and endoscope cannula 252 is mounted on camera cannula holder 254. Endoscopic camera handler 242 moves endoscope 112 around and through the remote center of movement 256.
[0066] During a typical surgical procedure with the robotic surgical system described with reference to Figures 1A-2C, at least two incisions are made in the patient's body (usually using a trocar to place the associated cannula). One incision is for the endoscope camera instrument, and the other incisions are for the necessary surgical instruments. Such incisions are sometimes referred to as portals, a term that can also mean a piece of equipment that is used within such an incision, as described in detail below. In some surgical procedures, several instrument and / or camera portals are required in order to provide the necessary access and imaging for a surgical site. Although the incisions are relatively small compared to larger incisions used for traditional open surgery, there is a need and desire to further reduce the number of incisions to further reduce the patient's trauma and for better cosmesis.
[0067] Single-portal surgery is a technique in which all instruments used for minimally invasive surgery are passed through a single incision in the patient's body wall, or, in some instances, through a single natural orifice. Such methods can be referred to by several terms, such as Single Portal Access (SPA), Single Site Laparoscopic Surgery (LESS), Single Incision Laparoscopic Surgery (SILS), Umbilical Surgery of a Portal (OPUS), Surgery using Conventional Equipment without Single Portal Incision (SPICES), Transumbilical Natural Orifice Surgery (NOTUS). The use of a single portal can be done using or insPetition 870190087467, from 05/09/2019, pg. 20/76
18/65 manual instruments or a robotic surgical system, such as the one described above. A difficulty arises with such a technique, however, because the single portal restricts the angle at which a surgical instrument can access the surgical site. Two instruments, for example, are positioned clearly side by side, making it difficult to obtain advantageous triangulation angles at the surgical site. In addition, since instruments and the endoscope enter through the same incision, straight instrument axes tend to obscure a large part of the endoscope's field of view. And, in addition, if a robotic surgical system is used, then the multiple manipulators may interfere with each other, due to both their size and their movements, which also limits the degree of movement of the terminal operator available to the surgeon.
[0068] Figure 3 illustrates the difficulty of using a robotic multiple arm surgical system for single portal surgery. Figure 3 is a diagrammatic view of multiple cannulas and associated instruments inserted through a body wall in order to reach a surgical site 300. As shown in Figure 3, a camera cannula 302 extends through a camera incision 304, a first instrument cannula 306 extends through a first instrument incision 308, and a second instrument cannula 310 extends through a second instrument incision 312. It can be seen that if each of these cannulas 302, 306, 310 to be extended through the same (slightly larger) hole 304, due to the requirement that each move around a remote center of movement and also due to the volume and movement of the manipulators described above that retain the cannulas in 302a mounting adjustments , 306a, 310a, then very little movement of the instrument terminal operators would be possible, the cannulas and instrument axes could obscure the surgical site in the field
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19/65 view of the endoscope.
[0069] For single portal surgery using hand instruments, an attempt was made to use rigid curved instrument axes to improve triangulation. Such curved axes typically feature a composite S-fold that inside the body allows them to curve away from the incision and then again to the surgical site, and outside the body to curve away from the incision to provide a free space for manipulating the instrument and the surgeon's hands. These curved instruments appear to be even more difficult to use than straight-axis hand instruments, because the curved axes additionally limit a surgeon's ability to accurately move the terminal operator's instruments, either by moving the shaft or using a manually operated plunger mechanism. Suturing, for example, seems to be extremely difficult with such rigid curved-axis instruments. In addition, the surgeon's ability to insert and remove such curved-axis instruments directly between the incision and the surgical site is limited because of its shape. And, due to its shape, the rotation of a rigid curved instrument can cause a portion of the instrument's axis to come into contact and possibly cause tissue damage without the surgeon's knowledge.
[0070] For single portal surgery using robotic surgical systems, methods are proposed to provide greater controllable degrees of freedom for surgical instruments. For example, the use of telerobotically controlled winding instruments and associated controllable guide tubes has been proposed as a way to access a surgical site through a single incision. Similarly, the use of instruments with a miniature mechanical parallel movement mechanism has been proposed. See, for example, U.S. Patent Application Publication No. US 20008/0065105 A1 (of
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20/65 approved on June 13, 2007) (which describes a minimally invasive surgical system). While such instruments can ultimately be effective, they are often mechanically complex. And, due to their greater demands for the degree of freedom, such instruments may not be compatible with existing robotic surgical systems.
Curved Cannula System [0071] Figure 4A is a schematic view of a portion of a robotic patient manipulator that supports and moves a combination of a curved cannula and a passively flexible surgical instrument. As shown in Figure 4A, a telerobotically operated surgical instrument 402a includes a force transmission mechanism 404a, a passively flexible shaft 406a, and an end operator 408a. Instrument 402a is mounted on an instrument cart assembly 212a of a patient handler 204a. (previously described components are schematically represented for the sake of clarity). Interface discs 414a engage servo actuator forces on patient manipulator 204a to move instrument components 402a. Terminal operator 408a illustratively operates with a single degree of freedom (for example, closing jaws). A plunger to provide one or more degrees of freedom for the terminal operator (eg tilt, yaw; see, for example, U.S. Patent No. 6,817,974 (filed June 28, 2002) (which describes a surgical tool featuring a multiple disc plunger joint driven by a positively positioned tendon), which is incorporated here for reference) is optional and is not shown. Many instrument implementations do not include such a plunger. Omission of the plunger simplifies the number of actuation force interfaces between patient manipulator 204a and the instrument 402a, and omission also reduces the
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21/65 number of force transmission elements (and, consequently, the complexity and dimensions of the instrument) that would be required between the proximal force transmission mechanism 404a and the distally driven part.
[0072] Figure 4A additionally shows a curved cannula 416a, which has a proximal end 418a, a distal end 420a, and a central channel 422a extending between proximal end 418a and distal end 420a. The 416a curved cannula is, in one implementation, a rigid one-piece cannula. As shown in Figure 4A, the proximal end 418a of the curved cannula 416a is mounted on the cannula holder of patient manipulator 204a. During use, the flexible shaft 406a of the instrument 402a extends through the central channel 422a of the curved cannula 416a so that a distal portion of the flexible shaft 406a and the end operator 408a extend beyond the distal end 410a of the cannula 416a in order to reach the surgical site.424. As described above, the mechanical constraints of the patient manipulator 204 (or, alternatively, the restrictions of the pre-programmed software in the control system for the patient manipulator 204a) cause the instrument 402a and the curved cannula 416a to move at an incline and yaw around the remote center of movement 426 located along the cannula 416a, which is typically placed in an incision in the patient's body wall. The I / O drive of the patient manipulator 204a, provided by the cart 212a, inserts and removes the instrument 402a through the cannula 416a to move the terminal operator 408a in and out. Details of instrument 402a, cannula 416a, and control of these two components are described below.
[0073] Figure 4B is a schematic view showing a second robotic patient manipulator that supports and moves a second combination of curved cannula and passive surgical instrumentPetition 870190087467, of 05/09/2019, pg. 24/76
22/65 flexible, added to the view in Figure 4A. Components of the second handler of patient 204b, instrument 402b, and curved cannula 416b are substantially similar to those described in Figure 4A and function substantially similar to those described in Figure 4A. The curved cannula 416b, however, curves in a direction opposite to the direction in which the curved cannula 416a curves. Figure 4B thus illustrates that two curved cannulas and associated instruments, which curve in opposite directions, are positioned to extend through a single incision 428 in the patient's body wall 430 to reach surgical site 424. Each curved cannula is initially angled away from a straight line between the incision and the surgical site, then bending again in the direction of the line to direct the extended instruments to the surgical site. With the operation of the patient manipulator 204a and 204b at an incline and yaw, the distal ends 420a, 420b of the curved cannulae move accordingly, and therefore the instrument terminal operators 404a and 404b are moved with reference to the surgical site (and, consequently, with reference to the field of view of the endoscope). It can be seen that, although the remote centers of movement for the two combinations of curved cannula and flexible instrument are not identical, they are close enough (adjacent) to each other so that they can both be positioned in the single incision 428.
[0074] Figure 4C is a schematic view showing an endoscopic camera handler holding an endoscope, added to the view in Figure 4B. Some previously used reference numbers are omitted for clarity. As shown in Figure 4C, the endoscopic camera handler 242 retains endoscope 112 so that it extends through single incision 428, along with the two curved cannula and instru
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23/65 flexible ment. Endoscope 112 extends through a conventional cannula 252 supported by cannula support 254. In some implementations, cannula 252 provides insufflation into a body cavity. The endoscopic camera manipulator 242 is positioned to place the remote center of movement of endoscope 112 in incision 428. As above, it can be seen that the remote centers of movement for the two combinations of curved cannula and instrument and endoscope 112 are not identical , and they can be positioned close enough to allow everyone to extend through single incision 428 without the incision being unduly large. In an exemplary implementation, the three remote centers can be positioned approximately in a straight line, as shown in Figure 4C. In other implementations, such as those described below, the remote centers are not linearly aligned, although they are grouped close enough.
[0075] Figure 4C also schematically illustrates that the patient handlers 204a, 204b and the endoscopic camera handler 242 can be positioned so that each has a significantly improved volume in which it moves in tilt and yaw without mutual interference. That is, if straight-axis instruments are used, then the patient's manipulators must, in general, remain in positions close to each other to maintain the axes in an almost parallel relationship for effective work through a single incision. But with curved cannulas, however, the patient's manipulators can be placed further apart from each other, so that each patient's manipulator can, in general, move within a relatively larger volume than with straight-axis instruments. In addition, Figure 4C illustrates how curved cannulas 416 provide improved triangulation for surgical instruments, so that surgical site 426 is relative
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24/65 unobstructed in the field of view 430 of the endoscope 112.
[0076] Figure 4C further illustrates that a portal feature 432 can be placed in incision 428. Cannulas 16a, 416a and 252 each extend through portal feature 432. Such a portal feature can have various configurations, as described in detail below.
[0077] Figure 5 is a diagrammatic view of an illustrative flexible instrument 500 used with a curved cannula. Instrument 500 includes a proximal end force transmission mechanism 502, a distal end surgical end operator 504, and an axis 506 that couples the power transmission mechanism 502 and end operator 504. In some implementations, the 506 axis it is passively flexible and includes three sections - a proximal section 506a, a distal section 506c, and an intermediate section 506b which is between the proximal and distal sections 506a, 506c. In some implementations, sections 506a, 506b and 506c can each be characterized by their different stiffness. The section 506a is the portion of the axis 506 that extends from the force transmission mechanism 502 in the direction of the curved cannula through which the other sections of the axis 506 extend. Consequently, section 506a is relatively rigid compared to the other sections 506b, 506c. In some implementations, section 506a may be effectively rigid. Section 506b is relatively more flexible than the other two sections 506a, 506c. Most of the section 506b is inside the curved cannula during a surgical procedure, so section 506b is formed relatively flexible to reduce friction with the inner wall of the curved cannula, although it is not so formed so as to deform during insertion under manual or servo controlled operation. The 506x section is relatively stiffer than the 506b section, because the 506c section extends from the distal end of the curved cannula. Consequen
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25/65, section 506c is formed flexible enough so that it can be inserted through the curved cannula fold, although it is rigid enough to provide a suitable cantilever support for the 504 terminal operator. In some implementations, however, shaft sections 506a - 506c each have the same physical structure - each being composed of the same material (s), and the material (s) chosen as having a acceptable bending stiffness for each section - so that the sections thus have the same stiffness. For instruments that require a degree of freedom of rotation from the terminal operator through axis rotation, all three sections 506a-506c are torsionally rigid enough to transmit the rotation movement from the proximal end of the instrument to the distal surgical terminal operator 504. An example is described with reference to Figure 9 below. In one implementation, the 506 shaft is about 43 cm long.
[0078] Figure 6 is a bottom view of an implementation of a 502 force transmission mechanism. As shown in Figure 6, the force transmission mechanism of a surgical instrument used in a da Vinci® Surgical System has been modified to eliminate mechanisms used to control a plunger mechanism on the instrument and to control the grip of a terminal operator (or other moving part) using only a single interface disk. Thus, in an illustrative implementation, an interface disk 602 rotates the axis 506 so as to provide a degree of freedom of rotation for the terminal operator 504, and a second interface disk 602b operates the claw mechanism of the terminal operator 504. In one implementation, a bulkhead in the 502 drive mechanism supports spiral tubes that run through the instrument shaft, as described in detail below. The force transmission mechanism 502 can be coupled to the patient manipulator 204 without any
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26/65 mechanical modifications required for the patient handler.
[0079] Figure 6 also shows that implementations of the power transmission mechanism 502 may include electrically conductive interface pins 604 and an electronic data memory 606 that is electrically coupled to interface pins 604. The relevant parameters for instrument 500 and its operation (for example, number of times the instrument has been used, DenavitHartenberg parameters for control (described below), etc.) can be stored in memory 606 and accessed by the robotic surgical system during the operation to properly use the instrument (see, for example, example, U.S. Patent No. 6,331,181 (filed October 15, 1999) (which describes robotic surgical tools, data architecture, and use), which is incorporated here for reference). In one implementation, kinematic data specific to the curved cannula through which the instrument extends can be stored in memory 606, so that if the system detects that a curved cannula is mounted (see, for example, Figure 10 and associated text below), the system will be able to access and use the stored cannula data. If more than one kinematic curved cannula configuration is used (for example, different lengths, bend radii, bend angles, etc.), then data specific to each permissible configuration can be stored in the associated instrument's memory, and the The system can access and use the data for the specific cannula configuration that is assembled. In addition, in some instances, if the robotic surgical system detects that a flexible instrument has been attached to a manipulator that retains a straight cannula instead of a curve, then the system can declare this to be an illegal state and prevent operation.
[0080] Figure 7 is a diagrammatic side view of an illustrative implementation of a distal portion of the surgical instrument
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27/65
500. As shown in Figure 7, a proximal shackle 702 is coupled (for example, laser welded, welded, etc.) to a sleeve 704, which, in one example, is made of stainless steel. Sleeve 704 is coupled (e.g., folded, glued, etc.), in turn, to the distal end of shaft 506. Other known coupling methods can be used. The proximal shackle 702 is illustrative of components of many surgical instrument terminal operators that can be used, including needle actuators, spherical nose dissectors, curved scissors, Maryland dissectors, clamp applicators, cauterization hooks, etc.
[0081] Figure 8 is a cut-away perspective view that allows an illustrative structure of a portion of the axis of the instrument 506. Two tension elements 802a, 802b extend through a distal portion of the axis 506 and are coupled to operate the operator terminal (shown diagrammatically; for example, a 5 mm surgical class terminal operator used on instruments in the da Vinci® Surgical System). Strain elements 802a, 802b can be separated, or they can be parts of the same element that, for example, involves a pulley on the terminal operator. In one implementation, the tension elements 802a, 802b are 0.4572 mm (0.018 inch) tungsten wire. As shown in Figure 8, the proximal ends of the tension elements 802a, 802b are coupled (e.g., folded, etc.) to the distal ends of the second tension elements 804a, 804b which additionally extend proximally across most of the axis 506 In one implementation, the tension elements 804a, 804b are 0.8128 mm (0.032 inch) stainless steel hypotubes. At the proximal end (not shown), the tension elements 804a, 804b are coupled to the transmission mechanism 502 using wires similarly coupled.
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28/65 [0082] As shown in Figure 8, the tension elements
804a, 804b extend through support tubes 806a, 806b, respectively, which guide tension elements 804a, 804b and prevent them from being deformed or screwed into the 506 axis. In one implementation, support tubes 806a, 806b are tubes stainless steel coils (for example, 304V (vacuum melt-reducing material) (internal diameter of 0.889 mm (0.035 inches) and external diameter of 1.651 mm (0.065 inches)), other materials and structures can be used to reduce the friction as each tension element slides into its support tube, a friction reduction cover 808a, 808b is placed between the tension element and the inner wall of the support tube. In one implementation, the covers 808a, 808b are made of polytetrafluoroethylene (PTFE) and other materials can be used, both support tubes 806a, 806b are placed inside a single tube with an internal axis 810. In one implementation, a stainless steel wire Spiral plane is used for the 810 inner shaft tube to provide torsional stiffness during rotation. An outer shaft tube 812 (for example, braided stainless steel mesh or other suitable material to protect the shaft components) surrounds the inner shaft tube 810. An outer layer of elastomer 814 (eg, Pellothane®, or other material appropriate) surrounds the outer shaft tube 812. The outer layer 814 protects the inner components of the 506 shaft from direct contamination, for example, by body fluids during surgery, and the outer layer facilitates the sliding of the 506 shaft within the curved cannula. . In some implementations, the 506 shaft is approximately 5.5 mm (0.220 inches) in diameter.
[0083] In an exemplary implementation, the support tube and tension element assemblies can be coated by immersion in PTFE to provide a cover that reduces friction. The space
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29/65 between the spirals is filled by immersion coating material to form a tube. In another exemplary implementation, the wire is pre-coated before the spiral is wound, and the spiral is then fired to again fuse the coating and form the solid tube. The ends of the tube can be sealed around the tension elements to prevent contamination (for example, body fluids) from entering between the tension element and the coiled tube.
[0084] The 506 axis can include additional components. As shown in Figure 8, for example, in some implementations, one or more stiffening rods 816 run through various portions of the 506 axis. The number, size, and composition of the rods 816 can be varied to provide the various rigidities of the 506a-506c portions, as described above. For example, in some implementations, the 816 shanks are stainless steel. In addition, in some implementations, one or more additional rods 818 of other material may run through one or more portions of the 506 axis. For example, Figure 8 shows a second rod of polyaryletherethercetone (PEEK) that, in one implementation, runs through the distal section 506c to provide stiffness in addition to the stiffness of the rods 516. In addition, one or more additional tubes to provide, for example, suction and / or irrigation can be included in the shaft 506, either in addition to the stiffening rods, or in the place of these. And, additional tension elements can be included to operate, for example, an optional plunger mechanism with multiple degrees of freedom at the distal end of the instrument shaft.
[0085] Figure 9 is a cut-away perspective view showing a second illustrative structure of a portion of the axis of the instrument 506. The tension elements 902a, 902b, 904a, 904b are similar to the tension elements 802a, 802b, 804a and 804b described above. The tension elements are each directed through
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30/65 individual channels in the multi-channel support tube 906. In one implementation, the 906 tube is an extrusion of fluorinated ethylene propylene (FEP) with multiple 908 channels, and other materials can be used. FEP provides a low friction surface against which the tension elements slide. One or more stiffening rods (not shown) similar to those described above in Figure 8 and the associated text can be directed through several other channels 908 in support tube 906 to provide the desired stiffness for each of the axis sections of the 506a instrument 506c. A seven-channel tube 906 is shown in Figure 9, and a stiffening rod or other element can be inserted into the central channel. Additional cables, for example, to operate an optional plunger mechanism with multiple degrees of freedom at the distal end of shaft 506, can be routed through other channels in tube 906. Alternatively, other functions, such as suction and / or irrigation, can be provided through the channels.
[0086] Figure 9 additionally shows a shaft body tube
910 (for example, extruded PEEK or other suitable material) surrounding the support tube 908 to provide axial and torsional rigidity to the axis 506. An outer layer or outer coating 912 surrounds the body tube 910 to reduce friction to the extent that the shaft 506 slides into the curved cannula and to protect the shaft components. In one implementation, the outer layer 912 is a 0.127 mm (0.005 inch) layer of FEP that is heat shrinkable around the support tube 910, and other suitable materials can be used. In an implementation of the structure shown in Figure 9, the outer diameter of the 506 shaft is approximately 5.5 mm (0.220 inches), with a single extruded PEEK body tube having an outer diameter of approximately 5.0 mm and a diameter internal diameter of about 3.5 mm. PEEK that is used because of its
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31/65 stiffness (elastic modulus, or Young modulus) is poor enough to allow bending with a radial force low enough to limit friction within the curved cannula so that the I / O instrument is not significantly affected, but its modulus of elasticity is superior enough to provide good cantilevered beam stiffness for the distal portion of the 506c axis that extends beyond the distal end of the curved cannula to resist deformation of any portion of the axis between the transmission mechanism and the proximal end of the cannula, and to transmit the rotation movement and torque along the length of the instrument axis with adequate rigidity and precision.
[0087] Mainly due to friction, as the bending radius of a curved cannula decreases, the rigidity of the instrument's axis must also decrease. If an isotropic material is used for the instrument axis, as illustrated in association with Figure 9, then the stiffness of the axis portion that extends from the distal end of the cannula is also reduced. At some point, either the stiffness of the extended distal end of the shaft or the stiffness of the portion of the shaft between the transmission mechanism and the cannula may become unacceptably low. Therefore, a range of stiffnesses can be defined for an isotropic material axis of fixed dimensions, depending on the bend radius and the inside diameter of a cannula.
[0088] Figure 10 is a diagrammatic view of an illustrative curved cannula 416. As shown in Figure 10, cannula 416 includes an assembly section 1002 and the body section of cannula 1004. Assembly section 1002 is configured to be mounted on a robotic system manipulator (eg, 204 patient manipulator). In some implementations, one or more features 1006 are placed in the mounting section 102 to be detected by the sensors 1008 in the manipulator cannula holder. The presence
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32/65 of a characteristic 1006, as detected by sensors 1008, can indicate, for example, that the cannula is properly assembled and the type of cannula (for example, straight or curved, length of the cannula, radius of the curve, etc.) . In one implementation, features 1006 are protruding annular metal rings and the corresponding sensors 1008 are Hall effect sensors.
[0089] Mounting section 1002 may also include a mechanical key feature 1009 that matches a corresponding feature on the manipulator to ensure that the cannula is mounted in proper orientation with reference to the manipulator's insertion axis. In this way, for example, left and right curved cannulas can be formed. In addition, to distinguish left versus right curve orientation, the key feature can be used to ensure that the cannula is rotated at the appropriate angle in the manipulator holder so that instruments approach the surgical site at a desired angle. Those skilled in the art will understand that many key features can be used (for example, corresponding pin / holes, ears / grooves, spheres / holders, and the like). Figure 10A illustrates an exemplary key feature. As shown in Figure 10A, key feature 1030 is connected (for example, welded) on the side of a 1032 mounting bracket to a curved cannula. Key feature 1030 includes a recess 1034 that receives a portion of a manipulator cannula mounting bracket and two vertical alignment pins 1036a and 1036b. Alignment pins 1036a and 1036b match the corresponding alignment spindle on the manipulator mounting bracket to ensure proper cannula rotation orientation with reference to the manipulator.
[0090] Figures 11A and 11B are diagrammatic views of the extremes
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33/65 distal cities 1102a and 1102b with two curved cannulae as a surgeon could see them on the 3D monitor of the surgeon's console 1104, which emits images captured in the field of view of the endoscope. On the monitor, the curved cannulas extend away from the endoscope to allow instruments 1106a and 1106b to reach tissue 1108 at the surgical site. The cannulas can be mounted on the manipulators at various angles of rotation, or the manipulators can be oriented during surgery, so that the instruments approach the surgical site at various angles. Consequently, the cannula rotation directions can be described in several ways. For example, the angles of rotation of the cannula can be described with respect to each other. Figure 1A shows that, in an implementation, the cannulas can be oriented with their distal curves being approximately in a single common plane, so that the instruments extend from directly opposite angles in the direction of the surgical site. Figure 11B shows that, in an implementation, the cannulas can be oriented with their distal curves being on planes that are angled with respect to each other, for example, at approximately 60 degrees, as shown, so that the instruments extend to from angles of displacement to the surgical site. Many angles with respect to the plane of the cannula curve are possible (for example, 120, 90, 45, 30, or zero degrees). Another way of expressing the cannula's rotation orientation is to define it as the angle between the plane that includes the cannula curve and a plane of movement for one of the manipulator's degrees of freedom (for example, inclination). For example, a cannula can be mounted so that its curve is on a plane that is angled 30 degrees with respect to the degree of freedom of the manipulator's inclination. Consequently, an illustrative way to obtain the position of the cannulae of the instrument, as shown in Figure 11B, is that of po
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34/65 position the two handlers of the patient facing each other with their tilt movement planes approximately parallel (the planes will be slightly displaced so that the two cannulas do not intersect at their centers of movement). Then, each curved cannula is oriented approximately 30 degrees with reference to its tilting plane of the corresponding patient's manipulator.
[0091] Referring again to Figure 10, the cannula body section 1004 is, in some implementations, divided into a proximal section 1004a, an intermediate section 1004b, and a distal section 1004c. The proximal section 1004a is straight, and its length is sufficiently formed to provide adequate clearance for the support patient handler. Intermediate section 1004b is curved to provide the necessary instrument triangulation for the surgical site from a position of the manipulator that provides a sufficient range of motion to complete the surgical task without significant collisions. In one implementation, the middle section 1004b is curved at 60 degrees with a bend radius of 127 mm (5 inches). Other bend angles and bend radii can be used for specific surgical procedures. For example, a cannula length, curve angle, and bend radius may be best suited to reach from a specific incision point (eg, in the navel) to a specific anatomical structure (eg, the gallbladder) while another cannula length, bend angle and / or bend radius may be best suited to reach from the specific incision point in the direction of a second specific anatomical structure (for example, the appendix). And, in some implementations, two cannulas can be used, each having different lengths and / or bend radii.
[0092] The relatively tight free space between the inter wall
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35/65 in that of the curved section and the flexible instrument that slides in requires that the cross section of the curved section be circular or almost circular in shape throughout its length. In some implementations, the curved cannula is formed of 304 stainless steel (by mechanical hardening), and the curved section 1004b is bent using, for example, a bending accessory or a computerized numerically controlled (CNC) tube bender. For an instrument with a 5.5 mm (0.220 inch) outside diameter, in some implementations, the inside diameter of the curved cannula is formed to be approximately 6.0706 mm (0.239 inch), which provides an acceptable tolerance for variations in internal diameter fabrication that will still provide good sliding performance for the instrument axis.
[0093] Distal section 1004c is a short straight section of the cannula body. With reference to Figure 12A, it can be seen that, due to the small space (shown exaggerated for emphasis) between the outside diameter of the instrument axis and the inside diameter of the cannula, and due to the resilience of the instrument axis (although passively flexible, it can prevent the tendency to be straight), the distal section 1202 of the instrument axis comes into contact with the outer edge of the distal end of the cannula. Consequently, if the curved cannula ends at the curved section 1004b, the distal section 1202 of the instrument will extend out of the cannula at a relatively greater angle (again, shown exaggerated) with reference to the cannula 1204's extended center line. angle between the instrument axis and the outer edge causes greater friction (for example, scraping) when removing the instrument. As shown in Figure 12B, however, adding distal section 1004c to the cannula decreases the angle between distal section 1202 and the cannula 1204's extended centerline and also decreases friction between the outer edge of the instrument shaft.
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36/65 [0094] As shown in Figure 12C, in some implementations, a sleeve 1206 is inserted at the distal end of the distal section 1004c. The glove 1206 strangles the inside diameter of the curved cannula at the distal end, and thus additionally helps to extend the distal section 1202 of the instrument axis close to the extended center line of the cannula 1204. In some implementations, the outer edge of the glove 1206 is rounded , and the inner diameter of sleeve 1206 is relatively close to the outer diameter of the instrument axis. This helps to reduce possible tissue damage by preventing the tissue from being pinched between the axis of the instrument and the cannula during removal of the instrument. In some implementations, the 1206 sleeve is formed of 304 stainless steel and is approximately 12.7 mm (0.5 inches) long with an internal diameter of approximately 5.715 mm (0.225 inches). Sleeve 1206 can be formed from a friction reducing material, such as PTFE. In an alternative implementation, unlike using a separate sleeve 1206, the distal end of the curved cannula can be oscillated to reduce the cannula's inner diameter to produce a similar effect.
[0095] Figure 13 is a schematic view illustrating an alternative implementation of a combination of curved cannula and flexible instrument. Instead of a simple C-shaped fold, as described above, the curved cannula 1302 has a composite S-shaped fold (either planar or volumetric). In an illustrative implementation, each bend has about a 76.2 mm (3 inch) bend radius. The distal fold section 1304 provides triangulation for the surgical instrument, and the proximal fold 1306 provides free space for, for example, patient manipulator 204b (alternatively, in a manual implementation, for manipulations of the surgical instrument and the hands of the patient). surgeon). As shown, the passively flexible axis 404b of controlled surgical instrument
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37/65 robotically 402b extends through curved cannula 1302 and beyond the distal end of cannula 1308. A second combination of curved cannula and flexible instrument is omitted from the drawing for the sake of clarity. The use of curved cannulas in the form of S is similar to the use of curved cannulas in the form of C, as described here. For an S-shaped cannula, however, in a frame of reference defined for the field of view of the endoscope, the manipulator that controls the instrument is positioned on the same side of the surgical site as the corresponding terminal operator. Since multiple folds in the S-shaped cannula cause contact between the instrument axis and the cannula wall at more points along the length of the cannula than the C-shaped cannula, with similar normal forces at each point, I / O and rotation friction between the instrument and the cannula is relatively greater with an S-shaped cannula.
Portal Feature [0096] Figure 14A is a diagrammatic plan view of an illustrative implementation of a portal feature 1402 that can be used with combinations of curved cannula and instrument, and with an endoscope and one or more other instruments, as described here . Figure 14B is a top perspective view of the implementation shown in Figure 14A. Portal feature 1402 is inserted into a single incision in a patient's body wall. As shown in Figure 14A, portal feature 1402 is a single body with five channels extending between an upper surface 1404 and a lower surface 1406. A first channel 1408 serves as an endoscope channel and is sized to accommodate a cannula endoscope. In alternative implementations, channel 1408 can be sized to accommodate an endoscope without a cannula. As shown in Figure 14A, the endoscope channel 1404 is displaced from the central axis 1410 of the portal feature
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1402. If a surgical procedure requires insufflation, it can be provided through well-known features in the endoscope cannula.
[0097] Figure 14A shows two more channels 1412a and 1412b that serve as instrument channels and that are each sized to accommodate a curved cannula, as described here. The channels 1412a, 1412b extend through the portal feature 1402 at opposite angles to accommodate the positioning of the curved cannulas. Thus, in some implementations, channels 1412a, 1412b extend across a plane that divides the portal feature into left and right sides in an orientation shown in Figure 14A. As shown in Figure 14A, the instrument channels 1412a and 1412b are displaced from the central axis 1410. During use, the remote centers of movement for the endoscope and instrument cannulae will generally be in intermediate vertical positions within their respective channels. With the horizontal displacement of the endoscope channel 1408 and the instrument channels 1412a, 1412b from the central axis 1410, a central point of this group of remote centers can be positioned approximately in the center of the portal feature (i.e., in the center of the incision). Placing the remote centers very close to each other minimizes the patient's trauma during surgery (for example, due to the stretching of the tissue during the movement of the cannula). And, the portal feature keeps the cannulas close to each other, but resists the tendency for the tissue to force the cannulas towards each other, thus preventing the cannulas from interfering with each other. Various channel angles can be used in various implementations to accommodate the specific configurations of the curved cannulas that are used or to facilitate the placement of the curved cannula required for a specific surgical procedure.
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39/65 [0098] Figure 14A shows two illustrative optional auxiliary channels 1414 and 1416 that extend vertically through the portal feature 1402 (the number of auxiliary channels may vary). The diameter of the first auxiliary channel 1414 is relatively larger than the diameter of the second auxiliary channel 1416 (several dimensioned diameters can be used for each auxiliary channel). The first auxiliary channel 1414 can be used to insert another surgical instrument (manual or robotic, such as a retractor or a suction instrument, with or without a cannula) through the portal feature 1402. As shown in Figure 14A, the canal of the endoscope 1408, instrument channels 1412a, 1412b, and first auxiliary channel 1414 each include a seal (described below), and the second auxiliary channel 1416 does not. And so, a second auxiliary channel 1416 can also be used to insert another surgical instrument, or it can be used for another purpose better served by not having a seal in the channel, such as to provide a channel for a flexible suction or irrigation pipe. (or other non-rigid instrument), or to provide a channel for insufflation or evacuation (insufflation can be performed using typical features in the endoscope cannula or another cannula).
[0099] Figure 14A shows that, in some implementations, an orifice orientation feature 1418 can be positioned on the upper surface 1404. During use, the surgeon inserts the portal feature 1402 into the incision and then guides the portal feature so that the 1418 orientation indicator is usually towards the surgical site. In this way, the portal feature is oriented to provide the necessary positions for the cannulas of the endoscope and curve in order to perform the surgical procedure. Orientation feature 1418 can be formed in several ways, such as molded or printed on the top surface 1404. Likewise
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40/65 mode, Figure 14A shows that, in some implementations, the instrument hole identification characteristics 1420a and 1420b (circled numerals 1 and 2 are shown) can each be positioned close to one of the two instrument to identify the instrument channel. A similar identification feature can be placed on cannulas designed to be used on the left and right sides, so that medical personnel can easily place a curved cannula in its appropriate orifice channel in matching the cannula and portal channel identifications.
[00100] In some implementations, portal feature 1402 is formed of a single injection-molded silicone piece having a durometer value of about 15 Shore A. Other configurations of portal feature 1402 can be used, including portal features of multiple parts with secondary cannulas that can accommodate, for example, both endoscope cannulas and curved cannulas, as described here.
[00101] With reference to Figure 14B, in some examples, the upper surface 1404 and the lower surface 1406 (not shown) are concave in shape. Figure 14B also shows that, in some examples, portal feature 1402 is provided with a narrower part. The narrower part 1422 provides an upper flange 1424 and a lower flange 1426 which help to retain the portal characteristic 1402 in position within the incision. Since the portal feature 1402 can be formed of a soft resilient material, the flanges 1424, 1426 formed by the narrowest part 1422 and the concave surface and bottom surfaces are easily deformed to allow the surgeon to insert the portal feature into the incision , then returning the flanges to their original shape to hold the portal feature in place.
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41/65 [00102] Figure 15A is a diagrammatic cross-sectional view taken at cut line AA in Figure 14, and illustrates how channel 1408b passes from the upper surface to the lower surface at an angle from side to side through of portal feature 1402. Channel 1408a is similarly directed in the opposite direction. The vertical position at which the two channels intersect (in the orientation of Figure 15A, channel 1412a (not shown) is closest to the viewer, crossing the portal feature from the upper right to the lower left) is approximately the vertical location of the respective remote centers of cannula movement, when properly inserted. As mentioned above, in some implementations, a seal can be placed on one or more channels through the portal feature 1402, and Figure 15A shows an example of such a seal illustratively positioned at the vertical location of the cannula's remote center of movement.
[00103] Figure 15B is a detailed view of an exemplary implementation of a seal 1502 within instrument channel 1412b. As shown in Figure 15B, seal 1502 includes an integrally shaped solid ring 1504 that extends from the inner wall 1506 of channel 1412b inwardly towards the longitudinal centerline of channel 1412b. A small opening 1508 remains in the center of ring 1504 to allow the ring to be stretched to open around an inserted object, although the opening is generally small enough to prevent any significant fluid passage (for example, exhaust gas escaping). insufflation). In this way, the seals allow insufflation (for example, through an auxiliary channel in the portal feature) before any instruments (for example, cannulas) are inserted. The seals will also improve the seal between the portal feature and the cannulas, when the portal feature is flexed, the channel shapes being colored
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42/65 untwisted by the movement of the cannula during surgery.
[00104] Those skilled in the art will understand that several other ways to implement an effective seal can be used. For example, in another sealing implementation, a fully molded resilient membrane completely blocks the channel, and the membrane is perforated the first time that an object is inserted through the channel. The membrane then forms a seal with the object. In still other implementations, a seal that is a separate part can be inserted into the channel. For example, an annular holder can be molded into the wall of channel 1506, and then a seal can be positioned and maintained on the holder.
[00105] Figure 15C is a diagrammatic cross-sectional view taken on the cut line B-B in Figure 14A. The BB cut line is taken through the endoscope channel center line 1408, and thus the BB cut line does not include the auxiliary channel 1414 or 1416 center lines. Figure 15C illustrates that, in some implementations, the channel endoscope 1408 includes a seal 1508, and auxiliary channel 1414 includes a seal 1510, but auxiliary channel 1416 has no seal. Figure 15C further illustrates that seals 1508 and 1510 are similar to seal 1502, although several seals can be used, as described above.
[00106] Figure 15D is a diagrammatic cross-sectional view taken at cut line AA in Figure 14, and illustrates that, in some implementations, there is an electrically conductive silicone layer 1512 that extends horizontally through the middle of the portal feature (for example, in the narrowest part 1422, as shown). Conductive layer 1512 is shown spaced halfway between the upper and lower surfaces of the portal feature, thus incorporating seals, as described above. In
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43/65 other implementations, the electrically conductive layer may be in another vertical position that does not incorporate the seals, or two or more electrically conductive layers may be used. In some implementations, the interior of the channels is strangled in the conductive layer, but not necessarily configured as seals, in order to provide the necessary electrical contact between the conductive layer and the instrument. In one implementation, the conductive layer 1512 is integrally molded with the upper portion 1514 and the lower portion 1516 of the portal feature. Electrically conductive silicone may have a higher durometer value than the upper and lower portions due to necessary additives, but since it is located approximately at the level of the cannula's movement centers, the higher stiffness does not significantly affect movement of the cannula, as compared to a similar portal feature without the electrically conductive layer. This electrically conductive layer forms an electrically conductive path between the patient's body wall, which is in contact with the external surface of the portal feature, and the cannula and / or the instrument passing through the channel. This electrically conductive path provides a path for electrical grounding during electrocautery.
[00107] As described above, in some cases, portal feature 1402 can be inserted through the entire body wall. In other cases, however, a single incision may not be formed across the entire body wall. For example, a single incision may include a single percutaneous incision made in the umbilicus (for example, in a Z-shape) and multiple incisions in the underlying fascia. Consequently, in some cases, the portal feature can be eliminated, and while each of the cannulas, the endoscope cannula or the curved cannula, extends through the single percutaneous incision, the cannulas pass, each through separate incisions in the
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44/65 fascia, and can be supported by them. Figure 16A is a diagrammatic view illustrating portions of the cannula of endoscope 1602, and left and right curved cannulas 1604a and 1604b that pass through a single skin incision 1606, and then each through separate fascia incisions 1608. In some For example, operating room personnel may want additional support for the cannulas in such a single percutaneous / multiple facial incision (for example, while fitting the cannulas into their associated robotic manipulators). In such example, a configured portal similar to the upper portion 1514 (Figure 15D) or a combination of the combined upper portion 1514 and conductive layer 1512 can be used.
[00108] Figure 16B is a cross-sectional view in diagrammatic perspective of another portal feature that can be used with a single skin / multiple fascia incision procedure. The 1620 portal feature is similar in configuration to the 1402 portal feature, and the features described above (eg, orientation and orifice indicators, seals, where applicable, soft resilient material, etc.) can be applied to the 1620 portal feature. also. The portal feature 1620 has a body with a generally cylindrical shape that includes an upper surface 1622, an inner surface 1624, and a narrower part of the narrowed side wall 1626 between the surface and bottom surfaces. Consequently, an upper flange 1628 and a lower flange 1630 are formed between the side walls and the upper and lower surfaces. During use, the skin is held in the narrowest part 1626 between the upper and lower flange, and the lower surface 1624 and the lower flange 1630 rest on the layer of fascia that underlies the skin.
[00109] Figure 16B shows four illustrative holes that extend between the upper and lower surfaces of the por characteristic
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45/65 such. Channel 1632 is an endoscope channel, and channel 1634 is an auxiliary channel, similar to the channels described above with reference to portal feature 1402. Likewise, channels 1636a and 1636b are angled instrument channels that are similar to such channels. described above, channel 1636b which is angled from upper right to lower left, as shown, and channel 1636a which is angled from upper left to lower right (hidden from view). Unlike the instrument channels of the portal feature 1402, however, the centerlines of the instrument channels 1636a and 1636b of the portal feature 1620 do not extend across the intermediate plant line of the portal feature. Instead, the angled instrument channels stop at the middle line of the 1620 portal feature, so that the remote centers of movement of the cannulas and instruments are positioned in the underlying fascia incisions (an illustrative position of the 1638 center of motion is illustrated ). Thus, it can be seen that the output locations of the instrument channels on the lower surface of the portal feature can be varied to place the centers of movement in a desired location with reference to a patient's tissue. [00110] For some surgical procedures, the straight line between a single incision and a surgical site (for example, between the navel and the gallbladder) begins to approach being at an acute angle to the patient's coronal (frontal) plane . Consequently, the cannulas enter the single incision at a relatively small (acute) angle with reference to the skin surface, and the body wall is twisted and exerts a twist on the cannulas / instruments or on the portal. Figure 17A is a diagrammatic top view, and Figure 17B is a diagrammatic side view of yet another portal feature 1702 that can be used to guide and support two or more cannulas that enter through a single incision. According
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46/65 shown in Figures 17A and 17B, portal feature 1702 includes an upper funnel section 1704, a lower front latch 1706, and a lower rear latch 1708. In some implementations, the funnel section and lugs are a single piece. The 1702 portal feature can be formed, for example, of relatively rigid molded plastic, such as PEEK, polyetherimide (eg Ultem® products), polyethylene, polypropylene, and the like, so that the 1702 portal feature retains, in general, its shape during use. When positioned in a 1710 incision, the lower tabs 1706, 1708 are inside the body, and the funnel section 1704 remains outside the body. As shown in the figures, in some implementations, the funnel section 1704 is formed as a circular or elliptical oblique cone, which reduces interference with the equipment positioned on the funnel section, when the portal feature is twisted in the incision, as described below. It can be seen that, once in position, the distal end 1712 of funnel section 1704 can be pressed towards the skin surface. This action causes the narrowest section section 1714 between the upper funnel portion and the lower tongues to be twisted in the incision, which effectively redirects the incision, and thus provides a more resistant free course to the surgical site. The front tongue prevents the portal feature 1702 from exiting the incision during this twist. In addition, pressing on the distal end 1712 of the funnel section raises the distal end 1716 of the front tongue. In some implementations, the front tongue can be dimensioned and formed to retract the fabric as the distal end of the tongue is raised. The rear tongue 1708 also helps maintain the portal feature 1702 in the incision.
[00111] The 1702 portal feature also includes at least two access channels to accommodate the cannulas of the endoscope and the
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47/65 instrument. As shown in Figure 17A, in some implementations, four exemplary channels are within the narrowest portion portion 1714. An endoscope cannula channel 1720 is placed in the middle of the narrowest portion portion 1714, and three instrument cannula channels 1722 are positioned around the 1720 endoscope cannula channel. In some implementations, the channels are formed in the single piece like the funnel section and the tongues. In other implementations, the channels are formed in a cylindrical part 1723 that is mounted to rotate as indicated by the arrows 1723a in the narrowest section section 1714. In some implementations, the 1722 instrument cannula channels are each formed in one ball joint 1724, which is positioned in the narrowest part section 1714 (for example, directly, or in the cylindrical part). The remote centers of movement of the cannulas are positioned at the spherical junctions, which then allow the cannulas to easily pivot within the 1702 portal feature. In other implementations, the channels are configured to receive a sphere that is affixed (for example, pressure-adjusted) ) in a cannula in the remote center of movement, and the cannula ball then pivots in the channel as a spherical joint. In some implementations, the upper and lower surfaces of the narrowest section (for example, the upper and lower surfaces of the cylindrical part) can be chamfered to allow for a greater range of movement of the cannula that moves at the spherical joint. In some implementations, the 1720 endoscope cannula channel does not include a ball joint. In some implementations, an endoscope and / or instruments with rigid axes can be directed through their respective channels without cannulas. [00112] Figure 18A is a diagrammatic top view, and Figure 18B is a diagrammatic side view of yet another 1802 portal feature that can be used to guide and support two or more
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48/65 cannulas that enter through a single incision. The basic configuration of the 1802 portal feature is similar to that of the 1702 portal feature - for example, the funnel section, the upper tongue, and the channels are generally similar. In the portal feature 1802, however, the rear tongue 1804 can be generated from a position aligned with the front tongue 1806, as indicated by the alternate position 1808, to a position opposite the front tongue, as shown in Figure 18B. Therefore, the rear tongue 1804 can be formed relatively longer than the rear tongue 1708 (Figure 17B), and the portal feature 1802 can also be inserted in a single small incision. The rear tongue 1804 is aligned with the front tongue 1806, when the portal feature 1802 is positioned in the incision, and then rotated to the rear position, when the portal feature is in place. In one implementation, the rear tongue 1804 is attached to the rotating cylinder containing the channels, as described above, and an ear 1810, located within the funnel section, on the cylinder part is rotated, as indicated by the arrows from its position 1812 alternative insert in the front direction to position the rear tab for surgical use.
[00113] Aspects of portal features, as described here are not limited to use with one or more curved cannulas, and such portal features can be used, for example, with straight instrument cannulas, rigid instrument axes (with or without cannulas), and for both robotic and manual surgery.
Insertion Accessory [00114] In minimally invasive multi-port surgery, the endoscope is typically the first surgical instrument to be inserted. Once inserted, the endoscope can be positioned to view other cannula and instrument inserts so that an instrument inadvertently contacts and damages the tissue. With
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49/65 a single incision, however, once the endoscope is inserted, the other cannulas and other instruments are inserted at least initially outside the field of view of the endoscope. And, for curved cannulas, it is difficult to ensure that the tip of a cannula is moved directly into the field of view of the endoscope without contact with other tissue. In addition, keeping the cannulae properly positioned and oriented as robotic manipulators are adjusted and then attached (fitted) to the cannulae may require considerable manual dexterity involving more than one person. Therefore, it is necessary to find ways to safely and easily insert multiple instruments through a single incision. During some surgical procedures, portal features, such as those described above, can provide adequate ways to safely insert multiple instruments. During other surgical procedures, or due to the surgeon's preference, other ways of safely inserting multiple instruments can be used.
[00115] Figure 19A is a perspective view of an example of a 1902 cannula insertion accessory. As shown in Figure 19A, the 1902 insertion accessory is capable of guiding an endoscope cannula and two curved instrument cannulas in one single incision. Other implementations can guide more or less cannulas. Insertion accessory 1902 includes a base 1904, an endoscope cannula support arm 1906, and two instrument cannula support arms 1908a and 1908b. As shown in Figure 19A, the endoscope cannula support arm 1906 is rigidly mounted to base 1904, although, in other implementations, it can be pivotally mounted. The distal end of the 1906 endoscope cannula support arm is curved downward in the direction of the base plane and contains a 1910 endoscope cannula support slot. The 1912 holders in the 1910 support slot allow
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50/65 the endoscope cannula is positioned and maintained at various angles.
[00116] Figure 19A also shows that an instrument cannula support arm 1908a is pivotally mounted on base 1904 at joint 1914a. An instrument cannula support 1916a is at the distal end of the cannula support arm 1908a and holds an illustrative instrument cannula (for example, a curved cannula, as described above). The 1916a cannula holder may include one or more key mechanical features to ensure that the cannula is maintained in a desired rotation orientation, as described above. Figure 19A shows the position of the support arm 1908a with its associated cannula in an inserted position.
[00117] Figure 19A additionally shows that another instrument cannula support arm 1906b is pivotally mounted on base 1904 at joint 1914b, on an opposite side of support arm 1908a. The support arm 1908b includes an instrument cannula support 1916b which is similar to the cannula support 1916a. Figure 19A shows the position of the support arm 1908b with its associated cannula before the cannula is inserted through the incision. The cannulas are held by the cannula supports 1916a, 1916b in such a way that the axes of rotation for the joints 1914a, 1914b are approximately on the axes of curvature for the curved cannulas. In this way, as the support arms rotate at the joints, the curved cannulas travel approximately through the same small area, which is aligned with a single incision or another entrance portal into the body. With reference to Figure 19B, it can be seen that the support arm 1908b was moved to insert its associated cannula, which runs in an arc through the incision. In addition, the joints 1914a, 1914b can be oriented in such a way that the two cannulas travel through slightly different areas in the incision
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51/65 in order to establish a desired free space and an arrangement between the various cannulas in the incision.
[00118] An illustrative use of the insertion accessory is with the single percutaneous / multifascial incision, such as the one described above. The surgeon first makes the only percutaneous incision. The surgeon then inserts a dissection plug (for example, pointy) into an endoscope cannula and attaches the endoscope cannula to the insertion attachment at a desired angle. At this point, the surgeon can insert an endoscope through the cannula of the endoscope to observe additional insertions, either by mounting the cannula of the endoscope and the endoscope in a robotic manipulator, or temporarily holding the endoscope by hand. The surgeon can then move the cannulas along their insertion arc until they come into contact with the body wall. With the use of a dissection plug, the surgeon can then insert each cannula through the fascia. The surgeon can then optionally remove the cannula dissection plugs and either leave the cannulas empty or insert the blind plugs. Then, the surgeon can continue to move the instrument's cannulas to their fully inserted positions, with their distal ends positioned to appear in the field of view of the endoscope. Once the cannulae are inserted, the robotic manipulators can be moved into position, and the instrument cannulae can then be mounted (fitted) on their robotic manipulators. The insertion accessory is then removed, and the flexible-axis instruments are inserted through the cannulas towards the surgical site under endoscopic view. This illustrative insertion procedure is an example of many possible variations for using the insertion accessory to insert and support any number of cannulas through various body incisions and openings.
[00119] In some cases, an implementation of an accessory
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52/65 insertion can be used to support cannulae while one or more manually operated instruments are inserted through the cannula (s) and used in the operating room.
[00120] In some alternative implementations, the insertion accessory can be simplified to just provide a way to retain the cannulae in a fixed position during fitting in their associated manipulators. For example, this can be achieved by first inserting the cannulas, then applying the attachment to the camera cannula, and then attaching the attachment to the curved cannulas. Once the inserted cannulas are attached to the accessory, the patient's robot and its manipulators are moved to appropriate positions with reference to the patient. Then, while the attachment holds the camera cannula and the curved cannulas in place, each cannula is fitted to its associated manipulator. In general, the camera cannula is fitted first.
[00121] Figure 19C is a perspective view of a 1930 cannula stabilization accessory. The 1930 accessory includes a 1932 base, two cannula supports 1934a, 1934b. The 1936a arm attaches the 1934a cannula holder to the 1932 base, and the 1936b arm couples the 1934b cannula holder to the 1932 base. The 1932 base is configured to receive an endoscope cannula in a 1938 opening, and two integral spring clips 1940a and 1940b on each side of the 1938 opening firmly hold the base in the endoscope cannula. Each cannula holder 1934a, 1934b is configured to retain a cannula from the instrument with the receipt of a key feature similar to the key feature described above with reference to Figure 10A. Holes in the cannula holders receive pins 1036, as shown in Figure 10A. The arms 1936a, 1936b are, in an illustrative implementation, heavy aluminum wire covered by silicone tubing, so the arms can be positioned as desired. Each
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The arm supports its associated cannula support and the instrument's cannula, so that the cannulas of the instrument are kept stationary with reference to the cannula of the endoscope, when all are positioned within a single skin incision. Those skilled in the art will understand that many variations of this accessory are possible to effectively retain the various cannulas as an exclusive unit in position during insertion and during fitting to a robotic manipulator.
[00122] Figures 20A-20D are diagrammatic views that illustrate another way of inserting cannulas into a single incision. Figure 20A shows, for example, an endoscope cannula 2002 and two curved cannulas 2004a and 2004b. In some instances, a 2006 endoscope can be inserted into the cannula of the 2002 endoscope. The distal ends of the cannulas, and, if applicable, the distal imaging end of an endoscope, are grouped together within a 2008 cap. In some implementations , the lid 2008 can be a straight circular cone formed of a material sufficiently rigid to function as a plug to penetrate a body wall. In some implementations, a surgeon first makes an incision, and then the 2008 cap with the cannulas grouped behind is inserted through the incision. In some examples, the cap may be formed of a transparent material that allows the endoscope to image the insertion path in front of the cap. In some implementations, the 2008 lid can be grouped together with a 2010 portal feature, such as the one described above or another suitable portal feature. Thus, in some examples, the portal feature can function as one or more cannulas for the endoscope and / or instruments. (As shown, the 2010 portal feature also illustrates that inflation through a 2012 inflation channel on any portal feature
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54/65 can be provided in some implementations, although, as described above, insufflation can be provided in several ways, such as through one of the cannulas). A 2014 rope is connected to the 2008 lid, and the rope extends outward from the body.
[00123] Figure 20B shows that the distal ends of the cannulas (or instruments, as applicable) remain grouped in the lid 2008 as it is inserted more advanced into the patient. As the 2010 portal feature remains attached to the 2016 body wall, the cannulas (or instruments, when applicable) slide through it to stay inside the 2008 lid. In some examples, the lid is moved further inward by pressing one or more of the cannulas (or instruments, as applicable). For example, the endoscope cannula and / or the cannula can be mounted on a robotic camera manipulator, and the manipulator can be used to insert the cap further inward.
[00124] Figure 20C shows that, once the distal ends of the cannulas (or instruments, as applicable) have reached a desired depth, the cannulas can be coupled to their associated robotic manipulators (for example, the cannula 2004a to the manipulator 2018a and the cannula 2004b to the manipulator 2018b). The surgical instrument can then be used to remove the cap from the distal ends of the cannulas (or other instruments, as applicable). Figure 20D shows that the lid 2008 can be placed away from the surgical site within the patient during a surgical procedure using the telescope and both robotically controlled instruments 2020a and 2020b. The 2008 lid can optionally incorporate a 2022 specimen bag for specimen recovery at the end of the procedure. This specimen bag can optionally incorporate a pull cord to close the bag, and the specimen bag pull cord can optionally be
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55/65 integral with the lid rope 2014. After the surgery is complete and the instruments, cannulae and portal feature are removed, the lid 2008 (and the optional bag) can be removed by pulling the rope 2014.
Control Aspects [00125] The control of minimally invasive surgical robotic systems is known (see, for example, North American Patents No. 5,859,934 (filed January 14, 1997) (which describes a method and apparatus for transforming systems of coordinates in a telemanipulation system), No. 6,223,100 (filed March 25, 1998) (which describes an apparatus and a method for performing computer-perfected surgery with an articulated instrument), No. 7,087,049 (filed on January 15, 2002) (which describes the repositioning and reorientation of the master / slave relationship in minimally invasive telesurgery), and No. 7,155,315 (deposited on December 12, 2005) (which describes the referenced camera control in a minimally invasive surgical device), and North American Patent Application Publication No. US 2006/0178559 (filed December 27, 2005) (which describes a multi-user medical robotic system) for collaboration or training in minimally invasive surgical procedures), all of which are incorporated for reference). Control systems for operating a robotic surgical system can be modified, as described here, for use with curved cannulas and passively flexible surgical instruments. In an illustrative implementation, the control system of a da Vinci® Surgical System is thus modified.
[00126] Figure 21 is a diagrammatic view of a curved cannula 2102, which has a proximal end 2104 that is mounted on a robotic manipulator, a distal end 2106, and a section 870190087467, of 05/09/2019, pg. 58/76
56/65 curved section (eg 60 degree bend) between the proximal and distal ends. A longitudinal centerline axis 2110 is defined between the proximal and distal ends of the curved cannula 2102. In addition, an insertion and withdrawal axis 2112 is defined to include a centerline extending along the longitudinal axis 2110 in a straight line from the distal end of the curved cannula. Since the distal section (506c, Figure 5) of the passively flexible instrument axis is relatively rigid, it will move approximately along the insertion and withdrawal axis 2112 as it extends out of the distal end of the cannula curve. Therefore, the control system is configured to assume that the flexible axis acts as a straight rigid axis with a 2112 insertion and withdrawal axis. That is, the instrument's I / O axis is assumed to be the longitudinal centerline. straight line from the distal end of the curved cannula, and the system determines a virtual location of the tip of the instrument as being along the I / O 2112 axis. This I / O movement of the instrument at the distal end of the cannula is illustrated by the double-headed arrow 2114. To prevent excessive lateral movement in the flexible shaft section that extends beyond the distal end of the cannula, in an implementation, the extension distance is regulated by the control system software and may depend, for example, on the stiffness of the section distal from the flexible axis to the specific instrument that is used. And, in an implementation, the control system will not allow the master manipulator to move the cannula or the instrument until the tip of the instrument extends beyond the distal end of the cannula.
[00127] The control system is also modified to incorporate kinematic limits associated with the curved cannula. The movement of the tip of the instrument that extends out of the cannula is described as if produced by a virtual serial kinematic chain of frames
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57/65 of reference, exclusively described by a set of parameters Denavit-Hartenberg. For example, boundary conditions at the distal end of the cannula 2106 are defined as the position of the tip, the orientation of the tip, and the length along the curved section. Such boundary conditions are used to define the appropriate DenavitHartenberg parameters. As shown in Figure 21, a frame of reference can be defined by having an origin at a location along longitudinal axis 2110 (for example, at the remote center of movement of the cannula 2116, as shown). An axis 2118 of such a frame of reference can be defined to intersect the extended I / O axis 2112 at a point 2120. A minimum distance can be determined between the origin of the frame of reference and the distal end of the cannula 2106. Various cannula configurations different (for example, length, bend angle, rotation, when mounted on the manipulator, etc.) will have several associated cinematic limitations. For instrument I / O, however, the effective path length along the curved section is used instead of the minimum distance between the remote center of movement and the distal tip of the instrument. Those skilled in the art will understand that several methods can be used to describe kinematic limitations. For example, an alternative way to solve the problem is to incorporate the homogeneous transformation that explicitly describes the geometry of the curved cannula in the serial kinematic chain.
[00128] Additional modifications to the control system allow the surgeon to receive haptic feedback on the master handlers (for example, 122a, 122b, as shown in Figure 1b). In various robotic surgical systems, the surgeon experiences a haptic servo motor force on the master manipulators. For example, if the system detects (for example, triggered by an encoder) that a slave side junction limit is reached or almost reached, then the cirur
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58/65 the region will experience a force on the master manipulator that tends to prevent the surgeon from moving the master manipulator in the direction of the slave side junction limit. As another example, if the system detects that an external force is applied to the instrument at the surgical site (for example, by detecting the excessive motor current that is used as the system tries to keep the instrument in its commanded position), then, the surgeon may experience a force on the master manipulator that indicates a direction and magnitude of the external force acting on the slave side.
[00129] Haptic feedback on master manipulators is used in an implementation of a control system used to provide the surgeon with an intuitive control experience while using curved cannulas. For flexible instruments that do not have a plunger, the control system provides haptic forces on the master manipulators to prevent the surgeon from moving the master manipulator of multiple degrees of freedom with a plunger motion. That is, the servo motors of the master manipulator attempt to keep the orientation of the master manipulator stationary in the inclination and yaw orientations as the surgeon changes the position of the master manipulator. This feature is similar to a feature used in common robotic surgical systems for instruments with straight rigid axes and no plunger. The system detects the type of instrument (for example, plunger, not plunger) and applies haptic feedback accordingly.
[00130] Haptic feedback is also used in an implementation to provide the surgeon with a sense of an external force applied to various points in the instrument's kinematic chain. Haptic feedback is provided to the surgeon for any detected external force applied to the manipulator (for example, how it could occur, if the manipulator collided with another manipulator) or to the proximal portion
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59/65 straight from the curved cannula. Since the cannula is curved, however, the system cannot provide adequate haptic feedback for an external force applied to the curved section of the cannula (for example, with collision with another curved cannula, either inside or outside the field of view. endoscope), because the system cannot determine the direction and magnitude of the applied force. In order to minimize such non-intuitive haptic feedback for this illustrative implementation, the collision of the cannula is minimized by the proper positioning of the robotic manipulators and their associated cannulas, for example, initially with the use of an accessory and / or during surgery with the use of a portal feature, as described above. Similarly, the haptic feedback that the system provides to the surgeon that is caused by the external force applied to the portion of the instrument that extends from the distal end of the cannula will not be accurate (unless experienced directly along the I / O axis). In practice, however, such forces at the distal ends of the instrument are low compared to the amount of friction and conformity in the instrument / transmission, and so any haptic feedback generated is negligible.
[00131] In other implementations, however, force sensors can be used to provide the surgeon with an accurate experience of an applied external force either to the curved section of the cannula or to the extended distal end of the instrument. For example, force sensors that use fiber optic voltage detection are known (see, for example, North American Patent Application Publications No. US 2007/0151390 A1 (filed September 29, 2006) (which describes the detection of force torque for surgical instruments), No. US 2007/0151391 A1 (deposited on October 26, 2006) (describing a modular force sensor), No. US 2008/0065111 A1 (deposited on September 29 2007) (which describes force detection for surgical instruments), No. US
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2009/0157092 A1 (deposited on December 18, 2007) (which describes a ribbed force sensor), and US No. 2009/0192522 A1 (deposited on March 30, 2009) (which describes a sensor temperature compensation strength), all of which are incorporated by reference. Figure 22 is a diagrammatic view of a curved cannula and the distal portion of a flexible instrument, and shows that, in an illustrative implementation, one or more force sensing optical fibers 2202a, 2202b can be positioned (for example, four fibers equally spaced around the outside) in the 2204 curved cannula (stress detection and stress determination interrogation components for optical fibers are omitted for clarity purposes). Similarly, the distal section 2206 of the flexible instrument can incorporate (for example, internally directed) one or more tension detection optical fibers 2208 that detect the bend at a location in the distal section, or in the shape of the distal section, and the degree of displacement and location with reference to the distal end of the cannula can be used to determine the external force on the extended instrument.
[00132] Figure 23 is a diagrammatic view of a 2300 control system architecture for a teleoperated robotic surgical system with telepresence. As shown in Figure 23, fb = human forces
Xb = master position and _m , _s = encoder values (master, slave) im, s = motor current (master, slave) 0m, x = junction positions (masters, slaves) Tm, s = junction torques (masters , slaves) fm, s = Cartesian forces (masters, slaves) Xm, s = Cartesian positions (masters, slaves) fe = environmental forces
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61/65
Xe = slave position [00133] In an implementation, modifications to the control system, as described above, are made in the Slave Kinematics 2302 portion of the 2300 control system architecture. Additional details describing the 2300 control system architecture are found, for example, in the references cited above. The data processing of the 2300 control system can be implemented in the electronic data processing unit 142 (Figure 1), or it can be distributed in several processing units throughout the surgical system.
[00134] With reference to Figures 11A and 11B, together with Figure 1B and Figure 4C, it can be seen that, in many implementations, the terminal operator of the triggering instrument by the left robotic manipulator appears on the right side of the field of view of the endoscope , and the terminal operator of the instrument driven by the right robotic manipulator appears on the left side of the robotic manipulator's field of view. Consequently, to preserve intuitive control of terminal operators, as seen by a surgeon on the surgeon's console monitor, the right master manipulator controls the left robotic manipulator and the left master manipulator controls the right robotic manipulator. This configuration is opposite to the configuration typically used with straight surgical instruments, in which the robotic manipulator and its associated instrument are both positioned on the same side with reference to a vertical division of the endoscope's field of view. During use with curved cannulas, the robotic manipulator and its associated instrument are positioned on opposite sides of the endoscope reference frame. This would not apply, however, to the use of certain composite curved cannulas, as illustrated by Figure 13 and the associated text.
Petition 870190087467, of 9/5/2019, p. 64/76
62/65 [00135] In this way, several implementations of the control system allow the surgeon to experience the intuitive control of the instrument's terminal operators and the resulting telepresence even without the use of an instrument plunger that provides tilt and yaw movements. The movement of a master manipulator (for example, 122a, Figure 1B) results in a corresponding movement either from the distal end of the associated curved cannula (for tilting and yawing movements at the surgical site) or the terminal operator of the instrument (for I / O , rotation, and grab (or other degrees of freedom for the terminal operator)). Consequently, the movement of a surgeon's hand in a master control can be reasonably well approximated with a corresponding slave movement at the surgical site without the use of a separate plunger mechanism on the instrument. The tips of the instrument move in response to changes in position of the master manipulator, not to changes in orientation of the master manipulator. The control system does not interpret such changes in the surgeon's plunger movement orientation.
[00136] In some implementations, the control system of a robotic surgical system can be configured to automatically switch between the use of straight cannulas with associated straight axis instruments, and the use of curved cannulas with associated flexible axis instruments. For example, the system can detect that both a curved cannula and a flexible axis instrument are mounted on a manipulator, as described above with reference to Figure 6 and Figure 10, and thus switch to a control mode associated with the curved cannula. and the flexible instrument. If, however, the system detects a straight cannula and a flexible instrument mounted on the manipulator, then this detection may trigger an illegal state, and the system will not operate.
[00137] In some implementations for ro surgical systems
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63/65 botics with multiple robotic manipulators, the control software can allow the surgeon to use a mixture of curved cannulas in several different shapes, flexible axis instruments of various different lengths, along with straight cannulas and rigid straight axis instruments. The tip movement of all of these instruments will appear similar, so the surgeon will experience intuitive control because of the automatic manipulation of the kinematic restrictions of the cannula, as described above.
[00138] In one aspect, a surgical system comprises a robotic manipulator, a rigid cannula, where the cannula comprises a proximal end, a distal end, and a curved section between the proximal and distal ends, where the proximal end of the cannula is mounted on the robotic manipulator, and where the robotic manipulator is configured to move the cannula around a remote center of movement in at least a degree of freedom of tilt or yaw, and a surgical instrument comprising a flexible shaft and a terminal operator coupled to a distal end of the flexible axis, where a first portion of the flexible axis extends through the curved section of the cannula, and where a second portion of the flexible axis extends beyond the distal end of the cannula.
[00139] In another aspect, a surgical system comprises a first robotic manipulator, a first curved cannula attached to the first robotic manipulator, and a first surgical instrument comprising a flexible axis that extends through the first curved cannula, where the first robotic manipulator is configured to move the first cannula attached to the second robotic manipulator, and a second surgical instrument comprising a flexible axis that extends through the second curved cannula, where the second robotic manipulator is configured to move the second cannula around a second movement center , where the first and the sePetition 870190087467, of 09/05/2019, p. 66/76
64/65 second movement centers are positioned close to each other, and where the distal ends of the first and second curved cannulas are oriented to direct the distal ends of the first and second surgical instruments towards a surgical site.
[00140] In another aspect, a cannula comprises a rigid tube with a proximal straight section and a curved section adjacent to the proximal straight section, and a robotic manipulator support coupled to the proximal end of the tube.
[00141] In another aspect, a surgical instrument comprises a passively flexible shaft comprising an intermediate section and a distal section, and a surgical terminal operator coupled to the distal section of the flexible shaft, where the stiffness of the distal section of the passively flexible shaft is greatest than the stiffness of the intermediate section of the passively flexible shaft.
[00142] In another aspect, a surgical portal feature comprises a portal feature body comprising an upper surface and a lower surface, a surgical instrument channel that extends in a first direction through a vertical intermediate section of the feature body portal from the upper surface to the lower surface, and a second surgical instrument channel extending in a second direction, opposite the first direction, through the vertical intermediate section of the portal feature body from the upper surface to the lower surface.
[00143] In another aspect, a surgical portal feature comprises a funnel portion, a tongue, a narrower portion portion between the funnel portion and the tongue, and at least two surgical instrument channels defined in the upper portion section. narrow.
[00144] In another aspect, a cannula mounting accessory comprises a first arm comprising a support
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65/65 endoscope cannula, and a second arm comprising a surgical instrument cannula mounting bracket, where the endoscope cannula mounting bracket and surgical instrument mounting bracket are each oriented to retain a cannula in the same opening in a patient's body.
[00145] In another aspect, a cannula mounting accessory comprises a pointed cap comprising an interior, where the inside of the cap is configured to removably retain a distal end of an endoscope and a distal end of a surgical instrument cannula.
[00146] In another aspect, a robotic surgical system comprises a master manipulator, a robotic slave manipulator, a curved cannula coupled to the robotic slave manipulator, a passively flexible instrument axis that extends beyond a distal end of the curved cannula, and a system control, where a straight-line instrument insertion and removal axis is defined extending from a longitudinal central axis of the curved cannula at a distal end of the curved cannula, and where, in response to a movement of the master manipulator, the system The control unit commands the robotic manipulator to move the distal end of the curved cannula around a remote center of movement, as if the instrument were positioned straight along the axis of insertion and removal of the instrument.

权利要求:
Claims (8)
[1]
1. Surgical system characterized by the fact that it comprises:
a first robotic manipulator (204a), a first curved cannula (416a, 2004a, 2102) coupled to the first robotic manipulator (204a), and a first surgical instrument (110, 402a, 500) comprising a flexible shaft (406a) extending through the first curved cannula (416a, 2004a, 2102), in which the first robotic manipulator (204a) is configured to move the first curved cannula (416a, 2004a, 2102) around a first center of movement;
a second robotic manipulator (204b), a second curved cannula (416b, 2004b) coupled to the second robotic manipulator (204b), and a second surgical instrument (110, 402b, 500) comprising a flexible axis (406b) that extends through the second curved cannula (416b, 2004b), wherein the second robotic manipulator (204b) is configured to move the second curved cannula (416b, 2004b) around a second center of movement;
wherein the first and second centers of movement are positioned close to each other; and in which distal ends of the first and second curved cannulas (416a, 2004a, 2102, 416b, 2004b) are oriented to direct the distal ends of the first and second surgical instruments (110, 402a, 402b, 500) towards a surgical site (424).
[2]
2. Surgical system, according to claim 1, characterized by the fact that:
the first curved cannula (416a, 2004a, 2102) comprises a rigid tube having a proximal straight portion and a curved section adjacent to the proximal straight section; and where the first robotic manipulator (204a) is coupled
Petition 870190087467, of 9/5/2019, p. 69/76
2/4 to the proximal straight portion of the first curved cannula (416a, 2004a, 2102).
[3]
3. Surgical system, according to claim 1 or 2, characterized by the fact that:
the flexible axis (406a) of the first surgical instrument (110, 402a, 500) comprises a passively flexible axis;
wherein the passively flexible axis comprises an intermediate section in a distal section; and wherein a stiffness of the passively flexible shaft distal section is greater than a stiffness of the passively flexible shaft intermediate section.
[4]
4. Surgical system according to any one of claims 1 to 3, characterized by the fact that it still comprises:
a portal feature (1402);
wherein the portal feature (1402) comprises a portal feature body comprising an upper surface (1404, 1622) and a lower surface (1406, 1624);
wherein the portal feature (1402) comprises a first channel (1412a) through which the first surgical instrument (402a) extends in a first direction towards a vertical intermediate section of the portal feature body from the upper surface (1404, 1622) for the bottom surface (1406, 1624); and where the portal feature (1402) comprises a second channel (1412b) through which the second surgical instrument (110, 402b, 500) extends in a second direction, opposite the first direction, in the direction of the vertical intermediate section of the portal feature body from the top surface to the bottom surface.
[5]
5. Surgical system according to any one of claims 1 to 3, characterized by the fact that it still comprises:
Petition 870190087467, of 9/5/2019, p. 70/76
3/4 a portal feature (1702);
wherein the portal feature (1702) comprises a funnel portion (1704), a tongue (1706, 1708), a narrower portion portion (1714) between the funnel portion (1704) and the tongue (1706, 1708) ), a first instrument channel (1720, 1722) defined in the narrowest portion (1714) through which the first surgical instrument (402a) extends, and a second instrument channel (1720, 1722) defined in the narrower part (1714) through which the second surgical instrument (110, 402b, 500) extends.
[6]
6. Surgical system according to any one of claims 1 to 5, characterized by the fact that it still comprises:
a cannula mounting accessory (1902);
wherein the cannula mount accessory (1902) comprises an endoscope cannula mount holder (254) and a curved cannula mount holder (1908a, 1908b); and wherein the endoscope cannula mounting bracket (254) and the curved cannula mounting bracket (1908a, 1908b) are each oriented to retain a cannula in the same opening in a patient's body.
[7]
7. Surgical system according to any one of claims 1 to 6, characterized by the fact that it still comprises:
a pointed lid (2008) comprising an interior;
wherein the interior of the cap (2008) is configured to removably retain a distal end of an endoscope (2006) and a distal end of the first curved cannula (416a, 2004a, 2102).
[8]
8. Surgical system according to any one of claims 1 to 7, characterized by the fact that it still comprises:
a master manipulator (122, 122a); and a control system (2300);
Petition 870190087467, of 9/5/2019, p. 71/76
4/4 in which a straight-line instrument insertion and removal axis (2112) is defined extending from a longitudinal central axis (2110) of the first curved cannula (416a, 2004a, 2102) at a distal end of the first curved cannula (416a, 2004a,
2102); and in which, in response to a movement of the master manipulator (122, 122a), the control system (2300) commands the first robotic manipulator (204a) to move the distal end (2106) of the first curved cannula (416a, 2004a, 2102) around the first remote center of movement as if the first surgical instrument (110, 402a, 500) was positioned straight along the insertion and removal axis of the instrument (2112).

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法律状态:
2018-03-27| B15K| Others concerning applications: alteration of classification|Ipc: A61B 17/34 (2006.01) |

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2019-01-08| B06F| Objections, documents and/or translations needed after an examination request according art. 34 industrial property law|

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2019-07-09| B06T| Formal requirements before examination|

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2019-11-26| B09A| Decision: intention to grant|

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2020-01-07| B16A| Patent or certificate of addition of invention granted|Free format text: PRAZO DE VALIDADE: 20 (VINTE) ANOS CONTADOS A PARTIR DE 27/08/2010, OBSERVADAS AS CONDICOES LEGAIS. |

优先权:

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申请号 | 申请日 | 专利标题

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US24517109P| true| 2009-09-23|2009-09-23|

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US61/245,171|2009-09-23|

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US12/618,549|US20110071541A1|2009-09-23|2009-11-13|Curved cannula|

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US12/618,549|2009-11-13|

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PCT/US2010/046948|WO2011037718A1|2009-09-23|2010-08-27|Curved cannula and robotic manipulator|

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