Patent Publication Number: US-11026564-B2

Title: Apparatus and methods for facilitating treatment of tissue via improved delivery of energy based and non-energy based modalities

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 15/229,177 (filed Aug. 5, 2016), which is a continuation of U.S. patent application Ser. No. 13/962,264 (filed Aug. 8, 2013; now U.S. Pat. No. 9,427,282), which is a divisional application of U.S. patent application Ser. No. 10/850,360 (filed May 19, 2004; now U.S. Pat. No. 8,517,923), which is a continuation-in-part of U.S. patent application Ser. No. 10/767,109 (filed Jan. 28, 2004; now abandoned), which was a continuation in-part of U.S. patent application Ser. No. 10/228,583 (filed Aug. 26, 2002; now U.S. Pat. No. 6,869,396), which is a continuation of U.S. application Ser. No. 09/790,204 (filed Feb. 20, 2001; now U.S. Pat. No. 6,468,203), which claims the benefit of priority from U.S. Provisional Patent Application No. 60/194,140 (filed Apr. 3, 2000), each of which is incorporated herein by reference in its entirety. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates generally to endoscopes and endoscopic medical procedures. More particularly, it relates to methods and apparatus for accessing and treating regions within the body which are difficult to reach through conventional surgical devices and procedures. 
     BACKGROUND OF THE INVENTION 
     Many surgical procedures typically require large incisions be made to provide access to regions within the body. For instance, operating on or near the posterior regions of the heart is ordinarily performed using open-chest techniques. Such a procedure generally requires a gross thoracotomy or sternotomy, which are both highly invasive and attendant with a great deal of risks, such as ischemic damage to the heart, formation of emboli, etc. A thoracotomy typically involves creating an incision in the intercostal space between adjacent ribs while a sternotomy involves the “chest spreader” approach, which is generally the most invasive. Moreover, such an invasive procedure produces significant morbidity, increased mortality rates, and significantly increases recovery time for the patient. 
     Minimally invasive surgery is an alternative surgical procedure in which small incisions are made in the patient&#39;s body to provide access for various surgical devices for viewing and operating inside the patient. Laparoscopes are typically used for accessing and performing operations within the body through these small incisions using specially designed surgical instruments. These instruments generally have handles which are manipulatable from outside of the patient&#39;s body by the surgeon to control the operation of the instrument typically through an elongated tubular section which fits through a tube, introducer, or trocar device entering the patient&#39;s body. 
     However, even conventional laparoscopic procedures are limited in applicability in part because of a “straight-line” requirement in utilizing laparoscopic tools. This requirement makes accessing certain areas within the body extremely difficult, if not impracticable. Moreover, the lack of flexibility of these tools have made access to certain regions of the body difficult, forcing many surgeons to resort to open surgery rather than utilizing conventional minimally invasive procedures. 
     Flexible endoscopic devices are also available for use in minimally invasive surgical procedures in providing access to regions within the body. Flexible endoscopes are typically used for a variety of different diagnostic and interventional procedures, including colonoscopy, bronchoscopy, thoracoscopy, laparoscopy and video endoscopy. A flexible endoscope may typically include a fiberoptic imaging bundle or a miniature camera located at the instrument&#39;s tip, illumination fibers, one or two instrument channels that may also be used for insufflation or irrigation, air and water channels, and vacuum channels. However, considerable manipulation of the endoscope is often necessary to advance the device through the body, making use of conventional devices more difficult and time consuming and adding to the potential for complications. 
     Steerable flexible endoscopes have been devised to facilitate selection of the correct path through regions of the body. However, as the device is typically inserted farther into the body, it generally becomes more difficult to advance. Moreover, friction and slack in the endoscope typically builds up at each turn, making it more difficult to advance and withdraw the device. Another problem which may arise, for example, in colonoscopic procedures, is the formation of loops in the long and narrow tube of the colonoscope. Such loops may arise when the scope encounters an obstacle, gets stuck in a narrow passage, or takes on a shape that incorporates compound curves. Rather progressing, the scope forms loops within the patient. In an attempt to proceed in insertion of the colonoscope, for example, excess force may be exerted, damaging delicate tissue in the patient&#39;s body. The physician may proceed with the attempted insertion of the endoscope without realizing there is a problem. 
     Through a visual imaging device the user can observe images transmitted from the distal end of the endoscope. From these images and from knowledge of the path the endoscope has followed, the user can ordinarily determine the position of the endoscope. However, it is difficult to determine the endoscope position within a patient&#39;s body with any great degree of accuracy. 
     None of the instruments described above is flexible enough to address the wide range of requirements for surgical procedures performed internally to the patient&#39;s body. Furthermore, the instruments described lack the ability to rotate the distal tip about the longitudinal axis of the instrument while fully articulating the tip to any setting relative to the tubular section of the instrument. This lack of flexibility requires surgeons to manually rotate and move the instrument relative to the patient body to perform the procedure. 
     BRIEF SUMMARY OF THE INVENTION 
     Endoscopic devices, as described below, may be particularly useful in treating various regions within the body. Such endoscopes may include a steerable distal portion and an automatically controlled proximal portion which may be controlled by a physician or surgeon to facilitate steering the device while the proximal portion may be automatically controlled by, e.g., a controller or computer. The steerable endoscope may be advanced within the body of a patient, e.g., via any one of the natural orifices into the body such as through the anus. Alternatively, the device may be introduced percutaneously through a small incision into the body. Once the endoscopic device has been introduced into the body, it may be advanced and maneuvered to avoid obstructing anatomical features such as organs, bones, etc., without impinging upon the anatomy of the patient. Examples of such devices are described in detail in the following patents and co-pending applications: U.S. Pat. Nos. 6,468,203; 6,610,007; U.S. patent application Ser. No. 10/087,100 filed Mar. 1, 2002; U.S. patent application Ser. No. 10/139,289 filed May 2, 2002, U.S. patent application Ser. No. 10/229,577 filed Aug. 27, 2002; U.S. patent application Ser. No. 10/229,814 filed Aug. 27, 2002, and U.S. patent application Ser. No. 10/306,580 filed Nov. 27, 2002, each of which is incorporated herein by reference in its entirety. 
     Using such a device, one method of treating an obstructed region of tissue within a body, may generally comprise advancing an elongate device into the body through an opening, the elongate device having a proximal portion and a selectively steerable distal portion and the elongate device having a plurality of segments, selectively steering the distal portion to assume a selected curve along a desired path within the body which avoids contact with tissue (or does not require displacement of adjacent tissue along the desired path or avoids applying excess force to the adjacent tissue), and further advancing the elongate device through the body and towards the region of tissue to be treated while controlling the proximal portion of the device to assume the selected curve of the distal portion. 
     Using any one of the controllable endoscopic devices, various regions of the body which are typically difficult to access and treat through conventional surgical techniques, may be accessed and treated accordingly. In one treatment variation, the endoscopic device may be utilized for neurological surgical applications. Because the endoscopic device is unconstrained by “straight-line” requirements for accessing regions of the brain which are conventionally difficult to reach and/or because the device avoids forming loops when advanced, the endoscope may be accurately advanced and positioned within the cranium by steering the device around the brain with minimal or no trauma to healthy brain tissue. The endoscope may also be advanced through the tissue as necessary to access treatment areas embedded deep within the tissue through pathways which may minimize any damage to healthy adjacent tissue. Furthermore, because the endoscopic device may allow access to sensitive regions over or within the brain, minimally invasive surgery may be performed where conventional surgery would normally require removal of portions of the skull, for instance, in craniotomy procedures or treatment of intracranial hematomas, etc. In addition, access through the nasal passages or other natural cranial orifices may be facilitated. 
     Another area of treatment in which the endoscopic device may be utilized may include use for coronary procedures, e.g., treatment of the mitral valve, tissue ablation for the treatment of atrial fibrillation, placement, removal, or adjustment of pacing leads, etc. In one example, the endoscopic device may be introduced within the heart via the superior vena cava and advanced through the right atrium. Once the endoscope is within the right atrium, the distal portion may be steered through the atrial septum and into the left atrium where the distal portion of the device may be positioned adjacent to the tissue to be treated, in this example, the mural valve. To affect treatment, various tools or devices, e.g., scalpels, graspers, etc., may be delivered through one or several working channels within the device to effect the treatment. 
     In yet another area of treatment in which the endoscopic device may be utilized, various thoracoscopy procedures may be accomplished in a minimally invasive procedure, e.g., percutaneously. As shown, the endoscope may be advanced into the patient via an introducer or port, which may also be configured as a datum for establishing a fixed point of reference for the endoscope during the procedure. The port or datum may be in electrical communication with a computer or processor used for determining and/or maintaining the position of the device within the patient. The endoscope may be advanced into the body of the patient through an incision made, e.g., in the intercostal space between the ribs. The endoscope may then be advanced into the thoracic cavity and maneuvered to regions within the body such as the posterior region of the heart which are normally inaccessible for conventional laparoscopic procedures due to a lack of straight-line access. 
     One embodiment of the present invention provides a method for facilitating a treatment within a body including inserting an endoscope having a steerable distal end and a controllable proximate end, the controllable proximate end being controlled to follow the steerable distal end. The endoscope is maneuvered into a position within the body to facilitate a treatment of a body portion. A treatment is performed on the body portion. The body portion could be, for example, in the thoracic cavity, the skull, or the peritoneal cavity. 
     Another embodiment of the present invention provides a system for performing a treatment of a condition related to a physiological indication within a body. There is a system for detecting and localizing a physiological indication within the body. A system for providing imaging of a portion of the body related to the physiological indication within the body. A steerable endoscope having a steerable distal end and a controllable proximate end under the control of a computer controller that receives information from the system for detecting and the system for providing. 
     Another embodiment of the present invention provides a system for facilitating a treatment of the heart having a system for indicating the location of an errant condition of the heart. There is also provided a controller system utilizing information generated by the system for indicating to assist in the articulation of a steerable endoscope having a steerable distal end and a controllable proximate end to follow the steerable distal end into a position to facilitate a treatment of the errant condition of the heart. In addition, there is provided a treatment device provided by the steerable endoscope to perform a treatment of the errant condition of the heart. 
     In another embodiment of the present invention, there is provided an apparatus for performing a cardiac ablation therapy having a steerable endoscope having a steerable distal end and a controllable proximate end configured to automatically follow the configuration of the steerable distal end. An ablation therapy device adapted to be deployed by the steerable endoscope. A fastener that fixes the position of the ablation therapy device. 
     Another embodiment of the present invention provides a method of performing a treatment within the body by advancing a steerable distal end of an endoscope along a pathway into a treatment position to facilitate a treatment within a body. The proximate end of the endoscope is controlled to follow the pathway of the steerable distal end of the endoscope. A treatment element is provided to the treatment position. 
     embodiment of the present invention utilizes a pair of steerable endoscopes to deliver a therapy within the body. The pair of endoscopes may be arranged such that one endoscope is within the other endoscope or, alternatively, where one endoscope is adjacent the other endoscope. In another embodiment, one steerable endoscope may be maneuvered into a desired position within the body to facilitate treatment and then fixed into that position. Thereafter, the second endoscope may be maneuvered to perform the therapy or facilitate a treatment utilizing the fixed position within the body provided by the first endoscope. This procedure may be useful in conditions of movement, such as beating heart treatments where the first endoscope may be used as a fixed treatment point for utilizing the second endoscope. 
     The endoscope device may also be utilized for procedures within the peritoneal cavity. Potential applications may include minimally invasive surgery for urologic, bariatric, and liver surgery. Moreover, minimally invasive access may be achieved for treatments in spinal or orthopedic surgery as well. In such a procedure, the endoscope may be introduced into the patient through an incision via a port, which may also function as a datum. The distal portion may be steered to avoid various organs while being advanced to a tissue region to be treated, e.g., the liver. The distal portion of the endoscope may accordingly be steered while the proximal portion may be automatically controlled to follow a path defined by the distal portion which minimizes contact with the surrounding and adjacent tissue and organs. In this or any other procedure, one or more laparoscopes may optionally be used in combination with the endoscope to assist with the surgical procedure. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  shows one variation of a steerable endoscope which may be utilized for accessing various regions within the body without impinging upon the anatomy of the patient. 
         FIG. 2A  shows a wire frame model of a section of the elongate body of the endoscope in a neutral or straight position. 
         FIG. 2B  shows an illustration of the endoscope body maneuvered through a curve with the selectively steerable distal portion and automatically controlled proximal portion. 
         FIG. 3  shows a cross-sectional side view of a patient&#39;s head with a variation of the endoscope being advanced therethrough. 
         FIG. 4  shows the interaction of several components to provide a method of positioning a steerable endoscope system to facilitate treatment. 
         FIG. 5  shows a cross-sectional anterior view of a heart with the endoscopic device introduced via the superior vena cava and advanced to the right atrium. 
         FIG. 6  shows an example of a thoracoscopy procedure which may be performed percutaneously with the endoscopic device. 
         FIGS. 7A, 7B, 7C, and 7D  progressively show an example of the endoscopic device being advanced about the posterior region of a heart to facilitate treatment of a supraventricular tachycardia. 
         FIGS. 8A, 8B, 8C, and 8D  progressively show an example of the endoscopic device being advanced about the posterior region of a heart and retracted to deploy a device to facilitate treatment of a supraventricular tachycardia. 
         FIG. 9  shows an embodiment of a treatment device having a plurality of fasteners to facilitate contact between the treatment device and the surrounding tissue. 
         FIGS. 10A and 10B  show additional examples of the endoscopic device advanced about the posterior region of a heart to facilitate treatment of a supraventricular tachycardia ( FIG. 10A ) and a combination of supraventricular and ventricular tachycardia ( FIG. 10B ). 
         FIG. 11  shows yet another example of a treatment for atrial fibrillation using the endoscopic device. 
         FIGS. 12A, 12B, 12C, and 12D  show additional examples of the endoscopic device advanced about the posterior region of a heart to facilitate treatment of a supraventricular tachycardia and/or combinations of supraventricular and ventricular tachycardia. 
         FIG. 13  shows an embodiment of a dual, steerable endoscope of the present invention utilized to facilitate treatment of the heart. 
         FIGS. 14A, 14B, and 14C  show side and end views, respectively, of various electrode configurations on the endoscope for tissue ablation treatment. 
         FIGS. 15A and 15B  show an embodiment of a needle array in a retracted ( FIG. 15A ) and a deployed ( FIG. 15B ) configuration. 
         FIG. 16  shows an embodiment of a needle array having a continuous spacing. 
         FIG. 17  shows an embodiment or a needle array having a variety of spacing configurations. 
         FIGS. 18A and 18B  show a side and isometric view of an embodiment of a treatment device of the present invention. 
         FIGS. 18C and 18D  show a plurality of the treatment devices in optimized positions for facilitating a therapy. 
         FIG. 19  shows a graph illustrating a technique to optimize placement of a device to facilitate therapy. 
         FIG. 20  shows an example of a procedure within the peritoneal cavity which may be performed with the endoscopic device. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     In treating various regions within the body, a number of different endoscopic devices may be utilized in facilitating access. Endoscopic devices which are particularly useful may include various endoscopes having a steerable distal portion and an automatically controlled proximal portion. Generally, the steerable distal portion may be controlled by a physician or surgeon to facilitate steering the device while the proximal portion may be automatically controlled by, e.g., a controller or computer. The steerable endoscope may be advanced within the body of the patient through a number of different methods. For instance, the endoscope may be introduced via anyone of the natural orifices into the body such as through the anus. Alternatively, the device may be introduced percutaneously through a small incision into the body. Once the endoscopic device has been introduced into the body, it may be advanced and maneuvered, as described below, to avoid obstructing anatomical features such as organs, bones, etc., without impinging upon the anatomy of the patient. 
       FIG. 1  illustrates one variation of a steerable endoscope  100  which may be utilized for accessing various regions within the body without impinging upon the anatomy of the patient. The endoscope  100  generally has an elongate body  102  with a manually or selectively steerable distal portion  104  and an automatically controlled proximal portion  106 . The selectively steerable distal portion  104  may be selectively steered or bent up to a full 180° bend in any direction, as shown by the dashed lines. A fiberoptic Imaging bundle  112  and one or more illumination fibers  114  may optionally be extended through the body  102  from the proximal end  110  to the distal end  108 . Alternatively, the endoscope  100  may be configured as a video endoscope with a miniaturized video camera, such as a CCD or CMOS camera, positioned at the distal end  108  of the endoscope body  102 . The images from the video camera may be transmitted to a video monitor by a transmission cable or by wireless transmission. Optionally, the body  102  of the endoscope  100  may also include at least one or two instrument channels  116 ,  118  that may be used to provide access through the endoscope for any number of tools. Channels  116 ,  118  may also be used for various other purposes, e.g., insufflation or irrigation. 
     The elongate body  102  of the endoscope  100  is highly flexible so that it is able to bend around small diameter curves without buckling or kinking. The elongate body  102  of the endoscope  100  may range in length typically from, e.g., 135 to 185 cm, and 12 to 13 mm in diameter. However, if the endoscope  100  were utilized in regions within the body which are smaller than the space within, e.g., the gastrointestinal tract, the device may be modified in size to be small in diameter. The endoscope  100  may also be modified in length to be longer or shorter, depending upon the desired application. 
     A handle  120  is attachable to the proximal end  110  of the elongate body  102 . The handle  120  may include an ocular  124  connected to the fiberoptic imaging bundle  112  for direct viewing and/or for connection to a video camera  126 . The handle  120  may also be connected to an illumination source  128  via an illumination cable  134  that may be connected to or continuous with the illumination fibers  114 . An optional first luer lock fitting  130  and an optional second luer lock fitting  132 , which may be in communication with instrument channels  116 ,  118 , respectively, may also be located on or near the handle  120 . 
     The handle  120  may be connected to an electronic motion controller  140  by way of a controller cable  136 . A steering control  122  may be connected to the electronic motion controller  140  by way of a second cable  138 . The steering control  122  may configured to allow the physician or surgeon to selectively steer or bend the selectively steerable distal portion  104  of the elongate body  102  in the desired direction. The steering control  122  may be a joystick controller as shown, or other known steering control mechanism. Alternatively, the steering may be effected manually, e.g. by the use of cables, hydraulics, or pneumatics, or any other known mechanical apparatus for controlling the distal portion of the elongate body. The electronic motion controller  140  may be used to control the motion of the automatically controlled proximal portion  106  of the elongate body  102  and may be implemented using a motion control program running on a microcomputer or through an application-specific motion controller. Alternatively, the electronic motion controller  140  may be implemented using a neural network controller. 
     An axial motion transducer  150  may be provided to measure the axial motion of the elongate body  102  as it is advanced and withdrawn. The axial motion transducer  150  can be made in many configurations, some of which are described below. In this variation, the axial motion transducer  150  is configured as a ring  152 , for illustrative purposes only, that surrounds the elongate body  102  of the endoscope  100 . The axial motion transducer  150  may be attached to a fixed point of reference, such as the surgical table or the insertion point for the endoscope  100  on the patience&#39;s body, as described below. As the body  102  of the endoscope  100  slides through the axial motion transducer  150 , it produces a signal indicative of the axial position of the endoscope body  102  with respect to the fixed point of reference and sends a signal to the electronic motion controller  140  by telemetry or by a cable (not shown). The axial motion transducer  150  may use optical, electronic, magnetic, mechanical, etc., methods to determine the axial position of the endoscope body  102 . In addition, the motion transducer may be configured to simultaneously measure and communicate rotational motion of the endoscope, so that this additional data may be used in the control of the instrument&#39;s motion. A further detailed description of the axial motion transducer  150  and variations thereof may be found in U.S. patent application Ser. No. 10/384,252 filed Mar. 7, 2003, which is incorporated herein by reference in its entirety. 
     To illustrate the basic motion of the steerable endo scope  100 ,  FIG. 2A  shows a wire frame model of a section of the body  102  of the endoscope  100  in a neutral or straight position. Most of the internal structure of the endoscope body  102  has been eliminated in this drawing for the sake of clarity. The endoscope body  102  is divided up into sections 1, 2, 3 . . . 10, etc. The geometry of each section is defined by four length measurements along the a, b, c and d axes. For example, the geometry of section 1 may be defined by the four length measurements 1 1a , 1 1b , 1 1c , 1 1d , and the geometry of section 2 may be defined by the four length measurements 1 2a , 1 2b , 1 2c , 1 2d , etc. The geometry of each section may be altered using the linear actuators to change the four length measurements along the a, b, c and d axes. For example, to bend the endoscope body  102  in the direction of the a axis, the measurements 1 1a , 1 2a , 1 3a  . . . 1 10a  can be shortened and the measurements 1 1b , 1 2b , 1 3b  . . . 1 10b  can be lengthened an equal amount. The amount by which these measurements are changed determines the radius of the resultant curve. In automatically controlled proximal portion  106 , however, the a, b, c and d axis measurements of each section may be automatically controlled by the electronic motion controller  140 . 
     In  FIG. 2B , the endoscope body  102  has been maneuvered through the curve C with the benefit of the selectively steerable distal portion  104  and now the automatically controlled proximal portion  106  resides in the curve C. Sections 1 and 2 are in a relatively straight part of the curve C, therefore 1 1a =1 1b  and 1 2a =1 2b . However, because sections 3-7 are in the S-shaped curved section, 1 3a &lt;1 3b , 1 4a &lt;1 4b  and 1 5a &lt;1 5b , but 1 6a &gt;1 6b , 1 7a &gt;1 7b  and 1 8a &gt;1 8b . When the endoscope body  102  is advanced distally by one unit, section 1 moves into the position marked 1′, section 2 moves into the position previously occupied by section 1, section 3 moves into the position previously occupied by section 2; etc. The axial motion transducer  150  produces a signal indicative of the axial position of the endo scope body  102  with respect to a fixed point of reference and sends the signal to the electronic motion controller  140 . Under control of the electronic motion controller  140 , each time the endoscope body  102  advances one unit, each section in the automatically controlled proximal portion  106  is signaled to assume the shape of the section that previously occupied the space that it is now in. Therefore, when the endoscope body  102  is advanced to the position marked 1′, 1 1a =1 1b , 1 2a =1 2b , 1 3a =1 3b , 1 4a &lt;1 4b , 1 5a &lt;1 5b , 1 6a &lt;1 6b , 1 7a &gt;1 7b , 1 8a &gt;1 8b , and 1 9a &gt;1 9b , and, when the endoscope body  102  is advanced to the position marked 1″, 1 1a =1 1b , 1 2a =1 2b , 1 3a =1 3b , 1 4a =1 4b , 1 5a &lt;1 5b , 1 6a &lt;1 6b , 1 7a &lt;1 7b , 1 8a &gt;1 8b , 1 9a &gt;1 9b , and 1 10a &gt;1 10b . Thus, the S-shaped curve propagates proximally along the length of the automatically controlled proximal portion  106  of the endoscope body  102 . The S-shaped curve appears to be fixed in space, as the endoscope body  102  advances distally. 
     Similarly, when the endoscope body  102  is withdrawn proximally, each time the endoscope body  102  is moved proximally by one unit, each section in the automatically controlled proximal portion  106  is signaled to assume the shape of the section that previously occupied the space that it is now in. The S-shaped curve propagates distally along the length of the automatically controlled proximal portion  106  of the endoscope body  102 , and the S-shaped curve appears to be fixed in space, as the endoscope body  102  withdraws proximally. 
     Whenever the endoscope body  102  is advanced or withdrawn, the axial motion transducer  150  may be used to detect the change in position and the electronic motion controller  140  may be used to propagate the selected curves proximally or distally along the automatically controlled proximal portion  106  of the endoscope body  102  to maintain the curves in a spatially fixed position. Similarly, if the endoscope  102  is rotated, a rotational motion transducer (separate from or integrated within transducer  150 ) may be used to detect the change in position and the electronic motion controller may be similarly used to adjust the shape of the endoscope body  102  to maintain the curves in a spatially fixed position. This allows the endoscope body  102  to move through tortuous curves without putting unnecessary force on the wall of the curve C. 
     Examples of other endoscopic devices which may be utilized in the present invention are described in further detail in the following patents and co-pending applications, U.S. Pat. Nos. 6,468,203; 6,610,007; U.S. patent application Ser. No. 10/087,100 filed Mar. 1, 2002; U.S. patent application Ser. No. 10/139,289 filed May 2, 2002, U.S. patent application Ser. No. 10/229,577 filed Aug. 27, 2002; U.S. patent application Ser. No. 10/229,814 filed Aug. 27, 2002, and U.S. patent application Ser. No. 10/306,580 filed Nov. 27, 2002, each of which has been incorporated herein by reference above. 
     Therefore, using anyone of the controllable endoscopic devices described above, various regions of the body which are typically difficult to access and treat through conventional surgical techniques, may be accessed and treated accordingly. In one treatment variation, the endoscopic device may be utilized for neurological surgical applications. Because the endoscopic device is unconstrained by “straight-line” requirements for accessing regions of the brain which are conventionally difficult to reach, the endoscope may be advanced and positioned within the cranium by steering the device around the brain with minimal or no trauma to healthy brain tissue. The endoscope may also be advanced through the tissue as necessary to access treatment areas embedded deep within the tissue through pathways which may minimize any damage to healthy adjacent tissue. Furthermore, because the endoscopic device may allow access to sensitive regions over or within the brain, minimally invasive surgery may be performed where conventional surgery would normally require removal of portions of the skull, for instance, in craniotomy procedures or treatment of intracranial hematomas, etc. 
       FIG. 3  shows a cross-sectional side view of head  202  of patient  200 . The brain  206  may be seen within the cranial cavity  210  of cranium  204 . The endoscopic device  212  is an embodiment of a steerable endoscope of the present invention that has been sized, shaped and configured for accessing the interior of the cranial cavity and external and internal regions of the brain. The movement, position, tracking and control of the endoscopic device  212  is performed by a user alone or in cooperation with any or all of imaging systems, position and location systems, and surgical planning methods and techniques. In treating regions of the brain  206  which may be difficult to normally access, the endoscopic device  212  may be introduced into the cranial cavity  210  from an easily accessible insertion site  222 , e.g., a perforation within the skull. The endoscope  212  may be then advanced through the insertion site  222  by controlling the steerable distal portion  214  to avoid brain tissue. As the endoscope  212  is further advanced into the cranial cavity  210 , the automatically controlled proximal portion  216  may attain the shape defined by the steerable distal portion  214  to avoid contact with brain tissue  206 . 
     The endoscope  212  may be further advanced through the cranial cavity  210  and within the cerebrospinal fluid so that the device is advanced above or within the layers of the meninges, e.g., within the subarachnoid space. In either case, the endoscope  212  may be steered along a path which avoids or minimizes contact or pressure against the brain tissue  206 . As the proximal portion  216  is advanced distally and attains the shape defined by the distal portion  214 , the proximal portion  216  likewise may be controlled to automatically avoid or minimize contact or pressure against the brain tissue  206 . Once the distal portion  216  is advanced to the desired treatment region  208 , various tools  220  may be introduced through the instrument channel  218  to enable treatment of the region  208 . Any number of treatments or procedures may accordingly be effected, e.g., tumor biopsy and/or removal, shunt placement, lead placement, device placement, drainage of excess cerebrospinal fluid or blood, etc. 
       FIG. 4  shows the interaction of several components to provide a method of positioning a steerable endoscope system to facilitate treatment. As mentioned above, the movement, position, tracking and control of endoscopic devices according to the present invention is performed by a user alone or in cooperation with any or all of imaging systems, position and location systems, and surgical planning methods and techniques. The system schematic  4000  illustrates one embodiment of an integrated detection, mapping and control system for positioning and controlling a steerable, controllable endoscope of the present invention. First, a suitable device, element or system is used to detect and localize a physiological indication ( 4010 ). A physiological indication could be any perceptible indicia of a condition for which treatment may be facilitated. In a coronary example, physiological indicators include electrophysiology data or electrical signals from the heart. This system would be capable of identifying or performing analysis of monitored data to identify or determine the location of errant activity. 
     Next, information regarding the detected and localized physiological indication is passed to an image/mapping system ( 4020 ). An image/mapping system includes any imaging modality that may provide position, location, tissue type, disease state, or any other information that facilitates correlating the physiological activity to an identifiable and/or localizable position within the anatomy or within a frame of reference. Examples of image/mapping systems include any of the imaging technologies such as x-ray, fluoroscopy, computed tomography (CT), three dimensional CAT scan, magnetic resonance imaging (MRI), and magnetic field locating systems. Examples of image/mapping systems specifically suited for the treatment of cardiovascular disorders include electrocardiogram detection systems, cardiac electrophysiology mapping systems, endocardial mapping systems, or other systems and methods that provide the ability acquire, visualize, interpret and act on cardiac electrophysiological data. An example of such a system is described in U.S. Pat. No. 5,848,972 entitled, “Method for Endocardial Activation Mapping Using a Multi-Electrode Catheter” the entirety of which is incorporated herein by reference. Additional examples are described in U.S. Pat. Nos. 5,487,385; 5,848,972; and 5,645,064, the entirety of each of these patents is incorporated by reference. Integrated mapping, detection and/or ablation probes and devices may also be delivered using the steerable endoscope of the present invention. One such integrated system is described in US Patent Application Publication US 2003/0236455 to Swanson et al the entirety of which is incorporated herein by reference. Additional other systems may provide mapping, display or position information of a local isochronal activation map of the heart along with the relative position of the endoscope and direction information or movement commands to position the endoscope (or components, elements or systems onboard the endoscope) to provide treatment to the source of the arrhythmia. 
     Next, information provided, compiled and/or analyzed in the prior steps or other additional information provided by a user or other system used by the user is input into or utilized by the endoscope controller ( 4030 ). This step indicates the ability of the endoscope controller to respond to the indication, position, image, mapping and other data and utilize that data for altering the scope configuration, position, orientation or other relational information indicative of the scope controller responding to the information provided. The endoscope is configured to provide of facilitate providing components, elements or systems to facilitate a treatment of the physiological indication being monitored. The controller utilizes the data provided to position the steerable, controllable endoscope into a position related to the location or site that exhibits the errant activity. The proximity of the endoscope to the location or site of the errant activity will vary depending upon, for example, the treatment being implemented, the element, component or system being used to facilitate treatment. 
     Finally, the position of the endoscope is supplied back into the image or mapping system as a form of feedback to better assist in guiding the endoscope into the desired position to facilitate treatment ( 4040 ). 
     In another embodiment, the system  4000  may include an overall mapping system that provides medically significant data that facilitates a treatment. This overall mapping or imaging system may include mapping or imaging an area of monitored activity. The area of monitored activity includes not only the portion of the body important to the treatment but also imaging information of those other parts of the body not impacted by the treatment but are instead the likely pathway(s) of the steerable, controllable endoscope to reach the area where the treatment will be facilitated. In addition, some embodiments of the system may include the ability to detect, localize or otherwise indicate the position of the treatment area or area of errant activity or conditions subject to treatment. These indications may then be utilized to augment the guidance of the steerable, controllable endoscope into the desired position to facilitate treatment. In addition, other medical imaging and tracking systems may be utilized to provide tracking, guidance and position feedback information to the control of the steerable endoscope. An exemplary system is described by Dumoulin et al. in U.S. Pat. No. 5,377,678 which is incorporated herein by reference in its entirety. 
     The above steps are only representative of one embodiment of how physiological indications, and position information may be utilized to improve the guidance system and controls used by steerable endoscopes to ensure the placement of the endoscope to facilitate treatment. It is to be appreciated that the steps were utilized for clarity and ease of discussion. The methods of embodiments of the invention are not so limited. For example, a single system could be used as an integrated indication, imaging, endoscope controller that receives endoscope position feedback in real time. In an alternative example, the physiological indication and image/mapping functions may be combined into a single unit. As such, while the above steps have been described as happening only once or in a serial fashion, it is to be appreciated that the steps may be conducted in as different order or multiple times. Other physiological indication detection and localization systems may be used and will correspond to an appropriate system useful in the treatment being performed. In addition, alternative image and mapping systems may also be employed and may also be selected depending upon the treatment being facilitated through the use of a steerable controllable endoscope of the present invention. The system may also control the movement of the endoscope automatically based on inputs from the user, pre-surgical planning data, or other indications of desired pathways or pathways to avoid. Alternatively, or in addition, a user may input additional guidance or control information into the system for furthering the guidance or desired placement of the endoscope. 
     Another area of treatment in which the endoscopic device may be utilized may include use for coronary procedures, e.g., treatment of the mitral valve, performing or facilitating treatment of supraventricular tachycardia, including, for example, tissue ablation for the treatment of atrial fibrillation, treatment of ventricular tachycardia alone or in combination with treatment of supraventricular tachycardia, treatments for the placement, repositioning or removal of device leads, etc. Atrial fibrillation is typically sustained by the presence of multiple electrical reentrant wavelets propagating simultaneously in the atria of the heart. Surgical and catheter-based techniques typically place segmented or continuous lesions near and around the pulmonary veins as one way to re-synchronize the atria. 
     In addition, a variety of ablation techniques using energy based and non-energy based modalities may be utilized to ablate soft tissue. Embodiments of the present invention may be utilized to facilitate ablation therapies, ablation elements and devices that employ one or a combination of energy modalities, such as, for example, cryogenic energy, hydraulic energy, laser energy, magnetic energy, mechanical energy, microwave energy, radiation energy, radio-frequency energy, thermal energy, and ultrasonic energy. Microwave ablation systems may include, for example, those based on AFx microwave surgical ablation systems such as the AFx Flex 4 or the like. AFx is currently owned by Guidant Corp. Cryogenic ablation systems may include, for example, systems available from Cryocath Technologies such as the “SurgiFrost,” “Frostbyte” or “Artic Circler” systems and the like. Ultrasound based surgical probes may be, for example, based upon the ultrasound ablation systems produced by EpiCor Medical or the like. A large number of commercially available ablation systems are available to illustrate the wide variety of ablation systems, techniques and modalities that may be delivered or utilized by embodiments of the steerable endoscopic systems of the present invention. 
     As shown in  FIG. 5 , a cross-sectional anterior view of heart  302  may be seen in coronary procedure  300  for treatment of the mitral valve MV located between the left atrium LA and the left ventricle LV. The endoscopic device  212  is shown in this treatment variation as being introduced within the heart  302  via the superior vena cava SVC and advanced through the right atrium RA. Also shown is the right ventricle RV below the tricuspid valve TV and inferior vena cava IVC. The endoscope  212  may be sized accordingly to be delivered intravascularly. Once the endoscopic device  212  is within the right atrium RA, the distal portion  214  may be steered towards the atrial septum AS which separates the left atrium LA and right atrium RA. Once at the atrial septum AS, a cutting tool deliverable through the device  212  may be used to perforate the atrial septum AS to allow passage of the endoscopic device  212  into the left atrium LA. The distal portion  214  may then be steered and positioned adjacent the mitral valve MV while the proximal portion  216  is automatically controlled to minimize any pressure which may be exerted by the device  212  against the tissue of the heart  302 . Once the endoscopic device is adjacent to the tissue to be treated, in this example the mitral valve MV, various tools or devices may be delivered through the channel  218  to effect the treatment. Once the procedure has been completed, the endoscope  212  may simply be withdrawn proximally in the same manner while minimizing any contact pressure against the tissue. 
     In yet another area of treatment in which the endoscopic device may be utilized, various thoracoscopy procedures may be accomplished in a minimally invasive procedure.  FIG. 6  shows an example of a thoracoscopy procedure  400  which may be performed percutaneously. As shown, the endoscope  212  may be advanced into the patient  402  via an introducer or port  412 , which may also be configured as a datum for establishing a fixed point of reference for the endoscope  212  during the procedure. The port or datum  412  may be in electrical communication via electrical lines  418  with a computer or processor  416  which may be used for determining and/or maintaining the position of the device  212  within the patient  402 . The endoscope  212  may be advanced into the body of the patient  402  through an incision  414  made, e.g., in the intercostal space between the ribs  404 . The endoscope  212  may then be advanced into the thoracic cavity and maneuvered to regions within the body such as the posterior region of the heart  408  which are normally inaccessible for conventional laparoscopic procedures due to a lack of straight-line access. 
     In this example, the endoscopic device  212  is shown having been inserted through port or datum  412  and advanced posteriorly of heart  408  behind sternum  406 . The lungs are not shown for the sake of clarity; however, the endoscope  212  may be steered and advanced around the lungs in a manner described above so as to avoid contact or to minimize contact with the lung tissue or any other organs or structures which may be obstructing a straight-line path. 
     The endoscopic device  212  is capable of reaching regions within the body, without damaging surrounding tissue, which is normally inaccessible via conventional laparoscopic procedures.  FIGS. 7A to 7D  show an example of the endoscopic device advanced about the posterior region of a heart to facilitate treatment of a supraventricular tachycardia. One example of a supraventricular tachycardia is atrial fibrillation. Another procedure  500  is shown in  FIGS. 7A to 7D , which illustrate how the endoscopic device may be utilized for the treatment of atrial fibrillation. The figures show a posterior view of the heart with the aorta AA and pulmonary trunk PT as anatomical landmarks. Atrial fibrillation is typically sustained by the presence of multiple electrical reentrant wavelets propagating simultaneously in the atria of the heart. Surgical and catheter-based techniques typically place segmented or continuous lesions near and around the pulmonary veins as one way to re-synchronize the atria. 
     The endoscopic device  212  may be utilized by advancing the device  212  into the thoracic cavity, as described above or through various other channels, and steered towards the posterior region of the heart. In the example shown in  FIGS. 7A to 7D , the steerable distal portion  214  may be advanced as shown in  FIG. 7A  such that the endoscope  212  approaches above the left pulmonary veins LPV. As shown in  FIG. 7B , the distal portion  214  may be steered around the right pulmonary veins RPV while the endoscope  212  is advanced distally. The automatically controllable proximal portion  216  may thus assume the shape defined by the distal portion  214  in traversing around the pulmonary vessels. As shown in  FIG. 7C , the distal portion  214  is steered around the left pulmonary vessels LPV while the proximal portion has assumed the curved path traversed by the device around the right pulmonary vessels RPV. Finally in  FIG. 7D , the device  212  may be fully advanced entirely around the pulmonary vessels such that the distal portion  214  and proximal portion  216  are in intimate contact against the heart tissue while maintaining its configuration. The tissue which is in contact against the device  212  may then be ablated by one or several electrodes located along the length of the distal and/or proximal portions  214 ,  216 , as described in further detail below. Alternately, an ablation device such as a catheter or other energy source, may be delivered through one or more working channels in or on the endoscope, and left in place as desired. This ablation device may then be used to deliver ablative energy in various forms, e.g., RF, microwave, cryogenic cooling, etc., as described herein or known to those of ordinary skill in the art. The device may be held fixedly in the desired location by various methods, e.g., vacuum, magnetically, temporary adhesives, sutures, or any other methods of attaching or approximating the device and tissue. 
       FIGS. 8A to 8D  show an example of a procedure  600  wherein a steerable endoscopic device is advanced about the posterior region of a heart and then retracted to deploy a device to facilitate treatment of a supraventricular tachycardia. The steerable endoscopic device  800  is capable of reaching regions within the body as described above and as an improvement over laparoscopic procedures. The figures show a posterior view of the heart with the aorta AA and pulmonary trunk PT as anatomical landmarks.  FIG. 8A  illustrates an endoscopic device  800  having a steerable, controllable distal end  805  and a controllable proximal end  810 . In  FIG. 8A , at the beginning of the procedure  600  the endoscopic device  800  has been maneuvered into position to initiate deployment of an ablation device  815 . It is to be appreciated that in this exemplary procedure  600  the steerable endoscopic device  800  has been maneuvered to the initial deployment point by tracing out a desired deployment or treatment pathway about the pulmonary veins. While illustrated with regard to the pulmonary veins for purposes of the discussion of procedure  600 , the utilization of the steerable endoscope is not so limited and may be used to trace out desired treatment pathways about organs, tissues and body portions as desired.  FIG. 8A  also illustrates the ablation device  815  distal end is attached to the heart using any of the attachment methods described in this application or known to those of ordinary skill in the art. 
     Next, in  FIGS. 8B and 8C , the steerable endoscope  800  is withdrawn proximally along the pathway leaving behind the ablation device  815 . Finally, in  FIG. 8D , the ablation device  815  is completely deployed about the pulmonary veins in the desired deployment pathway created by the steerable endoscope  800 . At this point a number of options are available in procedure  600 . The endoscope  800  may be withdrawn during the treatment that utilizes the ablation device  815 . The endoscope  800  may be utilized to visually inspect the position and orientation of each ablation element distributed along the ablation device  815  in those embodiments where the ablation device  815  comprises a plurality of ablation elements. In this illustrated embodiment, the ablation device  815  has been illustrated as a single ablation element for ease of illustration. The endoscope may also be utilized to ensure the ablation device  815  has been properly deployed into the desired position to facilitate treatment. In addition, the endoscope may be utilized to visually inspect any fasteners or other adhesives or affixing means used to maintain the position of the ablation device  815  relative to the pulmonary veins. 
       FIG. 9  shows an embodiment of a treatment device having a plurality of fasteners to facilitate contact between the treatment device and the surrounding tissue. An endoscopic device  900  has a controllable, steerable end  905  positioned to deploy or facilitate the deployment of an ablation device  915 . The ablation device  915  has a plurality of ablation elements  920 . The ablation device  915  also has a plurality of fasteners  925  to increase the contact between the ablation device  915  and the surrounding tissue, organ or body portion to facilitate ablation therapy. Note the position of the fasteners  925  relative to the ablation elements  920  to provide maximum contact between and to ensure the location of the ablation elements  920  relative to the surrounding tissue. The fasteners  925  may be in other positions and may also be of other configurations and type described elsewhere in this application and/or as known to those of ordinary skill in the art. 
     In another embodiment of the steerable endoscope  900 , the fasteners  925  could be configured such that as the steerable tip  905  is withdrawn proximally, the fastener  925  engages the surrounding tissue to secure the position of the ablation device  915 . Once the ablation device  915  is positioned, the ablation treatment proceeds as desired. When the ablation treatment is complete, the steerable endoscope  900  is advances proximally from the distal end of the ablation device  915 . As the steerable endoscope tip  905  advances distally past a fastener  925 , the fasteners  925  along with the ablation device  915  are withdrawn into the steerable endoscope  900 . It is to be appreciated that any of a wide variety of fasteners may be utilized to engage with the surrounding tissue. For example, the fasteners  925  could be formed from superelastic or shape memory alloy material. The properties of the shape memory alloy material could be selected such that the thermal energy of the body temperature is used to engage the fastener with the surrounding tissue. Alternatively, the shape memory alloy fasteners could be selectively actuated to release the shape memory effect to engage with the surrounding tissue. Engagement with the tissue includes fasteners that do not break the surface of the tissue as well as fasteners that do break the surface of the tissue. While some fasteners may disengage from the surrounding tissue through the movement of the steerable endoscope, it is to be appreciated that a tool or element may be present on or in the distal end of the endoscope  900  to facilitate the disengagement of the fastener from the surrounding tissue. 
       FIGS. 10A and 10B  show additional examples of the endoscopic device advanced about the posterior region of a heart to facilitate treatment of a supraventricular tachycardia ( FIG. 10A ) and a combination of supraventricular and ventricular tachycardia ( FIG. 10B ). In a specific example,  FIG. 10A  shows another variation  600  of treating atrial fibrillation where the device may be steered and configured to loop in a continuous manner about the pulmonary vessels in a first encirclement  602  over the left pulmonary vessels LPV and a second encirclement  604  over the right pulmonary vessels RPV. The encircled portions  602 ,  604  of the endo scope  212  may be activated to ablate the heart tissue only around the pulmonary vessels LPV, RPV or alternatively, it may be activated to ablate the heart tissue along the entire length of both distal portion  214  and proximal portion  216 . Moreover, a variety of ablation devices may be delivered to the desired areas, as described above. 
     In another specific example,  FIG. 10B  shows another variation  650  of treating atrial fibrillation where the device may be steered and configured to loop in a continuous manner about the pulmonary vessels in a first encirclement  602  over the left pulmonary vessels LPV and a second encirclement  652  over the right pulmonary vessels RPV and then across a portion of the ventricle ( 654 ). The encircled portions  602 ,  652 ,  654  of the endoscope  212  may be activated to ablate the heart tissue around the pulmonary vessels LPV, RPV and the ventricular portion adjacent  654 . Alternatively, it may be activated to ablate the heart tissue along the entire length of both distal portion  214  and proximal portion  216 . Moreover, a variety of ablation devices may be delivered to the desired areas, as described above. 
       FIG. 11  shows yet another example of a treatment for atrial fibrillation using the endoscopic device. In a specific embodiment,  FIG. 11  shows yet another variation  700  in which the endoscope  216  may be advanced and steered to contact the portions of tissue posteriorly adjacent to the pulmonary vessels LPV, RPV such that an encircled region is formed  702 . As illustrated, embodiments of the steerable endoscope of the present invention may be positioned about a portion of the coronary vasculature or other coronary landmarks to facilitate treatments of the heart. In this specific example, the endoscope  216  has been maneuvered using the techniques described herein into a position interior and adjacent the pulmonary veins and extended towards the inferior vena cava. The extreme configurability and controllability of the space and position of steerable endoscopes of the present invention enable placement of therapeutic devices, elements and systems about the heart and elsewhere within the body to facilitate treatment. 
       FIGS. 12A and 12D  illustrate additional alternative embodiments of steerable endoscopic devices of the present invention advanced about the posterior region of a heart to facilitate treatment of a supraventricular tachycardia and/or combinations of supraventricular and ventricular tachycardia. As described above with regard to  FIGS. 10A and 10B , the left pulmonary veins (LPV) and right pulmonary veins (RPV) are used as landmarks for purposes of illustration and discussion and not limitation.  FIG. 12A  illustrates an endoscopic device  1200  positioned about both the LPV and RPV and encircling one of the LPV and then proceeding anteriorly across a ventricular portion of the heart  1205 .  FIG. 12B  illustrates an endoscopic device  1200  positioned about both the LPV and RPV and encircling one of the LPV and then proceeding laterally across a ventricular portion of the heart  1210 .  FIG. 12C  illustrates an endoscopic device  1200  positioned about both the LPV and RPV, partially encircling the LPV and then proceeding anteriorly across a ventricular portion of the heart  1205 .  FIG. 12D  illustrates an embodiment of the present invention where two endoscopic devices  1250  and  1260  are utilized to facilitate an ablation therapy. The first steerable endoscopic device  1250  is positioned laterally across the heart and partially encircling a LPV and a RPV. The second endoscopic device  1260  is positioned adjacent a LPV, encircling a RPV and then proceeding anteriorly across a ventricular surface of the heart  1205 . It is to be appreciated that the first steerable endoscope  1250  may be used to facilitate a first ablation therapy at the same time, subsequent to or in a sequence with a second ablation therapy facilitated by the second steerable endoscope  1260 . As these illustrative embodiments demonstrate, the steerable endoscopes of the present invention may be deployed in a wide variety of circumstances to facilitate an ablation therapy. 
       FIG. 13  shows an embodiment of a dual, steerable endoscope  1300  of the present invention utilized to facilitate treatment of the heart. The dual steerable endoscope  1300  includes a first steerable endoscope  1305  and a second steerable endoscope  1310  disposed within the first steerable endoscope  1305 . In one embodiment, both endoscopes  1305 ,  1310  are articulated to an initial condition (I). Thereafter, the second endoscope  1310  proceeds along the pathway (a) through (i) to encircle the LPV, RPV and then proceed across a ventricular portion of the heart. The second endoscope  1310  may proceed along the pathway under control of a user. Alternatively, the second endoscope  1310  may proceed along the pathway by automatically deploying based upon any or a combination of pre-surgical planning imagery, real time imagery, mapping system receiving inputs from a detection or tracking system. In another alternative, the second endoscope  1310  proceeds using a combination of automatic controls and user input. 
     While described above in an application for treating the heart, it is to be appreciated that the first and second steerable endoscopes may be utilized to access portions of the neurovasculature, and other regions by maintaining the size of the second steerable endoscope to be much less than the size of the first endoscope. For example, the first endoscope may positioned in a first position, affixed in that position to act as a stable platform and/or datum for the second steerable endoscope. From that stable base, the second endoscope may be deployed to facilitate treatments. 
       FIGS. 14A to 14C  shows side and end views, respectively, of various electrode configurations on the endoscope for tissue ablation treatment. The endoscope  900  may be configured with a number of elements, devices or systems to facilitate treatment. In one specific embodiment, a steerable endoscope of the present invention may have a plurality of electrodes disposed along its outer surface to facilitate the tissue ablation along the length, or selected regions of length, of the endoscope, as shown as described herein. The figure shows the steerable distal portion  904  and part of the automatically controllable proximal portion  902  as one example of electrode placement over the endoscope  900 . As seen, one or any number of electrodes  906  may be circumferentially positioned, e.g., ring-shaped, along the length of endoscope  900  at intervals. The electrodes  906  are shown positioned at uniform intervals in this variation; however, they may be configured in any random, arbitrary, or specified locations over the outer surface of the endoscope  900 . Each of the electrodes  906  may be electrically connected via corresponding wires  908  to a power supply and/or controller. Thus, all the electrodes  906  may be configured to operate simultaneously or to operate only selected electrodes  906  which may be in contact with tissue. In yet another variation, various ablation devices may be delivered to the desired areas, again as described above. 
       FIG. 14B  shows another variation in endoscope  910  in which electrodes  916  may be configured to extend longitudinally over the proximal portion  912  and/or distal portion  914 . The electrodes may be configured to extend in a continuous strip along the endo scope length or the electrodes  916  may be alternatively configured to extend in a segmented manner longitudinally over the endoscope  910 , as shown. Having segmented electrodes  916  may allow for selected electrodes to be activated during tissue ablation. Although  FIG. 14B  shows a single line of electrodes  916  for illustration purposes, multiple lines of electrodes may be positioned over the outer surface of the device, as shown in the example of  FIG. 14C , which illustrates multiple lines of electrodes  918  spaced uniformly around the circumference of the endoscope surface. 
     These examples described above are intended to be illustrative and are not intended to be limiting. Any number of other configurations may be accomplished with the endoscopic device due to the ability of the device to steer and configure itself such that excessive contact with surrounding tissue is avoided. Moreover, access to any number of various regions within the thoracic cavity with minimal or no damage to surrounding tissue and organs may be accomplished using the controllable endoscopic device above. Other examples for treatment using the endoscope may include, but not limited to, lead placement, implantable device placement, treatment on the lungs such as emphysema treatments, etc. 
     Depending upon the treatment being facilitated, it may be advantageous to increase the degree of contact or ensure the position between the treatment tool, element, or device and the tissue, organ or portion of the body receiving the treatment. Examples of means for increasing contact or affixing the position of a treatment device include: biocompatible adhesives, glues and gels either alone or in combination with staples, suction, wires, barbed and barb-less hooks or hook shaped to loop around specific anatomy. One example of a hook shaped to loop around specific anatomy includes J-shaped hooks to loop, at least partially, about the coronary vasculature. For example, a J-shaped hook may be shaped and configured to at least partially encircle a pulmonary vein. In another example, wires, staples or other fastening components may be formed from shape memory alloy material such as, nitinol or other suitable, biocompatible shape memory alloy material. The shape memory alloy fastener could be held in a first or stowed condition while navigating to the site prior to facilitating treatment. Once the treatment device is positioned, the shape memory alloy fastener could be activated and use the shape memory effect to affix the treatment device into the desired position. 
     In another embodiment, a steerable endoscope having a magnetic portion could be deployed about the tissue, organ or region of the body to facilitate treatment. Thereafter, the steerable endoscope could be used as a guide for the placement of an ablation system. Permanent magnets or electromagnets could be used to magnetically couple the ablation system in a desired position adjacent the steerable endoscope. Once the treatment was completed, the magnetic field is broken and the ablation system and steerable endoscope withdrawn. 
     In another embodiment, the steerable endoscope itself may be looped around the organ, tissue or portion of the body to undergo treatment and then secured to itself in order to facilitate treatment. Alternatively, the distal end of the endoscope could be anchored with a dissolvable suture or other dissolvable biodegradable fastener that remains in place after the ablation treatment is completed and is then absorbed into the tissue or dissolves. 
     In addition, an array of needles may be configured along the length or a portion of the length of the ablation device or steerable endoscope or both. In one embodiment, an array of conductive needles are arranged to improve contact between an RF ablation based delivery system and the tissue undergoing treatment. In addition to needle arrays, other suitable elements may be employed to improve the effectiveness of other ablation modalities. It is to be appreciated therefore that while needle arrays are described as increasing the effectiveness of the delivery of RF ablation energy, other elements and configurations may be used to increase the effectiveness of other ablation therapy modalities. Alternatively, for non-energy based ablation, such as ablation techniques that use lacerations of the tissue, then the elements could be any suitable device for cutting or otherwise altering the tissue to achieve a therapeutic affect. 
       FIGS. 15A and 15B  show an embodiment of a needle array in a retracted ( FIG. 15A ) and a deployed ( FIG. 15B ) configuration. A portion of a steerable endoscope or ablation element  1500  is shown in cross section. Ablation needles  1505 ,  1510  are attached to backing plate  1515 . The needles are maintained in the stowed configuration ( FIG. 15A ) with the backing plate retracted to reduce the risk of inadvertent tissue damage as the steerable endoscope or ablation system is advanced to the treatment site. In the stowed configuration, the needles  1505 ,  1510  remain below the steerable endoscope or ablation element exterior surface  1502 . Once in position, the backing plate  1515  is advanced to the deployed condition ( FIG. 15B ). In the deployed position, the needles  1505 ,  1510  protrude beyond the steerable endoscope or ablation element exterior surface  1502 . When positioned in the body for treatment, the needles  1505 ,  1510  would make suitable contact with the surrounding tissue, organ or body portion to facilitate treatment. 
     It is to be appreciated that the backing plate may be moved between the retracted and deployed configuration utilizing any of a number of techniques. Examples of such techniques and methods include mechanical drives, hydraulics, motors, actuators, permanent magnets, electromagnets, spring loaded actuators, vacuum, or other conventional actuation means. Alternatively, the actuation means could be any suitable actuation force capable of displacing the backing plate  1515  to urge a portion or all of a needle array from a retracted position into a deployed position and hence into suitable contact with the organ, tissue or body portion to receive treatment. 
     In an alternative embodiment, the backing plate  1515  could be continuously biased outwardly, here, outwardly indicates a position where the needles would move into a deployed configuration. The ablation element or steerable endoscope having the needle array could be covered with a moveable sheath. Once the ablation element or moveable endoscope is in the desired position, the sheath is retracted releasing the backing plate bias and allowing the needles to move into a deployed configuration. 
     The illustrated embodiment illustrates a pair of needles in cross section. There may be additional needles arranged adjacent and similarly disposed as the needles  1505 ,  1510 . The additional needles may be, for example, arrayed in a regular continuous pattern as in  FIG. 16 . Alternatively, a single needle or array on continuous, discontinuous or random arrangement of needles may be used. In other configurations, more than teo needles may be used. The illustrated needles  1505 ,  1510  have a separation angle ϕ 1 . The separation angle may vary from 0 to 180 degrees in one embodiment, from 0 to 70 degrees in another embodiment or from 0-30 degrees in yet another embodiment depending upon application. In multiple needle applications (i.e., needle arrays having two or more separation angles), the needles may have a regular separation angle meaning that the needles are at regular angular intervals. Alternatively, the needles in a multiple needle configuration may be placed in non-regular or variable separation angles. 
     In addition to the angular placement of the needles in a needle array, the spacing between needles may also be continuous or variable. The needles may be arranged into a single continuous segment with uniform spacing. Such a uniform array of needles is illustrated in  FIG. 16 . The ablation element or steerable endoscope section configured for ablation  1600  is shown in  FIG. 16 . Needles  1610  are shown in a single segment or grouping of needles  1605 . 
       FIG. 17  shows an embodiment of a needle array segment  1700  having three sections ( 1705 ,  1710  and  1715 ) showing a variety of needle spacing configurations. The needle array segment  1700  illustrates how a nearly limitless variety of spacing configurations may be combined to obtain a desired needle array configuration to facilitate an ablation treatment. Section  1705  includes an upper array of needles  1726 ,  1728  and  1730  aligned in a continuous uniform fashion above a lower array of needles  1720 ,  1722  and  1724 . This configuration is similar to section  1600  in  FIG. 16 . Like section  1705 ; the upper array of section  1710  has evenly spaced needles  1732 ,  1734  and  1736 . The lower array of needles have only one needle aligned to the upper array. Needle  1738  is aligned with needle  1732 . There is no needle in the lower array that corresponds to needle  1736 . A plurality of needles ( 1740 ,  1741  and  1742 ) are spaced across from upper array needle  1734 . The section  1710  illustrates how there may be needle to needle correspondence ( 1732 ,  1738 ), no correspondence ( 1736 ) or one to many correspondence ( 1734 ,  1740 ,  1741 ,  1742 ) between the needles in the upper and lower arrays of a section. 
     Section  1715  further illustrates the configurability of the needle arrangements. Both the upper needles  1750 ,  1752 ,  1754   1756  and lower needles  1766 ,  1768 ,  1770 ,  1771 ,  1772 ,  1773  illustrate variable spacing. In addition, there is no alignment between the upper and lower arrays. In addition, section  1715  illustrates a middle array having upper needles  1758 ,  1760  spaced apart from lower needles  1762 ,  1764 . In the illustrated embodiment, the upper and lower needles are aligned but that need not be the case in all embodiments. Additionally, the middle array is illustrated without alignment to the upper array and the lower array. This need not be the case in all embodiments. In some embodiments, the middle array may be aligned with all or part of either a lower or an upper array. Accordingly, a needle pattern within a section could be predetermined and selected to facilitate a desired ablation treatment. Moreover, using pre-surgical planning techniques, the type, number, amount and ablation pattern could be predetermined and an appropriate combination of segments, sections and needles arrays could be loaded into a steerable endoscope or otherwise delivered utilizing a steerable endoscope to facilitate treatment. 
       FIGS. 18A and 18B  show a side and isometric view of an embodiment of a tunable treatment device of the present invention. The tunable treatment device  1800  includes an ablation element  1810  within a housing  1805 . The housing  1805  also includes an opening  1815  that allows the energy generated by the ablation element  1810  to pass outside of the housing. The opening  1815  is fitted with a cover  1820  that forms a seal between the environment the tunable treatment device  1800  is positioned in and the interior of the housing  1805 . In one embodiment, the housing  1805  is made of a first material and the cover  1820  is made of a second material. With respect to the energy generated or provided by the ablation element  1810 , the first material transmits less of the energy generated by the ablation element  1810  than the second material. In another embodiment, the first material acts as a shield separating the ablation energy generated by the ablation element and the surrounding environment. The second material acts as a transmission window or opening in an otherwise shielded housing. The transmission window or opening thus allows energy provided by the ablation element to be selectively passed via the opening into the tissue, organ or environment positioned adjacent the cover  1820 . Thus, the advantageous combination of shielding and openings allow for more precise delivery of the ablation energy to the desired tissue, organ or location while shielding the surrounding area from the ablation energy. 
     The tunable ablation delivery device  1800  is also provided with a detector  1830  for detecting a physiological indication useful in administering the ablation therapy. The detector  1830  may comprise a plurality of detection elements arrayed about the housing  1805 . In the illustrated embodiment, the detector  1830  includes a plurality of detection elements  1835 . The detection elements  1835  are arranged at regular intervals about the perimeter of the housing  1805 . A reading may be obtained from each element and then analyzed to determine which element or elements obtained the best reading for the physiological parameter being measured. Once that determination is made, the tunable ablation device  1800  may then be oriented to place the opening  1815  into position to facilitate ablation treatment. 
     In one specific example, the tunable ablation delivery device  1800  may be modified to facilitate an ablation treatment on the pericardium of the heart. In this example, the detection elements  1835  may be elements capable of detecting electrophysiological (EP) activity. For example, the detection elements  1835  could detect electrophysiological (EP) activity by detecting ECG activity. An example of the readings and/or signal strength obtained by each detector  1835  is illustrated in  FIG. 19 .  FIG. 19  shows a graph illustrating a technique to optimize placement of a tunable ablation device to facilitate therapy. Using conventional software, hardware and optimization techniques, the detection elements  1835  may be used to localize the position, relative to the housing  1805 , where the desired amount of physiological indication occurs. In the graph  1900  the desired activity is the peak EP activity. According to the graph  1900 , the peak EP activity occurs in proximity to sensor position  5 . This information can then be used by the control system that articulates, rotates, translates or otherwise positions the tunable ablation element  1800  to position the tunable ablation element  1800  into a position that facilitates an ablation treatment in the vicinity of sensor  5 . In the specific embodiment illustrated in  FIGS. 18A and 18B , the tunable ablation device  1800  would be rotated under the control of a control system having the relative position and orientation of the plurality of elements  1835  and the opening  1815  and ablation element  1810 . The tunable ablation device  1800  would be rotated under the control of a control system using for example, the engagement element  1845 , to align the opening  1815  and/or cover  1820  into the orientation of sensor  5 . 
     An example of how a plurality of tunable ablation elements may be advantageously deployed to increase the effectiveness of an ablation therapy will now be described with reference to  FIGS. 18C and 18D . Three tunable ablation elements  1800 A,  1800 B and  1800 C are positioned within a steerable endoscope  212  of the present invention. In  FIG. 18C  the three ablation elements have reached the deployment point for ablation element  1800 A. Note that in the initial position before optimizing any of the tunable ablation elements  1800 A, B or C, the windows  1820  are aligned. As described above the detectors  1830  on ablation element  1800 A are used to improve the effectiveness of the ablation element within the tunable ablation element  1800 A by indicating a desired position for applying the ablation therapy. As shown in  FIG. 18B , the determined position of the element  1800 A is when the window  1820  rotated into a slightly upward position from the initial position. Additionally, the mechanical linkage  1845  has been disengaged so that the control cable/component  1880  no longer rotates the element  1800 A. In addition, the fixation elements for element  1800 A have been omitted for clarity but have engaged to fix the position of element  1800 A.  FIG. 18D  also illustrates how the controller cable/component  1880  has utilized the detector  1830  onboard element  1800 B to optimize the position of the window  1820 . Note that the window  1820  for element  1800 B is rotated downward. At this point, the fixation elements for element  1800 B are engaged to fix the position of the element  1800 B. Thereafter, the linkage  1845  for element  1800 B is released so that element  1800 C may be positioned and then optimized as described herein for elements  1800 A and  1800 B. Accordingly, there are configurations of the tunable ablation elements where the windows of adjacent ablation elements are not in alignment but rather reflect an alignment of localized optimization for that ablation element. 
     In an alternative embodiment, the detector for detecting a physiological indication could also be a single detector. The single detector could be actuated to move about the surface of the tunable ablation delivery device  1800  measuring the indication. The obtained measurements could then be used to assist in positioning the ablation element  1810  and opening  1815  to facilitate treatment. In one specific embodiment, the single detector could move about the perimeter of the tunable ablation device and provide strength of indication relative to position information similar to  FIG. 19 . 
     A securing member  1840  is also provided to hold the tunable ablation device  1800  in the desired position during the readings from the indicator elements  1835 , or after rotation of the ablation device into the desired position for facilitating treatment. In the illustrated embodiment, the securing member  1840  may be a vacuum manifold  1855  having a plurality of suction ports  1860 . In a preferred embodiment, the securing means is releasable from the surrounding tissue, organ or region of interest to facilitate movement to align the ablation element for treatment or for easy removal once the treatment is complete. 
     The endoscope device may also be utilized for procedures within the peritoneal cavity. Potential applications may include minimally invasive surgery for urologic, bariatric, and liver surgery. Moreover, minimally invasive access may be achieved for treatments in spinal or orthopedic surgery as well.  FIG. 20  shows an example of a procedure  2000  within the peritoneal cavity which may be performed with the endoscopic device.  FIG. 20  shows an example of a procedure  2000  within the peritoneal cavity using the endoscopic device  212 . The endoscope  212  may be introduced into patient  2002  through an incision  2008  via a port, which may also function as a datum  2006 , as described above. The distal portion  214  may be steered to avoid various organs while being  2004 . The distal portion  214  of the endoscope  212  may accordingly be steered while the proximal portion  216  may be automatically controlled to follow a path defined by the distal portion  214  which minimizes contact with the surrounding and adjacent tissue and organs. One or more laparoscopes  2010  may optionally be used in combination with the endoscope  212  to assist with the surgical procedure. Once the distal portion  214  is posteriorly positioned of the liver  2004 , various tools or treatment devices may be advanced through the endoscope  212  from the proximal end to effect the desired treatment. Although this example shows treatment of the liver  2004  using the endoscope  212 , this is intended to be illustrative of other organs or procedures that may be effectively treated utilizing embodiments of the endoscope  212 . 
     As the above discussion illustrates, steerable endoscopic systems of the present invention may be advantageously utilized to facilitate a wide variety of procedures. When utilized to facilitate an ablation therapy, the ablation element, device or system may be part of the segmented steerable endoscope, deployed within a working channel or other passage created by the steerable endoscope, or a combination of fixed and moveable treatment elements, device or systems. Accordingly, steerable endoscopes of the present invention may, in one embodiment, facilitate treatment by deploying an ablation element, device or system affixed to the endoscope to a treatment location in a treatment position. The endoscope remains in place during the treatment and, when complete, retracts from the treatment position. 
     In another variation, the steerable endoscope is utilized to deploy and/or inspect the placement of a treatment device, is then withdrawn while the treatment proceeds. Thereafter, the steerable endoscope retrieves the treatment device. In yet another variation, the steerable endoscope may be inserted into a treatment area into a desired treatment pathway. Next, the steerable endoscope is retracted to leave the treatment device in place along the desired treatment pathway. The steerable endoscope may remain in place for visualization of the treatment as it proceeds, monitor a physiological indication or otherwise support the treatment. Alternatively, the steerable endoscope may withdraw from the treatment area or completely from the body. After the treatment is complete, the steerable endoscope may be advanced along the treatment device to remove/store the treatment device as the endoscope proceeds distally along the treatment device. Once the treatment device has been collected into the endoscope, the endoscope is withdrawn. Accordingly, there have been shown various ways to position a treatment element, device or system within a body, affix or otherwise maintain the position of the treatment device relative to the area or areas of treatment to increase the effectiveness of the treatment or therapy being performed. 
     Separately or in combination with the techniques described above, various imaging and control systems may be used to facilitate control of the steerable endoscope. For example, the steerable endoscope may proceed along and envelope a deployed treatment device utilizing a recorded pathway to retrace steps used to place the treatment device. The steerable endoscope may also track a way point set to indicate the next fastener where the fastener is in a preprogrammed position, in a position identifiable using an imaging system or the fastener is otherwise configured for easy identification, such as through use of an RPID, for example. The steerable endoscope may also use an imaging system for guidance in recovering a treatment device. The steerable endoscope may also utilize fly by wire techniques to fly by wire using the treatment device as the wire. In yet another embodiment, the treatment device could be automatically withdrawn into the steerable endoscope using mapping, imaging or other system controls to retrace track or otherwise dislodge or disengage the treatment device from the internal position to perform a treatment. 
     Embodiments of the present invention may also include tools, devices or systems to pierce, lacerate, cut, puncture, or otherwise provide a passage or controlled perforation of tissue to allow access of the steerable, guided endoscope into the region of interest. In a neurological application for accessing the brain, such a device would be suited for creating a suitable opening in the dura for example. In a cardiovascular application for accessing the heart, such a device would be suited for creating a suitable opening in the pericardium for example. The tools, devices or systems to pierce, lacerate, cut, puncture, or otherwise provide a passage or controlled perforation to enable passage of the endoscope may be disposed permanently on the distal end of the scope. Alternatively, the tools, devices or systems may be mounted on the distal end of the endoscope but be positionable between a retracted and extended position to help minimize the risk of inadvertent damage while the endoscope is moving within the body to the region of interest. In another alternative, the tools, devices or systems may be provided conventionally via a working channel in the endoscope. Examples of the tools, devices or systems include scissors, electrocautery devices and systems, small snips, shaped blades and shaped tips. 
     While embodiments of the present invention have been shown and described as dispensing treatment within the brain, cranial interior, the interior of the heart, the exterior of the heart, it is to be appreciated that embodiments of the methods and apparatus of the present invention may be used in other applications as well. For example, embodiments of the invention may be used to facilitate treatment of disorders of other organs and portions of the body, for example, the stomach, the gastrointestinal tract, the esophagus, the bladder, the liver, the kidneys and the lungs. Additionally, embodiments of the present invention may be used to facilitate treatment of localized disorders within the body, portions of the body or a disorder of a physiological system. 
     The applications of the devices and methods discussed above are not limited to regions of the body but may include any number of further treatment applications. Other treatment sites may include other areas or regions of the body. Additionally, the present invention may be used in other industrial and commercial environments such as exploratory procedures on piping systems, ducts, internal inspection of mechanical systems including automotive, aeronautical, aerospace, and marine systems and equipment, etc. Modification of the above-described assemblies and methods for carrying out the invention, and variations of aspects of the invention that are obvious to those of skill in the art are attended to within the scope of the claims.