DETAILED DESCRIPTION OF THE INVENTION

[0081] I. Overview

[0082] An embodiment of a system 2 of the present invention is illustrated in FIG. 1 . The system 2 includes an elongated main body 10 having a proximal end 12 and a distal end 14 terminating in a distal tip 16 . The main body 10 is used to access an internal target location within a patient's body. Typically, the distal end 14 is passed through a body orifice and one or more naturally occurring body lumens to the target location, such as in endoscopy, while the proximal end 12 remains outside of the body. Therefore, the main body 10 has a deflectable and/or steerable shaft 20 , either due to choice of material or design of the shaft 20 to include links, hinges, coils or other similar structures to allow deflection. Thus, FIG. 1 illustrates the main body 10 in a deflected position wherein the body 10 includes curvatures. Such deflection and/or steering may be useful in traversing body lumens to the target location and is achievable by manipulation of a handle 22 near the proximal end 12 . It may be appreciated, however, that the system 2 may be used in laparoscopic procedures wherein such deflection and/or steering may be less utilized for placement of the main body 10 . In either case, rigidization of some or all the shaft 20 may be desired, for example to provide a stable visualization platform. Therefore, portions of the shaft 20 of the main body 10 are lockable to maintain a desired shape and provide rigidity, either due to choice of material or design of the shaft 20 to include locking mechanisms, as will be described in later sections.

[0083] The main body 10 also includes at least one arm guide lumen 26 which extends over or through at least a distal section of the main body 10 , typically along the majority of the length of the body 10 as shown. Here in FIG. 1 , two arm guide lumens 26 are shown, each extending from a position along the shaft 20 near the proximal end 12 to the distal tip 16 . In addition, the main body 10 includes a scope lumen 24 which extends through the shaft 20 to the distal tip 16 .

[0084] The system 2 also includes at least one tool arm 30 , two are shown in FIG. 1 , each arm 30 of which is insertable through a separate arm guide lumen 26 as indicated by dashed line. Each tool arm 30 has a proximal end 32 , a distal end 34 and a shaft 36 therebetween. The distal end 34 is steerable, such as by manipulation of adjacent links as schematically indicated. Such steerability may be controlled by a steering cuff 35 which is part of the proximal end 32 . The shaft 36 is typically flexible or deflectable to allow deflection of the surrounding main body shaft 20 . Each tool arm 30 additionally includes a tool deployment lumen 38 therethrough.

[0085] In this embodiment, the system 2 also includes at least one tool 40 , two are shown in FIG. 1 . Each tool 40 includes a distal end 42 , a proximal end 44 and an elongate shaft 46 therebetween to allow passage through the tool deployment lumen 38 of the arm 30 . Each tool 40 has an end effector 48 disposed at the distal end 42 and optionally a handle 50 at the proximal end 44 for manipulation of the end effector 48 from outside the body. The tool 40 is advanced so that the end effector 48 emerges from the distal end 34 of the arm 30 .

[0086] FIG. 2 illustrates the system 2 of FIG. 1 in an assembled arrangement. Here, the tool arms 30 are shown inserted through the arm guide lumens 26 of the main body shaft 20 . The steerable distal ends 34 of the arms 30 protrude from the distal end 14 of the main body 10 and the proximal ends 32 of the arms 30 protrude from the proximal end 12 of the main body 10 . As shown, the steering cuffs 35 are located at the proximal ends 32 of the arms 30 . In addition, the tools 40 are shown inserted through the tool deployment lumens 38 so that the end effectors 48 extend beyond the steerable distal ends 34 of the arms 34 . Likewise, the proximal ends 44 of the tools 40 with handles 50 are shown protruding from the steering cuffs 35 . Movement of the tools 40 against the steering cuffs 35 will actuate steering of the distal ends 34 of the arms 30 , as will be described in later sections.

[0087] FIG. 2A provides a cross-sectional view of system 2 of FIG. 2 . Since the shaft 20 of the main body 10 has a generally cylindrical exterior in this embodiment, the cross-section of the shaft 20 has a circular shape. It may be appreciated that cylindrical shafts may alternatively have an elliptical, oval or oblong cross-section. The shaft 20 has an outer diameter in the range of about 5 to 25 mm, preferably approximately 14 mm. The shaft 20 has a wall 21 with a thickness in the range of about 0.5 to 5 mm, preferably about 2-3 mm, defining an inner central lumen 23 . Within the wall 21 lies various pushwires or pullwires 96 , hereinafter referred to as pullwires, for steering the main body 10 which may be present in a variety of quantities and arrangements. Alternatively, the pullwires 96 may be present within the central lumen 23 . At least one arm guide lumen 26 , two are shown, extend through the central lumen 23 . Each arm guide lumen 26 has an inner diameter in the range of about 0.5 to 5 mm, preferably about 4 mm. Positioned within the lumens 26 are the shafts 36 of the tool arms 30 . And, likewise, positioned within the shafts 36 are the tools 40 . FIG. 2A also illustrates the scope lumen 24 which has an inner diameter in the range of about 2 to 10 mm, preferably about 4 mm. In this embodiment, the two arm guide lumens 26 and the scope lumen 24 are arranged in a generally triangular pattern which is maintained to the distal tip 16 , however any suitable arrangement may be used which allows viewing of the tool arms, particularly the end effectors, by the scope. For example, FIG. 2B illustrates a cross-section of an embodiment wherein the shaft 20 has an oval shape and the arm guide lumens 26 and the scope lumen 24 are generally aligned. Here, the scope lumen 24 is disposed between the arm guide lumens 26 to facilitate viewing of the tool arms 30 . Also illustrated in FIGS. 2A and 2B are additional lumens which may be used for various needs. For example, an irrigation/suction lumen 60 , an insufflation lumen 56 and an auxiliary lumen 58 may be present, each having an inner diameter in the range of about 0.5 to 5 mm, preferably about 2 mm. The auxiliary lumen 58 may be utilized for a variety of uses, such as insertion of additional tools, such as a macerator, a grasping tool, a cutting tool or a light source, to name a few, for use in conjunction with the end effectors present at the distal ends of the arms 30 or the distal ends of the tools 40 inserted through the arms 30 .

[0088] FIGS. 3 A- 3 D illustrate a series of movements of the steerable distal ends 34 of the tool arms 30 . This series serves only as an example, as a multitude of movements may be achieved by the distal ends 34 independently or together. FIG. 3A illustrates the distal tip 16 of the main body 10 . The scope lumen 24 is shown along with two arm guide lumens 26 terminating at the distal tip 16 and forming a triangular pattern as illustrated in FIG. 2A . FIG. 3B illustrates the advancement of the distal ends 34 of the tool arms 30 through the arm guide lumens 26 so that the arms 30 extend beyond the distal tip 16 . FIGS. 3 C- 3 D illustrate deflection of the arms 30 to a preferred arrangement. FIG. 3C illustrates deflection of the arms 30 laterally outward. This is achieved by curvature in the outward direction near the base 64 of the steerable distal end 34 . FIG. 3D illustrates deflection of the tip section 66 of the distal end 34 laterally inward achieved by curvature in the inward direction so that each arm 30 forms a hook shape. By facing the tip sections 66 of the arms 30 toward each other as shown, the tip sections 66 are positioned directly in the path of the scope lumen 24 . Therefore, when a scope 28 is positioned within the scope lumen 24 , the tip sections 66 of the tool arms 30 and any tools 40 advanced therethrough, will be visible through the scope 28 . In FIGS. 3 C- 3 D, deflection of the arms 30 is achieved with the use of adjacent links 62 in the areas of desired curvature. Embodiments of such links 62 and other mechanisms of deflection will be discussed in later sections. Further, the deflection of FIGS. 3 A- 3 D are shown to be within a single plane. However, various embodiments include deflection in multiple planes. Likewise, the arms 30 are shown to be deflected simultaneously in FIGS. 3 A- 3 D, however the arms 30 may be deflected selectively or independently.

[0089] FIGS. 4 - 6 illustrate additional possible movements of the tool arms 30 . For example, FIG. 4 illustrates axial movement of the tool arms 30 . Each tool arm 30 can independently move distally or proximally, such as by sliding within the tool deployment lumen 38 , as indicated by arrows. Such movement maintains the arms 30 within the same plane yet allows more diversity of movement and therefore surgical manipulations. FIG. 5 illustrates rotational movement of the tool arms 30 . Each tool arm 30 can independently rotate, such as by rotation of the arm 30 within the tool deployment lumen 38 , as indicated by circular arrow. Such rotation moves the arm 30 through a variety of planes. By combining axial, lateral and rotational movement, the arms 30 , and therefore the tools 40 positioned therethrough, may be manipulated through a wide variety of positions in one or more planes.

[0090] FIG. 6 illustrates further articulation of the tool arms 30 . In some embodiments, the arms 30 are deflectable to form a predetermined arrangement, such as illustrated in FIG. 3D . Typically, when forming the predetermined arrangement, the arms 30 are steerable up until the formation of the predetermined arrangement wherein the arms 30 are then restricted from further deflection. In other embodiments, the arms are deflectable to a variety of positions and are not limited by a predetermined arrangement. Such an embodiment is illustrated in FIG. 6 wherein the arms 30 articulate so that the tip sections 66 curl inwardly toward the distal tip 16 of the main body 10 . Again, the tip sections 66 are positioned in front of the scope lumen 24 and scope 28 for viewing. Typically, the tip sections 66 a are positioned on opposite sides of a central axis 31 of the scope 28 , wherein the field of view (indicated by arrow 29 ) spans up to approximately 140 degrees, approximately 70 degrees on each side of the central axis 31 . In addition, the depth of field is typically in the range of approximately 1-10 cm.

[0091] As mentioned previously, the endoluminal tool deployment system 2 of the present invention may be used to access a various internal tissues or organs to perform a wide variety of surgical procedures. FIGS. 7 A- 7 B illustrate the use of an embodiment of the system 2 to perform a mucosectomy, or removal of a portion of the mucosa and/or submucosa of the stomach. FIG. 7A illustrates advancement of the main body 10 through the esophagus E to the stomach S. The main body 10 is then steered to a desired position within the stomach S and the stomach mucosa M is visualized through the scope 28 at the distal tip 16 . Referring to FIG. 7 B, the tool arms 30 are then advanced through the main body 10 and articulated. As mentioned, tools 40 may be advanced through the tool arms 30 or an end effector 48 may be disposed at the distal end of each arm 30 . Here, a grasper 80 is disposed at the distal end of one arm 30 and a cutter 81 is disposed at the distal end of the other arm 30 . The grasper 80 is used to grasp a portion of the mucosa M. The grasped portion of mucosa M can then be elevated by rotation or manipulation of the tool arm 30 . This allows safe resection of the portion of mucosa M by cutting with the use of the cutter 82 , as shown. Manipulation and resection of the tissue is visualized throughout the procedure through the scope 28 which is aligned with the tip sections 66 , and therefore end effectors 48 .

[0092] It may be appreciated that the systems, methods and devices of the present invention are applicable to diagnostic and surgical procedures in any location within a body, particularly any natural or artificially created body cavity. Such locations may be disposed within the gastrointestinal tract, urology tract, peritoneal cavity, cardiovascular system, respiratory system, trachea, sinus cavity, female reproductive system and spinal canal, to name a few. Access to these locations may be achieved through any body lumen or through solid tissue. For example, the stomach may be accessed through an esophageal approach, the heart through a port access approach, the rectum through a rectal approach, the uterus through a vaginal approach, the spinal column through a port access approach and the abdomen through a port access approach.

[0093] A variety of procedures may be performed with the systems and devices of the present invention. The following procedures are intended to provide suggestions for use and are by no means considered to limit such usage: Laryngoscopy, Rhinoscopy, Pharyngoscopy, Bronchoscopy, Sigmoidoscopy (examination of the sigmoid colon, the sigmoid colon is the portion that connects the descending colon to the rectum; primarily for diagnostic purposes, however a biopsy procedure and trans anal micro surgery may be performed for removing tumors), Colonoscopy (examination of colon; for the removal of polyps and tumors or for biopsy), and Esophagogastroduodenoscopy (EGD) which enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain.

[0094] In addition, endoscopic retrograde cholangiopancreatography (ERCP) may be achieved which enables the surgeon to diagnose disease in the liver, gallbladder, bile ducts, and pancreas. In combination with this process endoscopic sphincterotomy can be done for facilitating ductal stone removal. ERCP may be important for identification of abnormalities in the pancreatic and biliary ductal system. Other treatments include Cholecystectomy (removal of diseased gallbladder), CBD exploration (for common bile duct stones), appendicectomy.(removal of diseased appendix), hernia repair TAP, TEPP and other (all kinds of hernia), fundoplication and HISS procedures (for gastro esophageal reflux disease), repair of duodenal perforation, gastrostomy for palliative management of late stage upper G.I.T. carcinoma), selective vagotomy (for peptic ulcer disease), splenectomy (removal of diseased spleen), gastric restrictive and malabsorbtive procedures (for morbid obesity), upper and lower G.I. endoscopies (diagnostic as well as therapeutic endoscopies), pyloroplastic procedures (for children's congenital deformities), colostomy, colectomy, adrenalectomy (removal of adrenal gland for pheochromocytoma), liver biopsy, gastrojejunostomy, subtotal liver resection, gastrectomy, small intestine partial resections (for infarction or stenosis or obstruction), adhesions removal, treatment of rectum prolaps, Heller's Myotomy, devascularization in portal hypertension, attaching a device to a tissue wall and local drug delivery to name a few.

[0095] II Main Body

[0096] As mentioned previously, the system 2 of the present invention includes an elongated main body 10 having a proximal end 12 and a distal end 14 terminating in a distal tip 16 . The main body 10 may have a variety of features which are present in a variety of combinations. Generally, the features include deflectability, steerability, torqueability, lockability, lumens for the passage of visualization elements, tool arms, and/or instruments, and integral visualization elements, tool arms, and/or instruments, to name a few. In addition, the main body may have any of these features throughout any portion of the main body, including the entire length of the main body or individual subportions.

[0097] One embodiment of the main body 10 is illustrated in FIGS. 8 A- 8 C, 9 A- 9 D. In this embodiment, the main body 10 includes deflectability and/or steerability and lumens for the passage of visualization elements, tool arms, and/or instruments, such as scope lumen 24 . FIG. 8A illustrates the main body in a straight configuration. Since the main body 10 is used to access an internal target location within a patient's body, the main body 10 has a deflectable and/or steerable shaft 20 . Thus, FIG. 8B illustrates the main body 10 having various curvatures in its deflected or steered state. In preferred embodiments, the main body 10 is steerable so that the main body 10 may be advanced through unsupported anatomy and directed to desired locations within hollow body cavities. In some embodiments, the main body 10 includes a first section 90 which is proximal to a second section 92 , as indicated in FIG. 8B . Although both sections 90 , 92 are steerable, the first section 90 may be locked in place while the second section 92 is further articulated. This is illustrated in FIG. 8 C, wherein the first section 90 is shown in a locked position unchanged from FIG. 8 B and the second section 92 is shown in various retroflexed positions. In retroflexion, the second section 92 is curved or curled laterally outwardly so that the distal tip 16 is directed toward the proximal end 12 of the main body 10 . Optionally, the second section 92 may also be locked, either in retroflexion or in any other position.

[0098] Steering and locking may be achieved by any suitable mechanisms. In some embodiments, the shaft 20 comprises a multiplicity of nestable elements 260 , as illustrated in FIG. 9A . FIG. 9B provides an exploded view of the nestable elements 260 of FIG. 9A . Here it can be seen that the elements 260 are disposed so that a distal surface 262 of one element 260 coacts with a proximal surface 264 of an adjacent element. Each of the nestable elements 260 includes one or more pullwire lumens 98 through which pullwires 96 pass. The pullwires 96 are used to hold the elements 260 in nesting alignment and to provide steering and locking. The pullwires 98 preferably are made from a superelastic material, e.g. nickel titanium alloy, to provide flexibility, kink-resistance and smooth movement of the pullwires 96 through the pullwire lumens 98 . Alternatively, the pullwires 96 may be made from braided stainless steel, a single stainless steel wire, poly-para-phenylene terephthalamide (such as Kevlar®), a high tensile strength monofilament thread, combinations thereof or any suitable materials.

[0099] Generally, the adjacent surfaces 262 , 264 are contoured to mate so that when the pullwires 96 are relaxed, surfaces 262 , 264 can rotate relative to one another. This allows the shaft 20 to form curvatures throughout its length in any direction. Each pullwire 96 is fixed at its distal end to a specific element 260 along the shaft 20 or to the distal tip 16 . When tension is applied to a specific pullwire 96 , a curvature forms in the shaft 20 proximal to the fixation point, thus steering the shaft 20 . The pullwires 96 may be arranged in various patterns to achieve steering in various directions. For example, FIG. 9C is a cross-sectional view of the shaft 20 in the first section 90 of FIG. 8B . Here, eight pullwires 96 (four pullwires 96 a and four pullwires 96 b ) are shown passing through the wall 21 . Four pullwires 96 a terminate at the distal end of the first section 90 and are used to steer the first section 90 . Since the pullwires 96 a are equidistantly positioned, applying tension to the pullwires 96 a , either individually or in combination, steers the first section 90 in any desired direction. The first section 90 may be locked in place by holding the tension in the pullwires 96 a using any suitable mechanisms. For example, tension may be applied to the pullwires 96 simultaneously until the elements 260 are compressed to a state in which they are locked by friction wherein the tension is held.

[0100] FIG. 9D is a cross-sectional view of the shaft 20 in the second section 92 of FIG. 8B . Here, four pullwires 96 b are shown passing through the wall 21 . These pullwires 96 b extended through the first section 90 , as indicated in FIG. 9 C, and terminate near the distal tip 16 . Since the pullwires 96 b are equidistantly positioned, applying tension to the pullwires 96 b , either individually or in combination, steers the second section 92 in any desired direction. Since the pullwires 96 b also pass through the first section 90 , such steering may also effect the curvature in the first section 90 when the first section is not locked. However, such effects are minimal, may be counteracted or compensated for by steering in the first section 90 , and may be avoided by locking. The second section 92 may be also be locked in place by holding the tension in the pullwires 96 b using any suitable mechanisms.

[0101] In this embodiment, the wall 21 extends continuously from the proximal end 12 to the distal end 14 with the first and second sections 90 , 92 determined by the termination points of the pullwires 96 which extend therethrough. Alternatively, the first and second sections 90 , 92 may be comprised of separate shafts which are coaxially positioned adjacent to one another.

[0102] In the embodiment illustrated in FIG. 9 B, the nestable elements 260 have a central lumen 23 which passes through the length of the main body 10 . Instruments or tools may be passed through this lumen 23 , as indicated in FIGS. 9 C- 9 D, or tubes may be present within the lumen 23 through which instruments or tools may be passed. In preferred embodiments, the nestable elements 260 have holes formed therein so that lumens are formed by alignment of the holes when the elements 260 are stacked. For example, FIG. 9E provides a cross-sectional view of a nestable element 260 illustrating the holes formed therein which serve as lumens. As shown, a scope lumen 24 , arm guide lumens 26 , and auxiliary lumens 58 extend through the center of the element 260 while pullwire lumens 98 are located around the periphery.

[0103] It may be appreciated that pullwire lumens 98 may also extend through the center of the element 260 . For example, FIG. 10A illustrates an embodiment having a pullwire 96 which extends through the center of the stacked nestable elements 260 . FIG. 10A provides an exploded view of the nestable elements 260 wherein the elements 260 are disposed so that a distal surface 262 of one element 260 coacts with a proximal surface 264 of an adjacent element. As shown, each of the nestable elements 260 includes a pullwire lumen 98 through its center. FIG. 10B provides a cross-sectional view of a nestable element 260 of FIG. 10A . As shown, the nestable element 260 includes a locking pullwire lumen 98 c having a pullwire 96 c therethrough in the center of the element 260 surrounded by various other lumens, such as a scope lumen 24 , arm guide lumens 26 , auxiliary lumen 58 and various pullwire lumens 98 used for steering. Once the elements 260 are positioned in a desired arrangement, the shaft 20 may be locked in place by the central pullwire 96 c . Applying tension to the pullwire 96 c compresses the elements 260 to a state in which they are locked by friction wherein the tension is held.

[0104] In addition, liners 266 may be passed through any of the lumens of the stacked nestable elements 260 . Such liners 266 form create a continuous lumen connecting the lumen holes of the nestable elements 260 . FIG. 1C illustrates the nestable elements 260 of FIG. 10A with the inclusion of liners 266 passing through, for example, the arm guide lumens 26 . Likewise, FIG. 10D provides a cross-sectional view of a nestable element 260 of FIG. 10C . Here, liners 266 are shown positioned through the nestable element 260 forming lumens 24 , 26 , 58 therethrough. It may also be appreciated that liners 266 may extend through pullwire lumens 98 as well. The liners 266 may be coated on their luminal surface with a hydrophilic coating for reducing friction or the liners 266 may be comprised of a lubricious polymer such as Teflon®, fluoroethylene polymer (FEP) or the like.

[0105] As mentioned previously, it may be appreciated that the shaft 20 of the main body 10 may have a variety of structures to provide features such as deflectability, steerability, torqueability, lockability, visualization and various tools, etc. Exemplary embodiments of structures which provide deflectability, steerability and or lockability are described above and provided in co-pending U.S. patent application Ser. No. 10/281,462 filed Oct. 25, 2002, which is a continuation in part of U.S. patent application Ser. Nos. 10/173,203, 10/173,227, 10/173,238 and 10/173,220, all of which were filed on Jun. 13, 2002 and herein incorporated by reference for all purposes. Also of interest and incorporated by reference for all purposes are co-pending U.S. patent application Ser. Nos. 10/281,461 and 10/281,426 each filed on Oct. 25, 2002. It is understood that lockablility includes locking the main body in a desired configuration to maintain one or more curvatures along its length. Thus, in these instances the main body is shape lockable. Structures which provide torqueability will be described in later sections, however it is understood that these features are applicable to any of the embodiments described herein.

[0106] In addition, it may be appreciated that the main body 10 may be comprised of a traditional endoscope or laparoscope. Exemplary embodiments of traditional endoscopes are provided in U.S. Pat. Nos. 3,948,251; 4,036,218; 4,201,198; 4,224,929; 4,988,171; 5,020,539; 5,035,231; 5,068,719; 5,170,775; 5,172,225; 5,187,572; and 5,196,928, all of which are herein incorporated by reference for all purposes. FIG. 10E illustrates the shaft 20 of the main body 10 comprising a traditional endoscope 650 , or other endoscope, which includes a visualizing element 652 and at least one light source 654 . In this embodiment, the endoscope 650 includes two arm guide lumens 26 for the passage of tool arms 30 . The tool arms 30 each have end effectors 48 , as shown, or tools 40 which have end effectors 48 may be advanced through a tool deployment lumen 38 in each arm 30 . FIG. 10F provides a cross-sectional view of the shaft 20 of FIG. 10E . FIG. 10G illustrates the shaft 20 of the main body 10 comprising a plurality of steerable and/or lockable nestable elements 260 and a traditional endoscope 650 , or other endoscope, passing therethrough which includes a visualizing element 652 and at least one light source 654 . The endoscope 650 may be advanceable and/or retractable through an endoscope lumen 656 in the shaft 20 of the main body 10 or may be fixed within the shaft 20 . The endoscope 650 may be positioned so that a distal end 658 of the endoscope 650 is flush with the distal tip 16 of the shaft 20 or is disposed at any position along the shaft 20 including extending beyond the distal tip 16 , as shown. FIG. 10H provides a cross-sectional view of FIG. 10G . Here, the wall 21 of the shaft 20 is more clearly visible including pullwires 96 for steering and/or locking. Further, the shaft 20 of the main body 10 may include one or more arm guide lumens 26 for the passage of tool arms 30 , as shown in FIG. 101 . The tool arms 30 each have end effectors 48 , as shown, or tools 40 which have end effectors 48 may be advanced through a tool deployment lumen 38 in each arm 30 . FIG. 10J provides a cross-sectional view of FIG. 10I .

[0107] FIG. 10K illustrates the shaft 20 of the main body 10 having an integral or integrated visualizing element 652 and at least one light source 654 . Again, the shaft 20 comprising a plurality of nestable elements 260 for steering and/or locking. Optionally, the shaft 10 may also include a lumen 660 , illustrated in FIGS. 10 M- 10 N, for passage of a variety of tools, instruments or devices therethrough, including tool arms 30 . Or, as shown in FIG. 10 O, the shaft 20 having an integral visualizing element and at least one light source 654 may have individual arm guide lumens 26 for the passage of tool arms 30 . It may also be appreciated that the tool arms 30 of FIG. 10O may alternatively be fixed or integral with the shaft 20 .

[0108] The visualizing elements 652 of any of the embodiments include elements which transmit and/or detect a visual image. For example, such visualizing elements 652 may include a coherent fiber optic bundle, an ultrasound device, and/or charge coupled devices (CCD) for operation in the visible spectrum of electromagnetic radiation, the infrared spectrum of electromagnetic radiation, the ultraviolet spectrum of electromagnetic radiation, and/or the x-ray spectrum of electromagnetic radiation.

[0109] III Tool Arms

[0110] As mentioned previously, system 2 also includes at least one tool arm 30 , each arm 30 of which is insertable through a separate arm guide lumen 26 in the main body 10 . As shown in FIG. 11 , each tool arm 30 has a proximal end 32 , a distal end 34 and a shaft 36 therebetween. The distal end 34 is steerable, such as by manipulation of adjacent links 62 as schematically indicated. Such stecrability may optionally be controlled by a steering cuff 35 , disposed within the proximal end 32 . Each tool arm 30 additionally includes a tool deployment lumen 38 therethrough.

[0111] A. Distal End

[0112] FIGS. 12 A- 12 B illustrate an embodiment of adjacent links 62 disposed at the distal end 34 to allow steerability of the arm 30 . Here, links 62 are pivotally connected by hinge structures 100 . As shown in FIG. 12 A, the links 62 are shaped so that connection by the hinge structures 100 creates gaps 102 between the links 62 directly opposite to the hinge structures 100 . A pullwire 96 is shown extending through the links 62 and terminating at a fixation point 104 . Referring now to FIG. 12 B, retraction of the pullwire 96 draws the links 62 together, minimizing the gaps 102 between the links 62 . Due to the shape and arrangement of the links 62 , this movement creates a curve in the arm 30 as shown. The distal end 34 may be steered to have any curvature between substantially straight and a maximum curvature wherein the gaps 102 are completely closed or another limiting feature is established. In some embodiments, up to 360 degree curvature of the distal end 34 is possible. The distal end 34 may be returned to a straightened position by advancement of the pullwire 96 or by the presence of a spring which will straighten the distal end 34 by recoil force.

[0113] FIGS. 13 A- 13 B illustrate a similar embodiment of adjacent links 62 disposed at the distal end 34 to allow steerability of the arm 30 . Again, links 62 are pivotally connected by hinge structures 100 . However, as shown in FIG. 13 A, the links 62 are shaped so that connection by the hinge structures 100 creates gaps 102 between the links 62 on both sides of the hinge structures 100 . A pullwire 96 is shown extending through the links 62 and terminating at a fixation point 104 . Referring now to FIG. 13 B, retraction of the pullwire 96 draws the links 62 together, minimizing the gaps 102 between the links 62 along the pullwire 96 and maximizing the gaps 102 on the opposite side of the hinge structures 100 . Due to this shape and arrangement of the links 62 , this movement creates a curve in the arm 30 as shown. The distal end 34 may also be returned to a straightened position by advancement of the pullwire 96 or by the presence of a spring which will straighten the distal end 34 by recoil force. However, in this embodiment, the distal end 34 may be deflected or curved in the opposite direction by continued advancement of the pullwire 96 . Advancement of the pullwire 96 minimizes the gaps 102 on the opposite side of the hinge structures 100 causing a curvature in the opposite direction. Likewise, a spring may be present to straighten the distal end 34 from a curvature in this opposite direction.

[0114] FIG. 14 illustrates an embodiment similar to the embodiment illustrated in FIGS. 13 A- 13 B. The links 62 are shown pivotally connected by hinge structures 100 . Here the hinge structures 100 comprise pivot pins 106 which are arranged in parallel to limit deflection to a single plane. In some embodiments, the hinge structures comprise male and female bearing surfaces which define axes, wherein the axes are disposed in parallel to limit deflection of the distal section to within the single plane. The links 62 are shaped so that connection by the pivot pins 106 creates gaps 102 between the links 62 . Closure of the gaps 102 on one side of the pivot pins 106 simultaneously opens gaps on the other side of the pins 106 . FIG. 14 also illustrates an end effector 48 of a tool 40 which has been advanced through the tool deployment lumen 38 of the arm 30 .

[0115] FIG. 15 illustrates examples of possible deflections or movements of the tool arms 30 . Here, two arms 30 are shown emerging from the distal tip 16 of the elongated main body