Abstract:
A manipulator includes a control unit ( 1 ), with handle ( 4 ) and control buttons ( 4   a - 4   d ), and a connecting arm ( 2 ) which, at its proximal end ( 2   a ), carries the control unit ( 1 ) and, at its distal end ( 2   b ), carries a work unit ( 3 ). The control buttons ( 4   a - 4   d ) control at least a first inclination motor, which causes a movement of inclination of a tool support ( 5 ) of the work unit ( 3 ) about a transverse inclination axis ( 11 ), and they control the actual rotation of the tool support ( 5 ) about its direction of inclination (II) and control the orientation of the direction of inclination (II) about the longitudinal axis (I-I) of the connecting arm ( 2 ). A particularly ergonomic manipulator is thus obtained which is easy to learn to use and which efficiently separates the stresses arising from movements of the tool support ( 5 ) and the stresses arising from holding and moving the manipulator itself.

Description:
TECHNICAL FIELD OF THE INVENTION 
       [0001]    The present invention relates to devices for guidance and manipulation, permitting the movements of a manipulation instrument located inside the operating area to be controlled from outside an operating area. 
         [0002]    In particular, said devices for guidance and manipulation permit a surgical instrument to be controlled in applications for minimally-invasive surgery carried out by endoscopy. 
         [0003]    In said applications, it is necessary to be able to displace and control a surgical instrument to carry out various operations such as providing a suture, tying a knot or delicate dissection of tissue. These are intricate, precise operations in which the movements to be carried out are complex. 
         [0004]    Devices for guidance and manipulation by remote-controlled robot have already been proposed, for example the device disclosed in the document U.S. Pat. No. 5,797,900. In this case, a master arm which is able to be actuated by an operator is completely mechanically separated and remote from a slave arm which carries the surgical instrument. The slave arm is carried by a support in the vicinity of the operating table. The master arm is located on a remote control unit, provided with means for visualization, the two units being connected by lines for transmitting visualization signals and control signals. Such a device is particularly complex, costly and bulky, comprising a remote manipulation unit for remote control of a slave unit carrying the surgical instrument. 
         [0005]    The invention relates more specifically to portable devices for guidance and manipulation, in which the surgical instrument is placed at the end of a portable manipulator, essentially having a connecting arm with a proximal end and a distal end. Portable manipulators are known in which the proximal end of the connecting arm carries a control unit having a handle capable of being held by one hand. Control members, mounted on the handle, are capable of being actuated by at least one finger of the hand holding the handle. A working unit is mounted on the distal end of the connecting arm, and comprises a tool support capable of supporting a surgical tool. 
         [0006]    The tool support is mounted in a manner in which it is able to be inclined in the working unit relative to the connecting arm, by rotation about a transverse inclination axis. The control members thus make it possible to control the orientation of the tool support in a direction of inclination by rotation about the transverse inclination axis. The control members also permit the orientation of the direction of inclination about the longitudinal axis of the connecting arm to be controlled, in order to communicate to the tool an orientation which is able to be selected within a cone about the longitudinal axis of the connecting arm. The control members also make it possible to control the specific rotation of the tool support about the direction of inclination. 
         [0007]    Such a device is disclosed, for example, in the document US 2005/0222587 A1 and comprises:
       a control unit, having a handle capable of being held by one hand,   control members mounted on the handle and capable of being actuated by at least one finger of the hand holding the handle,   a connecting arm extending along a longitudinal axis, having a proximal end in which the control unit is mounted, and having a distal end,   a working unit mounted on the distal end of the connecting arm and comprising a tool support capable of supporting a tool,   the tool support being mounted in a manner in which it may be inclined in the working unit relative to the connecting arm by rotation about a transverse inclination axis,   the control members make it possible to control the transverse inclination of the tool support in a direction of inclination by rotation about the transverse inclination axis,   the control members make it possible to control the specific rotation of the tool support about the direction of inclination;       
 
         [0015]    furthermore:
       in its transverse inclined rotation, the tool support is driven by at least one first inclination actuator controlled by a first of the control members of the handle,   in the specific rotational movement of the tool support about the direction of inclination, the manipulator is controlled by a second of the control members of the handle which controls one or more actuators,   in the movement of orientation of the direction of inclination about the longitudinal axis of the connecting arm, the manipulator is controlled to perform a rotation about the longitudinal axis, by the handle being urged in rotation by a motorized drive member relative to the remainder of the manipulator about the longitudinal axis of the connecting arm.       
 
         [0019]    Due to the use of actuators controlled by control members arranged on the handle, the hand holding the handle is able to carry the manipulator and hold it in a position which is well-defined and easily controllable by the operator, who thus controls the position of the surgical tool in a natural manner. At the same time, the specific movements of rotation and inclination of the tool support at the end of the manipulator are controlled by the actuation of the control members mounted on the handle, and said control members may be activated by movements of low force and low amplitude of the fingers of the hand holding the handle, providing an effective disassociation between holding the manipulator to fix the position of the surgical tool and controlling the movements of the tool support about its position defined by the position of the manipulator. 
         [0020]    At the same time, the different potential movements for orienting the direction of inclination about the longitudinal axis of the connecting arm make it possible to provide the tool with any necessary positions within a cone extending the connecting arm. 
       SUMMARY OF THE INVENTION 
       [0021]    It has, however, been shown that with such a device the transmission of the different movements of the tool carrier is bulky, in particular by the arrangement of a plurality of joints in cascade along the longitudinal axis, and also because no means is provided to carry out all the transmissions of movement within a small diameter of the distal part of the manipulator. Thus a need exists to design further transmission means, simultaneously providing reduced bulk and sufficient rigidity of the transmissions which require it. 
         [0022]    To achieve this, the present invention provides that the specific rotational movements and possible opening-closing movements of the forceps are transmitted to the tool support by gears and tubes or shafts housed in the working unit, whilst the inclination movements about the transverse axis are transmitted by cables. 
         [0023]    One advantage of the gears and tubes or shafts is to provide a rigid transmission of forces for the movements which require this feature, whilst the transmission by cables for the inclination movement makes it possible at the same time to reduce the bulk of the device. 
         [0024]    In practice, it is advantageously possible to provide that the specific rotational movement of the tool support is provided by an input tube, in turn driven in rotation by a specific rotation actuator and carrying a conical end pinion which itself drives in rotation a lateral conical pinion rotating about a transverse axis and which drives an axial conical pinion fixed to the tool support. 
         [0025]    Similarly, it is also possible to provide that the tool is forceps and that:
       a forceps actuator is coupled to an axial input shaft oriented along the longitudinal axis of the connecting arm,   the axial input shaft carries a conical end pinion which drives a lateral conical pinion rotating about a transverse axis and driving a conical pinion mounted at the end of the axially threaded and wedged output shaft on which is mounted a nut fixed to a mobile jaw of the tool.       
 
         [0028]    Said arrangement makes it possible to provide a high clamping force which is useful, in particular, when the forceps is a needle holder. 
         [0029]    In the case of forceps, it is also advantageous to provide that the forceps comprise a fixed jaw and a mobile jaw: the fixed jaw facilitates the positioning of a needle before closing the mobile jaw. 
         [0030]    In the case of a tool in the form of forceps, it is also possible to provide that the tool support comprises an arched portion pivotably mounted about a transverse axis on the distal end of the connecting arm and fixed to a pulley urged in rotation by a cable which is itself activated by an inclination actuator. 
         [0031]    To improve further the disassociation between controlling the specific rotational movement of the tool support and all the other movements of the tool support and, in particular, holding the manipulator in position, it is advantageously possible to provide that the second of the control members comprises a first input member, of which the actuation causes the specific rotation of the tool support in a first rotational direction and a second input member, of which the actuation causes the specific rotation of the tool support in the second rotational direction. Thus the operator is provided with a great facility for inclining the tool support at the end of the connecting arm by natural movements of the fingers of the hand. 
         [0032]    According to an advantageous embodiment, the first of the control members may comprise a third input member, of which the activation causes a positive increase in the inclination angle, and a fourth input member, of which the activation causes a negative increase in the inclination angle. 
         [0033]    According to a first embodiment, the input members of the first and second control members may be of the “all or nothing” type and may each control the movement of the tool support in one respective direction according to a substantially constant rotational speed. 
         [0034]    Alternatively, it is possible to provide that the input members are of the progressive type, each controlling the movement of the tool support according to a rotational speed which is variable between a rapid speed and a slow speed. Thus a good compromise is achieved between the speed of actuation and the precision. 
         [0035]    Preferably, it is possible to provide that the input members are of the “all or nothing” type in stepped mode, changing to continuous mode at higher speeds by maintaining the activation. 
         [0036]    More advantageously, it is possible to provide that the first of the control members also has the potential for activating resetting, which returns the tool support into the axis of the support arm. In this manner, the operator is provided with an excellent facility for locating the position from the neutral position at the end of the connecting arm. 
         [0037]    In the case of a forceps-type tool, advantageously the manipulator may also comprise on the handle a forceps control member, of which the actuation controls at least one forceps actuator which selectively causes the opening and closing of the forceps. Thus the actuation of the forceps is also implemented by a simple movement of a finger of the hand, without interfering with holding the manipulator and with the other movements of the tool support. 
         [0038]    In this case, the forceps control member may comprise, in particular, a first open forceps position, at least one second forceps position closed by light clamping and at least one third forceps position closed by strong clamping. 
         [0039]    In addition or alternatively, it is possible also to provide an actuator for rotating the arm, carrying out the specific rotation of the connecting arm about its longitudinal axis relative to the handle, said actuator for specifically rotating the arm being controlled by the third control member of the handle. 
         [0040]    According to a further advantageous embodiment, the manipulator may comprise a positioning arm between the handle and the connecting arm, and by which the operator can modify and fix the angular and/or spatial position relative to the handle with regard to the connecting arm. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0041]    Further subjects, features and advantages of the present invention will emerge from the following description of particular embodiments, made with reference to the accompanying figures, in which: 
           [0042]      FIG. 1  is a basic sketch illustrating the overall structure of a manipulator according to an embodiment of the present invention in the position of use; 
           [0043]      FIG. 2  illustrates the manipulator of  FIG. 1 , with the handle slightly pivoted; 
           [0044]      FIG. 3  illustrates the manipulator of  FIG. 1  in the position pivoted about the trocar; 
           [0045]      FIG. 4  is a schematic view of the manipulator of  FIG. 3  with the handle pivoted; 
           [0046]      FIG. 5  is an overall view of the manipulator of the preceding figures, illustrating the inclination movement of the tool support; 
           [0047]      FIG. 6  illustrates the specific rotational movement of the tool support; 
           [0048]      FIG. 7  illustrates an embodiment of the manipulator of the preceding figures and shows the different movements of the tool; 
           [0049]      FIG. 8  illustrates a further embodiment for obtaining the movements of the tool; 
           [0050]      FIG. 9  illustrates a further embodiment for obtaining the movements of the tool, 
           [0051]      FIG. 10  illustrates a further embodiment for obtaining the movements of the tool; 
           [0052]      FIG. 11  illustrates an advantageous embodiment for obtaining the movements of the tool; 
           [0053]      FIG. 12  illustrates a further embodiment of the manipulator with a resilient axial return means between the trocar and the manipulator body; 
           [0054]      FIG. 13  is a side sectional view illustrating a working unit according to an embodiment of the present invention; 
           [0055]      FIG. 14  is a perspective view partially illustrating the working unit according to  FIG. 13 ; 
           [0056]      FIG. 15  illustrates an embodiment of the means for driving the tool support in an inclined manner; 
           [0057]      FIG. 16  is an overall perspective view of a manipulator according to an embodiment of the invention; 
           [0058]      FIG. 17  is a perspective view of the manipulator of  FIG. 16 , with the cap of the control unit removed; 
           [0059]      FIG. 18  illustrates, in a sectional side view, the means for transmitting movements in a further embodiment of a working unit of the invention; 
           [0060]      FIG. 19  is an overall perspective, schematic view of a manipulator according to the embodiment of the invention; 
           [0061]      FIG. 20  illustrates the stages of a manual rotational movement of the body of the manipulator using an articulated handle; 
           [0062]      FIG. 21  illustrates in perspective the different stages of a specific motorized axial rotational movement of a manipulator body relative to the handle; 
           [0063]      FIG. 22  illustrates two angular positions of the manipulator relative to the handle in a particular embodiment with manual means for orienting the direction of inclination; 
           [0064]      FIG. 23  is a partial side sectional view of the manual orientation means of  FIG. 22 ; 
           [0065]      FIG. 24  is a perspective view of the manual orientation means according to a variant of the invention; 
           [0066]      FIG. 25  illustrates schematically a manipulator according to a further embodiment of the invention, with a deformable connection between the handle and the body of the manipulator; 
           [0067]      FIG. 26  illustrates a further embodiment of the manipulator according to the invention, with an articulated connection between the handle and the body of the manipulator; and 
           [0068]      FIG. 27  illustrates an example of positioning the input members on a handle. 
       
    
    
     DESCRIPTION OF PREFERRED EMBODIMENTS 
       [0069]    Firstly, the overall structure of a manipulator according to the invention is considered, as illustrated in  FIGS. 1 to 12 . 
         [0070]    Such a manipulator  100  generally comprises a control unit  1 , a connecting arm  2  and a working unit  3 . 
         [0071]    The control unit  1  is mounted on the proximal end  2   a  of the connecting arm  2  whilst the working unit  3  is mounted on the distal end  2   b  of the connecting arm  2 . 
         [0072]    The control unit  1  comprises a handle  4  capable of being held by one hand of an operator, and a control body containing various drive means to produce the appropriate movements in the working unit  3 . 
         [0073]    The working unit  3  comprises a tool support  5  capable of supporting a tool  6 . In the figures, a tool  6  has been illustrated in the form of forceps with two arms  6   a  and  6   b.    
         [0074]    The handle  4  comprises control members, for example a first control member  4   a,  a second control member  4   b,  a third control member  4   c  and a forceps control member  4   d.    
         [0075]    As in the known devices, the connecting arm  2  passes into a trocar  7  providing the connection and passage into an opening  8  formed in the body wall  9 . The control unit  1  remains outside the body of the patient, whilst the working unit  3  penetrates inside the body of the patient to reach the operating area where the tool  6  has to carry out movements controlled by the control unit  1 . 
         [0076]    In  FIGS. 1 to 4 , the tool  6  and the tool support  5  are in alignment with the longitudinal axis I-I of the connecting arm  2 . As may be seen in these figures, the operator is able to position the working unit in a precise manner in the operating area by the sliding CO of the connecting arm  2  into the trocar  7  and by the inclination IN of the connecting arm  2  and of the trocar  7  in the opening  8  of the body wall  9 . 
         [0077]    In  FIG. 5 , a first movement of the tool support  5  has been illustrated, namely an inclined movement  12  about a transverse axis of inclination  11 . Said movement is obtained by the activation  13  of the first control member  4   a  of the handle  4  which controls an inclination actuator housed in the control body  10 . By way of illustration, it is possible to refer to  FIG. 17 , illustrating the inclination actuator  40   a  which is connected to the working unit  3  by an inclination transmission cable  41   a  illustrated in  FIG. 15 . 
         [0078]    In  FIG. 5 , by actuation  13  of the first control member  4   a,  the tool support  5  has been inclined to orientate it in a direction of inclination II. 
         [0079]    Now  FIG. 6  will be considered, which illustrates a second movement of the tool support  5 , namely a specific rotational movement  14  about the direction of inclination II. Said specific rotational movement  14  of the tool support  5  about the direction of inclination II is obtained by an activation  15  of the second control member  4   b  which controls one or more inclination actuators housed in the control body  10 . 
         [0080]    The generation of specific rotational movements  14  may advantageously be implemented according to the invention by the activation  15  of the second control member  4   b  of the handle  4  which controls a specific rotation actuator  40   b  housed in the control body  10  ( FIG. 17 ). 
         [0081]    Now  FIG. 7  will be considered, which illustrates a further movement of the tool support  5 , namely a movement by which the direction of inclination II is oriented about the longitudinal axis I-I of the connecting arm  2 . Said orientation movement is illustrated by the arrow  16 . 
         [0082]    According to the invention, it is possible to produce said orientation movement  16  either by causing the specific relative rotation of the connecting arm  2  about its longitudinal axis I-I relative to the handle  4 , or by a manipulation of the handle  4  for a rotation of the entire manipulator about the longitudinal axis I-I of the connecting arm  2 . 
         [0083]    In the first case, the rotation of the connecting arm  2  is obtained by the activation of the third control member  4   c  of the handle  4  which controls an actuator for rotating the arm  40   c  housed in the control body  10  ( FIG. 17 ). 
         [0084]    As a variant to this first case, the rotation of the connecting arm  2  may be obtained, as illustrated in  FIGS. 22 to 24 , by providing a joint for axial rotation relative to the handle  4  on the remainder of the manipulator, with means for indexing the position relative to the handle  4 . In practice, it is possible to provide that the handle  4  is mounted on a handle support  4   f  which is itself articulated in axial rotation relative to the control body  10 . Preferably, the control body comprises a gripping part  10   a  which the operator is able to activate to produce the relative rotation of the handle  4  and the control body  10 . 
         [0085]    In the second case, to permit easy axial rotation of the entire manipulator  100  by manipulation of the single handle  4 , the handle  4  is itself articulated about an axis of articulation of the handle  4   e  as illustrated in  FIG. 11 . 
         [0086]    Thus, in  FIG. 7 , a first embodiment of the manipulator  100  has been illustrated, according to which the handle  4  comprises a first control member  4   a  of which the actuation causes the motorized inclined movement  12  of the tool support  5 , a second control member  4   b  of which the actuation causes the specific rotational movement  14  of the tool support  5  about its direction of inclination II and a third control member  4   c  to produce the specific rotational movement  16  of the connecting arm  2  about its longitudinal axis I-I. In this manner, it is possible to orientate the tool  6  in all directions of a cone covering the distal end  2   b  of the connecting arm  2 . 
         [0087]    Furthermore, in the embodiment of  FIG. 7 , as the tool  6  is forceps, the handle  4  comprises a forceps control member  4   d,  providing the control of the forceps clamping movement illustrated by the arrow  60 . In practice, the clamping  60  of the forceps may be implemented by the actuation of the forceps control member  4   d  which controls the rotation of a forceps actuator  40   d  housed in the control unit  10  ( FIG. 17 ). 
         [0088]    According to the variant illustrated in  FIG. 11 , the connecting arm  2  is fixed to the control body  10  whilst the handle  4  is articulated about an axis of articulation  4   e.  In this case, the specific rotational movement  16  is obtained by rotation R ( FIG. 20 ) of the entire control unit  1 —connecting arm  2 , the rotation R being produced by the hand of the operator who holds the handle  4 . Such a rotation R is illustrated by the series of views of  FIG. 20 . The joint of the handle  4  allows the hand to maintain a correct grip of the handle  4  without exaggerated movement of the joint of the handle, during a sufficient rotation of the manipulator about the longitudinal axis I-I. The other movements of the tool support  5  are obtained in a motorized manner, as in the embodiment of  FIG. 7 . 
         [0089]    In the embodiment of  FIG. 8 , the orientation movement of the direction of inclination II about the longitudinal axis I-I of the connecting arm  2  is obtained by activation of the third control member  4   c  of the handle  4 , which controls a second inclination actuator located in the control body  10 , which actuator drives the tool support  5  in rotation along an intersecting transverse axis which is perpendicular to the transverse axis of inclination  11  and the longitudinal axis I-I. Said second transverse axis of articulation is denoted by the reference numeral  20  in  FIG. 8  and the rotation is illustrated by the arrow  21 . 
         [0090]    Thus, by combining the two inclined rotations about the axes  11  and  20 , it is possible to orientate the tool  6  in all orientations within a cone covering the distal end  2   b  of the connecting arm  2 . 
         [0091]    The other movements of the tool support  5  are identical to those of  FIGS. 7 and 11  and are motorized in the same manner. 
         [0092]    The first inclined movement  12  about the transverse inclination axis  11 , the forceps clamping movement  60  for the tool  6 , the second movement of inclination by rotation  21  about a second intersecting transverse axis and the specific rotational movement  16  of the connecting arm  2  about its longitudinal axis I-I are in the embodiment illustrated in  FIG. 9 . In this case, it is not essential to provide further means to ensure the specific rotation of the tool  6  about its direction of inclination II as this movement may be carried out by the synchronous combination of rotations about the axes  11 ,  20  and I-I. 
         [0093]    However, a specific rotational movement of the tool about its inclination axis II may advantageously be added, as illustrated in  FIG. 10 . 
         [0094]      FIG. 12  illustrates a variant in which a resilient compression system  70  is interposed between the trocar  7  and the control body  10 , to relieve the operator of part of the weight of the manipulator. 
         [0095]    In all the embodiments disclosed above, the control members  4   a - 4   d  may be of the push-button, or touch button, type or any other type of device which is able to be actuated by a finger along a short path and using a small actuating force. In this manner, the risk of interference is further reduced between the actuation of the control members and the holding in position of the entire manipulator by the hand which carries the handle  4 . 
         [0096]    According to an advantageous embodiment, illustrated by  FIG. 27 , the second control member  4   b  comprises a first input member H, of which the actuation causes the specific rotation of the tool support  5  in a first clockwise rotation and a second input member AH, of which the actuation causes the specific rotation of the tool support  5  in a second counter-clockwise direction of rotation. For example, the input members H and AH may be two push-buttons. 
         [0097]    Said push-buttons H and AH may each control the rotation of the tool support  5  according to a speed of rotation which is substantially constant. 
         [0098]    Alternatively, the push-buttons may be of the progressive type, each controlling the rotation of the tool support  5  according to a variable rotational speed between a rapid speed and a slow speed. 
         [0099]    According to a further possibility which is more advantageous, permitting in particular the preparatory stages of adapting the manipulator before an operating movement to be shortened, the buttons may be push-buttons of the “all or nothing” type in stepped mode, changing to continuous mode at higher speeds when maintaining the actuation. 
         [0100]    As regards the first control member  4   a,  it may be advantageously produced in the form of a third input member D, of which the activation causes a positive increase in the angle of inclination, and a fourth input member G, of which the activation causes a negative increase in the angle of inclination. For example, there may be two push-buttons G and D which each control a motor in one respective rotational direction, and the motor stops when the buttons G and D are released. 
         [0101]    Advantageously, it is also possible to provide the possibility of activation for rapid resetting, which returns the tool support  5  into the axis of the connecting arm  2 , for example if the two push-buttons G and D are pressed simultaneously. 
         [0102]    As regards the forceps control member  4   d,  it is possible to produce it, for example, in the form of a ratchet-type push-button, which controls the clamping of the forceps following a first activation by pressing, and which controls the opening of the forceps following a second activation by pressing, controlling the forceps actuator  40   d  in both rotational directions. 
         [0103]    Advantageously, it is possible to control the forceps actuator with a forceps control member  4   d  having a first open forceps position, a second forceps position closed by light clamping and a third forceps position closed by strong clamping. This permits the operator, for example, to place a needle in the forceps, to control the light clamping to perfect the positioning of the needle by sliding into the forceps, and then to lock the needle in position by controlling the strong clamping. 
         [0104]    Now  FIGS. 13 and 15  will be considered which illustrate an embodiment of the working unit  3 , in the case of a forceps-type tool  6  having a fixed jaw  6   a  and a mobile jaw  6   b  about a transverse axis of rotation  6   c.    
         [0105]    An axial input shaft  31  is provided for the clamping or unclamping movement of the forceps  6 , said axial input shaft being coupled to the forceps actuator, being oriented along the longitudinal axis I-I of the connecting arm  2 , carrying a conical end pinion  32  which drives a lateral conical pinion  33  rotating about a transverse axis  11  and driving the conical pinion  34  which is itself mounted at the end of a threaded and axially wedged output shaft  36 . A nut  37  is mounted on the threaded part of the output shaft  36  and is axially displaced during the rotation of the output shaft  36  to drive the mobile jaw  6   b  of the tool  6  pivotably about the transverse rotational axis  6   c.    
         [0106]    The specific rotation of the tool  6  about the axis of inclination II is provided by an input tube  38  oriented along the longitudinal axis I-I, driven in turn in rotation by the specific rotation actuator, and fixed to a conical end pinion  39  which itself drives in rotation a lateral conical pinion  40  rotating about a transverse axis  11  and which drives an axial tubular conical pinion  41  fixed to the tool support  5  (fixed to the fixed jaw  6   a  in the present case). In other words, the tool  6  is mounted with its fixed jaw  6   a  in the fixed position on the pinion  41 , which itself is mounted axially rotatably in the arched portion  50 . A bushing  42  guides the input tube  38  in its rotation about the axis I-I in the connecting arm  2 . 
         [0107]    The arched portion  50  is pivotably mounted about the transverse axis  11  on the distal end  2   b  of the connecting arm  2 . In its rotation, the arched portion  50  is fixed to a pulley  43  urged in rotation by a cable  41   a , more clearly visible in  FIG. 15 . 
         [0108]    As may be seen in  FIGS. 15 and 17 , the inclination actuator  40   a,  of the motorized type, causes by its rotation the driving of the cable  41   a  and the pulley  43  for the inclination of the arched portion  50  and the tool support  5  about the transverse axis  11  as far as a direction of inclination II. 
         [0109]    The specific rotation actuator  40   b  ensures the specific rotation of the tool support  5  about the direction of inclination II, by driving the input tube  38 . The forceps actuator  40   d  ensures the clamping of the forceps  6  by rotation of the input shaft  31 . 
         [0110]    In  FIG. 17  an actuator is also shown for rotating the arm  40   c  which is capable of causing the rotation of the entire manipulator about the handle  4 . 
         [0111]    In the embodiment illustrated in  FIG. 18 , the tool support  5  is rotatably mounted according to a spherical joint  55  on the distal end  2   b  of the connecting arm  2 . The oriented driving of the tool support  5  is provided by peripheral cables  57  for pivoting in all possible orientations of the sphere. 
         [0112]    The transmission of the clamping movement of the forceps  6  takes place by a central cable  56  whilst the specific rotational movement is carried out by transmission by a universal joint  58 . It is possible to consider the description of the French pending patent application No. 2 927 011 which is incorporated here by way of reference. 
         [0113]    In  FIG. 19  may be seen the entire manipulator according to this embodiment, with cables for the transmission of the movements. 
         [0114]      FIG. 20  illustrates the specific rotational movement of the manipulator itself, in the case of an embodiment where the specific rotation of the connecting arm  2  is not motorized. Due to the articulation of the handle  4 , the hand is able to follow the movements without the fingers being released from the handle  4 , ensuring sufficient rotation of the manipulator about its longitudinal axis. 
         [0115]    In  FIGS. 21 and 17  the embodiment has been illustrated where the control body  10  and the connecting arm  2 , which are fixed together, are motorized in rotation relative to the handle  4 . 
         [0116]    In  FIG. 22 , the handle  4  is driven manually in axial rotation about the axis I-I due to an axial joint and a gripping part  10   a  on the control body  10 . In practice, the handle  4  is articulated according to the transverse joint  4   e  on a handle support  4   f,  itself mounted in free axial rotation by an axial joint  4   g  on the control body  10 . 
         [0117]    The axial joint  4   g  and the gripping part  10   a  form a member for manually driving in rotation the handle  4  relative to the remainder of the manipulator about the longitudinal axis I-I of the connecting arm  2 . The activation of the gripping part  10   a  by a finger of the hand holding the handle  4 , or by a different hand, is useful for carrying out rotations of large amplitude for the orientation of the direction of inclination II about the axis I-I. Rotations of small amplitude, during the operating movement, are carried out ergonomically by manual activation of the handle  4  in rotation. 
         [0118]    In the variant illustrated in  FIG. 23 , the handle  4  is attached and fixed to the handle support  4   f.  The joint  4   g  is a bearing of which the external race is fixed to the handle support  4  and of which the internal race is fixed to the connecting arm  2  and the gripping part  10   a  in the form of a thumbwheel attached to the connecting arm  2 . 
         [0119]    Alternatively, in the variant illustrated in  FIG. 24 , the gripping part  10   a  is directly fixed to the control body  10 . 
         [0120]    In  FIGS. 25 and 26 , the handle  4  is connected to the control body  10  by a positioning arm  30  which may be used independently of the other features described here. By means of this positioning arm  30 , the handle  4  may be oriented differently or even offset at a distance from the longitudinal axis I-I of the manipulator, for more ergonomic gripping in certain operating conditions. 
         [0121]    In  FIG. 25 , the positioning arm  30  is a semi-rigid rod 5 to 30 cm long, deformable by flexion under flexional or torsional forces greater than the forces produced alone by the weight of the manipulator and the resistance of the tissue treated by the manipulator. The handle  4  may be fixed to the end of the semi-rigid rod  30 . Alternatively, it may be articulated according to a transverse axis of articulation  4   e.    
         [0122]    In  FIG. 26 , the positioning arm  30  is a rigid rod, carrying at its proximal end the handle  4  with a possible transverse joint  4   e,  and articulated at its distal end to the control body  10  by a joint  35  which may be locked in position. 
         [0123]    As disclosed in some of the preceding embodiments, the handle  4  may advantageously be mounted freely in rotation about an axis of articulation  4   e.    
         [0124]    For example, the axis of articulation  4   e  may be a transverse axis relative to the longitudinal axis I-I of the connecting arm  2 . 
         [0125]    However, it is possible to provide further orientations of the axis of articulation  4   e,  for example a longitudinal orientation or an oblique orientation, each possibility having respective advantages. 
         [0126]    In all embodiments, each of the actuators may be, for example, of the electric motor, hydraulic actuator or pneumatic actuator type. Actuators of the electric motor type are preferable, in particular for the ease of power supply and flexibility of control. 
         [0127]    The present invention is not limited to the embodiments which have been specifically described but it incorporates different variants and generalizations contained within the scope of the following claims.