Abstract:
A method of performing a medical procedure on a patient comprises conveying control signals from a remote controller to a drive unit, intraluminally introducing a first medical instrument within the patient, extraluminally introducing a second medical instrument within the patient, and operating the drive unit in accordance with the control signals to actuate a first tool on the first medical instrument and a second tool on the second medical instrument, in unison, to perform the medical procedure at a target region within an anatomical vessel. In one method, the control signals are conveyed from the remote controller to the drive unit in response to user commands, which may be movements made at a user interface that correspond to movements of the medical instrument.

Description:
RELATED APPLICATIONS  
       [0001]     This application is a continuation of U.S. application Ser. No. 0/639,785, filed Aug. 12, 2003, which claims benefit of priority from U.S. Application Ser. No. 60/403,621, filed Aug. 14, 2002. This application is also related to U.S. application Ser. No. xx/xxx,xxx (Attorney Docket No. HNMD-EA005 CON1), U.S. application Ser. No. xx/xxx,xxx (Attorney Docket No. HNMD-EA005 CON2), U.S. application Ser. No. xx/xxx,xxx (Attorney Docket No. HNMD-EA005 CON3), U.S. application Ser. No. xx/xxx,xxx (Attorney Docket No. HNMD-EA005 CON4), and U.S. application Ser. No. xx/xxx,xxx (Attorney Docket No. HNMD-EA005 CON5), all of which are filed on the same date herewith. The entire disclosures of the above applications are expressly incorporated herein by reference. 
     
    
     BACKGROUND OF THE INVENTION  
       [0002]     Robotically controlled surgical instruments are usually controlled from a master station at which a surgeon or other medical practitioner is situated. The master station may include one or more input devices manipulated by the user for, in turn, controlling, at an operative site, respective instruments used in performing a surgical procedure or application.  
       SUMMARY OF THE INVENTION  
       [0003]     In accordance with the present inventions, a method of performing a medical procedure on a patient is provided. The method comprises conveying control signals from a remote controller to a drive unit. The method further comprises intraluminally introducing a first medical instrument within the patient, and extraluminally introducing a second medical instrument within the patient. The first medical instrument may be introduced within the patient through a natural body orifice or percutaneously, and the second medical instrument may be introduced within the patient through a surgical opening or laparoscopically. The method further comprises operating the drive unit in accordance with the control signals to actuate a first tool on the first medical instrument and a second tool on the second medical instrument, in unison, to perform the medical procedure at a target region within an anatomical vessel.  
         [0004]     If the medical procedure is a surgical procedure (e.g., a suturing procedure or sewing procedure), each of the tools may be a surgical tool. In one method, the control signals are conveyed from the remote controller to the drive unit in response to user commands, which may be movements made at a user interface that correspond to movements of the medical instrument. In another method, the first and second medical instruments are introduced into the patient by operating the drive unit in accordance with the control signals.  
         [0005]     In one example, the target region is located in a bowel, in which case, the medical procedure may comprise repairing a bowel wall defect. In another example, the target region is located in a stomach, in which case, the medical procedure may comprise treating a gastric ulcer. In still another example, the target region is located in a urinary bladder. The target region may be a sphincter (e.g., one located at the base of a ureter or at a gastro-esophageal junction), in which case, the medical procedure may comprise constricting the sphincter. The medical procedure may, e.g., comprise securing a stent to an anatomical vessel or transversely securing a first anatomical vessel to a sidewall of a second anatomical vessel.  
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0006]     The foregoing and other objects, features and advantages of the invention will be apparent from the following more particular description of preferred embodiments of the invention, as illustrated in the accompanying drawings in which like reference characters refer to the same parts throughout the different views. The drawings are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the invention.  
         [0007]      FIG. 1  is a perspective view of one embodiment of a robotic surgical system in which the principles of the present invention are applied;  
         [0008]      FIG. 2  schematically illustrates a surgical procedure using intralumenal and extralumenal instruments, one flexible and one rigid;  
         [0009]      FIG. 3  illustrates respective end effectors of rigid and flexible instruments used in performing a suturing procedure at a wall of a lumen;  
         [0010]      FIG. 3A  shows a next step in the suturing process with the needle having punctured the anatomic wall;  
         [0011]      FIG. 3B  shows still another suturing step with the suture being pulled through the wall, and further illustrating the placement of a viewing endoscope attached internally;  
         [0012]      FIG. 3C  is a schematic illustration of dual end effectors used in a sewing technique for attaching vessel segments together;  
         [0013]      FIG. 3D  illustrates the completion of the sewing technique of  FIG. 3C ;  
         [0014]      FIG. 3E  illustrates a surgical procedure in the stomach using dual instruments, a flexible instrument passing into the stomach and either a rigid or flexible instrument outside the stomach wall;  
         [0015]      FIG. 3F  schematically shows the end of the sewing or suturing technique at the stomach wall;  
         [0016]      FIG. 3G  illustrates the dual instruments used for securing or re-securing an internal object such as a stent in an artery, vein, or other anatomic lumen or vessel;  
         [0017]      FIG. 3H  illustrates a first step in a procedure for attaching one vessel to another such as in bypass surgery;  
         [0018]      FIG. 3I  illustrates a second step in a procedure for attaching one vessel to another;  
         [0019]      FIG. 3J  illustrates a third step in a procedure for attaching one vessel to another;  
         [0020]      FIG. 3K  shows the use of dual instruments in a bladder procedure;  
         [0021]      FIG. 3L  illustrates the use of dual instruments in a stomach procedure;  
         [0022]      FIG. 4  is an exploded perspective view of another version of the cable drive mechanism and tool in accordance with the present invention;  
         [0023]      FIG. 5  is a top plan view of the instrument insert itself;  
         [0024]      FIG. 6  is a perspective view of another embodiment of the present invention;  
         [0025]      FIG. 7  is an enlarged detail perspective view of the tool;  
         [0026]      FIG. 8  is a perspective view at the tool;  
         [0027]      FIG. 9  is a side elevation view of the needle driver;  
         [0028]      FIG. 10  is a perspective view of an embodiment of a flexible or bendable wrist just proximal to the tool;  
         [0029]      FIGS. 11-14  illustrate different end effector constructions that may be used with either flexible or rigid instruments;  
         [0030]      FIG. 15  is a perspective view at the slave station of the system of  FIG. 1  illustrating the interchangeable instrument concepts;  
         [0031]      FIG. 16  is a cross-sectional view through the storage chamber and as taken along line  16 - 16  of  FIG. 15 ;  
         [0032]      FIG. 17  is a longitudinal cross-sectional view, as taken along line  17 - 17  of  FIG. 15 , and showing both a stored articulating instrument and a stored fluid dispensing;  
         [0033]      FIG. 18  is schematic diagram of the instrument systems of the present invention as deployed through the urethra for a surgical procedure in the bladder;  
         [0034]      FIG. 19  gives further details of the bladder procedures of  FIG. 18 ; and  
         [0035]      FIG. 20  illustrates still another concept using a single controllable instrument. 
     
    
     DETAILED DESCRIPTION OF THE INVENTION  
       [0036]     A description of preferred embodiments of the invention follows.  
         [0037]      FIG. 1  is a perspective view of one embodiment of a robotic surgical system in which the principles of the present invention are applied.  FIG. 1  illustrates a surgical instrument system  10  that includes a master M at which a surgeon  2  manipulates an input device, and a slave station S at which is disposed a surgical instrument. In  FIG. 1  the input device is illustrated at  3  being manipulated by the hand or hands of the surgeon. The surgeon is illustrated as seated in a comfortable chair  4 . The forearms of the surgeon are typically resting upon armrests  5 .  
         [0038]      FIG. 1  illustrates a master assembly  7  associated with the master station M and a slave assembly  8  associated with the slave station S. Assembly  8  may also be referred to as a drive unit. Assemblies  7  and  8  are interconnected by means of cabling  6  with a controller  9 . As illustrated in  FIG. 1 , controller  9  typically has associated therewith one or more displays and a keyboard. Reference is also made to, for example, the aforementioned U.S. Ser. No. 10/014,143, for further detailed descriptions of the robotic and computer controller operation and associated operating algorithm.  
         [0039]     As noted in  FIG. 1 , the drive unit  8  is remote from the operative site and is preferably positioned a distance away from the sterile field. The drive unit  8  is controlled by a computer system, part of the controller  9 . The master station M may also be referred to as a user interface vis—vis the controller  9 . Commands issued at the user interface are translated by the computer into an electronically driven motion in the drive unit  8 . The surgical instrument, which is tethered to the drive unit through the cabling connections, produces the desired replicated motion.  FIG. 1 , of course, also illustrates an operating table T upon which the patient P is placed.  
         [0040]      FIG. 1  illustrates both a flexible system and a rigid system. Only one drive unit is depicted it being understood that there is also a drive unit associated with the rigid instrument system such as shown in  FIG. 4 . Each of the drive units is controlled from cabling that couples from the controller. This is electrical cabling that drives corresponding motors in each drive unit.  
         [0041]     Thus, the controller couples between the master station M and the slave station S and is operated in accordance with a computer algorithm. The controller receives a command from the input device  3  and controls the movement of the surgical instrument so as to replicate the input manipulation. The controller may also receive commands from the master station for controlling instrument interchange.  
         [0042]     With further reference to  FIG. 1 , associated with the patient P is the surgical instrument  14 , which in the illustrated embodiment actually comprises two separate instruments one rigid and one flexible, along with an endoscope E. The endoscope includes a camera to remotely view the operative site. The camera may be mounted on the distal end of the instrument insert, or may be positioned away from the site to provide additional perspective on the surgical operation. In certain situations, it may be desirable to provide the endoscope through an opening other than the one used by the rigid surgical instrument. In this regard, in  FIG. 1  three separate ingress locations are shown, two for accommodating the rigid surgical instrument and the endoscope, and the third accommodates the flexible instrument through a natural body orifice. A drape is also shown.  
         [0043]     The viewing endoscope may also be formed integral with the instrument whether it be a rigid instrument or a flexible instrument. The optics and camera may be mounted directly on the distal part of the instrument such as at or adjacent the end effector. In particular, with respect to a flexible instrument the optics and camera may be supported at the distal end of the instrument.  
         [0044]     In  FIG. 1 , as indicated previously two separate instruments are depicted, a rigid instrument system  14  and a flexible instrument system  500 . In the rigid instrument system there is an instrument insert that carries at its distal end an end effector  18 A entering the anatomy through a small incision. This may be for the purpose of providing access to the area about the bowel or bladder, for example. In the flexible instrument system there is a flexible and bendable instrument section terminating at the end effector  500 A, and entering the anatomy, for example, through a natural body orifice such as through the anus in the case of a bowel procedure.  
         [0045]     An end effector is usually associated with each of the instrument systems. In  FIG. 1  this is illustrated by the end effectors  18 A and  500 A. These can take on a variety of different form such as scissors, graspers or needle drivers. Both of the medical instrument members comprise active work elements at respective member working ends and are usually disposed at opposite sides of an anatomic wall. By “active”, reference is made to end effectors that are useable in performing a surgical procedure or application and that are capable of being manipulated from a master station such as from a surgeon controlled input device.  
         [0046]     The instrument system  14  is generally comprised of two basic components, including a surgical adaptor or guide  15  and an instrument insert  16 .  FIG. 1  illustrates the surgical adaptor  15 , which is comprised primarily of the guide tube  24 , but also includes a mechanical interface that interfaces with a corresponding mechanical interface of the instrument itself. In  FIG. 1  the instrument  14  is not clearly illustrated but extends through the guide tube  24 . The instrument  14  carries at its distal end the instrument member or insert. The surgical adaptor  15  is basically a passive mechanical device, driven by the attached cable array.  
         [0047]     In  FIG. 1  there is illustrated cabling that couples from the instrument  14  to the drive unit. The cabling  22  is preferably detachable from the drive unit. Furthermore, the surgical adaptor  15  may be of relatively simple construction. It may thus be designed for particular surgical applications such as abdominal, cardiac, spinal, arthroscopic, sinus, neural, etc. As indicated previously, the instrument  14  couples to the adaptor  15  and essentially provides a means for exchanging the instrument tools. The tools may include, for example, forceps, scissors, needle drivers, electrocautery etc. Other tool interchanges are also shown in further drawings herein.  
         [0048]     Referring still to  FIG. 1 , the surgical system  10  includes a surgeon&#39;s interface  11 , computation system or controller  9 , drive unit  8  and the surgical instrument  14 . The surgical system  10 , as mentioned previously, is comprised of an adaptor or guide  15  and the instrument insert  16 . The system is used by positioning the instrument, which is inserted through the surgical adaptor or guide  15 . During use, a surgeon may manipulate the input device  3  at the surgeon&#39;s interface  11 , to affect desired motion of the distal end of the instrument within the patient. The movement of the handle or hand assembly at input device  3  is interpreted by the controller  9  to control the movement of the guide tube  24 , instrument, and, when an articulating instrument is used, the end effector or tool  18 A. Also, movements at the master station may control instrument exchange.  
         [0049]     The surgical instrument  14 , along with the guide tube  24  is mounted on a rigid post  19  which is illustrated in  FIG. 1  as removably affixed to the surgical table T. This mounting arrangement permits the instrument to remain fixed relative to the patient even if the table is repositioned. As indicated previously, connecting between the surgical instrument  14  and the drive units  8 , are cablings. These include two mechanical cable-in-conduit bundles. These cable bundles may terminate at two connection modules, not illustrated in  FIG. 1 , which removably attach to the rigid instrument drive unit  8 . Although two cable bundles are described here, it is to be understood that more or fewer cable bundles may be used. Also, the drive unit  8  is preferably located outside the sterile field, although it may be draped with a sterile barrier so that it may be operated within the sterile field.  
         [0050]     In the preferred technique for setting up the system, and with reference to  FIG. 1 , the surgical instrument  14  is inserted into the patient through an incision or opening. The instrument  14  is then mounted to the rigid post  19  using a mounting bracket. The cable bundle or bundles are then passed away from the operative area to the drive unit. The connection modules of the cable bundles are then engaged into the drive unit. The separate instrument members of instrument  14  are then selectively passed through the guide tube  24 . This action is in accordance with the interchangeable instrument concepts also described herein.  
         [0051]     The instrument  14  is controlled by the input device  3 , which is be manipulated by the surgeon. Movement of the hand assembly produces proportional movement of the instrument  14  through the coordinating action of the controller  9 . It is typical for the movement of a single hand control to control movement of a single instrument. However,  FIG. 1  shows a second input device that is used to control an additional instrument. Accordingly, in  FIG. 1  two input devices are illustrated and two corresponding instruments. These input devices are usually for left and right hand control by the surgeon. Many other forms of input device control may also be used. For example, instead of finger graspers a joystick arrangement may be used.  
         [0052]     The surgeon&#39;s interface  11  is in electrical communication with the controller  9 . This electrical control is primarily by way of the cabling  6  illustrated in  FIG. 1  coupling from the bottom of the master assembly  7 . Cabling  6  also couples from the controller  9  to the actuation or drive units. This cabling  6  is electrical cabling. Each of the actuation or drive units, however, is in mechanical communication with the corresponding instrument. The mechanical communication with the instrument allows the electromechanical components to be removed from the operative region, and preferably from the sterile field. The surgical instrument provides a number of independent motions, or degrees-of-freedom, when an articulating type instrument such as a tool, gripper, etc. is used. These degrees-of-freedom are provided by both the guide tube  24  and the instrument insert.  
         [0053]      FIG. 1  shows primarily the overall surgical system.  FIGS. 15-17  show further details particularly of the interchangeable instrument concepts as applied to this system. The rigid instrument part of the system is adapted to provide seven degrees-of-freedom when an articulating tool is used such as the tool  18 A shown in  FIG. 1 . Three of the degrees-of-freedom are provided by motions of the adaptor  15 , while four degrees-of-freedom may be provided by motions of the instrument. As will be described in detail later, the adaptor is remotely controllable so that it pivots, translates linearly, and has its guide tube rotate. The instrument insert also rotates (via rotation of the instrument driver), pivots at its wrist, and has two jaw motions at the tool.  
         [0054]     Now, mention has been made of bowel and bladder procedures illustrated schematically in  FIG. 2 . This shows the two separately controlled instruments including rigid instrument system  14  that may be engaged laparoscopically through a small incision, and flexible instrument system  500  that may be engaged through the anus in the case of a bowel procedure or the urethra in the case of a bladder procedure.  FIG. 2  also shows the respective end effectors  18 A and  500 A. These end effectors are shown positioned on either side of an anatomic wall W shown schematically in dotted outline in  FIG. 2 .  
         [0055]     Refer now also to  FIG. 3  for an illustration of further details showing the end effectors  18 A and  500 A positioned to perform a suturing step with a needle  19 A being grasped by the end effector  18 A. The rigid instrument has been passed through a small incision and is positioned outside the vessel wall  20 A. The flexible instrument with end effector  500 A is positioned within the lumen  20 C between walls  20 A and  20 B. The end effector  500 A is shown grasping a tissue at the wall, assisting in the suturing step. In  FIG. 3  both of the instruments include at their distal ends, proximal of the end effectors, bendable sections  18 B and  500 B. Each of these bendable sections or segments is remotely controllable from the master input devices, allowing additional degrees of freedom of motion of the respective end effectors. The end effectors of both instruments are preferably also remotely computer-controlled from a master station input device or devices. Also, illustrated is a viewing endoscope VE directed at the operative site where the end effectors are acting.  
         [0056]     Reference is now made to  FIG. 3A  showing a next step in the suturing procedure. The needle  19 A has now passed through the vessel wall  20 A. The suture  19 B is attached to the end of the needle  19 A, as illustrated. In  FIG. 3A  there is illustrated a viewing endoscope  19 C that is attached to the instrument  18  just proximal of the end effector  18 A.  
         [0057]     In  FIG. 3B  the needle  19 A is shown in the next step with the suture  19 B having passed through the anatomic wall  20 A. In this arrangement the viewing endoscope  19 C is shown secured to the chest wall  19 E. There may be provided a clamp  19 D, or the like for holding the viewing endoscope in place and in a good viewing location for the surgical procedure that is being performed. In both  FIGS. 3A and 3B  the instrument system  500  is within the lumen  20 C, while the instrument system  14  is outside the lumen  20 C. The instrument systems  500  within the lumen are usually of the flexible type so as to be able to maneuver through an anatomic body part. The instrument system outside the lumen is illustrated as being of the rigid type but could also be of the flexible type.  
         [0058]      FIG. 3C  shows the use of another dual instrument system that is adapted for intralumenal/extralumenal positioning. This particular arrangement is for sewing between two separate vessels V 1  ands V 2 . This procedure may be used in a variety of different types of operations in which it is desirable to secure together two vessels or lumens, end-to-end. For this purpose there are provided two instrument systems, both of which are preferably robotically controlled from a master station input device. The control of the two systems may be under direct surgeon control such as from an input device manipulated by the surgeon, or, alternatively the systems may be automatically controlled so that once a sequence is initiated the ensuing steps are performed automatically. For example in a sewing procedure it may be desirable to position the instrument systems and, once positioned, it may be desirable to initiate a sequence of suturing steps or stitches so that the suturing occurs essentially automatically, with little or no surgeon intervention except for safety concerns.  
         [0059]     Now, in  FIG. 3C  there is illustrated a dual instrument system that includes an internally disposed system  150 , and an externally disposed system  160 . The system  150  is usually of the flexible type as the instrument shaft has to negotiate a vessel or lumen that typically has non-straight portions. The instrument system  160 , on the other hand, may be flexible or rigid, but would usually be rigid as it would enter the anatomy through an incision or percutaneously. In  FIG. 3C  the instrument systems together define a sewing system including, on the instrument system  150  a hook end effector  152 , and on the instrument system  160  a needle end effector  162 . Together these instrument systems are adapted to be operated in unison and usually in an automatic manner, although the sewing steps can also be performed under manual control of the surgeon from a master station.  
         [0060]     The combination of the instrument systems  150  and  160  provide a sewing technique. The system  150  with its hook end effector  152  cooperates with the needle end effector  162  supported by the instrument system  160 . This arrangement may be used to provide a chain stitch. Both of the end effectors are controllable with multiple degrees of freedom. Thus, if the systems are used under manual robotic control the hook end effector  152  is moved in unison with the needle end effector  162  to provide the stitch  164 . The needle end effector  162  is adapted to reciprocate relative to its presser foot  166 . At the beginning of each stitch, the needle end effector  160  pulls a loop of suture material through the tissue. The hook end effector  150  moves in synchronism with the needle end effector  160  and grabs the loop of suture material before the needle end effector  160  pulls up. The instrument system proceed about the vessel portions and  FIG. 3D  shows the final stitch  164  that attaches the vessels or lumens together, end-to-end.  
         [0061]     In connection with the systems shown in  FIGS. 3C and 3D  these instrument systems may also be controlled automatically and under computer control. In that case, once the instrument systems are in place, sensors associated with each instrument system detects the relative position between them. Then the computer at the controller that is disposed between master and slave stations, controls the instrument systems in unison to perform the stitching action. In other words the computer controls the action of the needle end effector and hook end effector to perform the stitch such as a chain stitch.  
         [0062]     In the arrangement shown in  FIGS. 3C and 3D  the needle end effector is shown outside the lumen while the hook end effector is shown inside the lumen. In an alternate embodiment the positions of the instruments may be interchanged do the hook end effector is outside the lumen and the needle end effector is inside the lumen. The positioning between the end effectors can be controlled by sensing electromagnetic signals associated with sensors associated with each instrument system. The stitching sequences described can provide a variety of different stitch patterns. Inversion or eversion of sewed edges can be provided depending upon the particular surgical procedure being performed. For example, for cardiac procedures a slight inversion of the stitch is desired.  
         [0063]      FIG. 3E  illustrates a surgical procedure in the stomach using dual instruments, a flexible instrument passing into the stomach and either a rigid or flexible instrument outside the stomach wall.  FIG. 3F  schematically shows the end of the sewing or suturing technique at the stomach wall. The flexible instrument system  160 A passes through the esophagus  167  entering initially through the patient&#39;s mouth. The outlet from the stomach is at the duodenum  168 . This flexible instrument system is illustrated as having an operative segment O controlled by the surgeon in a telerobotic manner to control bending at that segment for guidance of the distal end effector  160 . An outside instrument system  150  is also illustrated which may be either a flexible or rigid instrument system. This is illustrated in  FIG. 3E  by system  150 A carrying the end effector  150 . In  FIGS. 3E and 3F  the end effectors may be the same as shown in  FIGS. 3C and 3D  used in performing a sewing or suturing operation. The instrument systems are controlled to perform the sewing or suturing action forming stitches  170  as illustrated in  FIG. 3F . This stitching action closes the hole  169 .  
         [0064]      FIGS. 3E and 3D  illustrate a surgical procedure on the stomach  165  particularly at the stomach wall  171 . An ulcerated hole  169  is disclosed and it is the purpose of the instrument system shown to close up this hole by means of a sewing or suturing technique employing the instrument systems  150 A and  160 A. The procedure shown in  FIGS. 3E and 3F  can be performed manually from the master station or can be performed automatically under computer control initiated from the master station. The same or a similar procedure can also be used for gastric ulcers or for repairing a bowel wall defect.  
         [0065]      FIG. 3G  shows still another technique that can be practiced with the instrument systems described herein. In  FIG. 3G  the same reference characters are used to identify similar components as previously described in connection with  FIGS. 3C and 3D . In this instance an object is being stitched within the body vessel  174 . The object may be, for example, a stent  173  that is being secure or re-secured within the vessel walls. For this purpose in  FIG. 3G  there is illustrated the instrument systems  150 A and  160 A. Usually the instrument system  150 A is flexible as it has to conform to the shape and contour of the inside of the vessel or lumen. The instrument systems  150 A and  160 A carry respective end effectors  150  and  160 . These may be the same type end effectors described in connection with  FIGS. 3C and 3D .  FIG. 3G  shows the stitching being completed at  175  at one end of the stent  173 , and further shows the instrument systems in action at the other end of the stent securing the other end thereof by means of the illustrated instrument systems  150 A and  160 A.  
         [0066]     In  FIG. 3G  the instrument system  150 A may enter the anatomy through a lumen from a natural body orifice, or percutaneously. The instrument system  160 A may be positioned at the lumen via an incision at a convenient location proximal to the operative site. The stitching action may be direct surgeon controlled my manipulation at a master station or can be under automatic control. In  FIG. 3G  the securing may be for a newly placed object or can be used to repair an existing object. For example, the technique explained can be used for AAA stent failures.  
         [0067]     Refer now to  FIGS. 3H through 3J  for an illustration of another surgical procedure that can be performed using the present inventive techniques. This example relates to the attachment of one vessel or lumen  177  to another vessel or lumen  178 . This is a technique that can be used, for example, in performing a cardiac by-pass. In the illustrated steps the same instrument systems may be employed as previously discussed in connection with earlier embodiments that are described herein. This may include both flexible and rigid systems. Furthermore it is noted in this particular procedure that more than two instrument systems are employed. For example, refer to  FIG. 3I  where three instrument systems are shown, two positioned within respective lumens and one positioned outside the lumens.  
         [0068]      FIG. 3H  shows the lumen or vessel  178  to which the vessel or lumen  177  is to be attached. This illustrates the first step in the procedure of positioning the lumen  177  by means of the instrument system  180  that is disposed within the lumen  177 . The instrument system  180  may carry a balloon  181  for example, that is inflated to hold the lumen  177  in place. The instrument system  180  may then be advanced to position the lumen  177  toward the position illustrated in  FIG. 3I . The control of movement of the instrument system  180  may be by means of surgeon control from a master station input device. In this procedure, as well as other procedures described herein a viewing endoscope is used to assist in the positioning of instrument systems.  
         [0069]      FIG. 3I  now shows the next step in the procedure of attaching the tapered end of the vessel  177  to the side wall of the vessel  178 . For this purpose there is provided the previously described instrument systems  150 A and  160 A. These instrument systems are used to sew or suture about the open end of the vessel  177  to attach it to the side wall of the vessel  178 . This sewing or suturing step is performed with the use and control of the end effectors  150  and  160 . In  FIG. 3I  it is noted that the instrument system  180  may be kept in place during this step to hold the vessel or lumen  177  against the vessel or lumen  178  to assure accurate attachment. At least parts of the procedures may be performed automatically, particularly the sewing or suturing technique.  
         [0070]     After the step illustrated in  FIG. 3I  is completed then an opening is to be cut in the sidewall of lumen  178  to allow fluid flow between lumens. This is illustrated in  FIG. 3J  where additional instrument systems are now employed. One instrument system  182  may carry a cutting blade to perform the opening of the sidewall in the lumen  178 . In the other lumen  178  there is disposed the instrument system  183  that carries a balloon  184  that is meant to hold the sidewall in place as the cutting operation is performed. For the purpose of illustration only one balloon id shown in  FIG. 3J , however, instead a pair of balloons may be used, one positioned on either side of the opening so that there is no interference between the cutting instrument and the supporting balloons.  
         [0071]     Refer now to another use of the concepts of the invention illustrated in  FIG. 3K .  
         [0072]     This illustrates a surgical procedure that is performed in the bladder  185 .  FIG. 3K  shows one instrument system  160 A passing through the urethra  188  into the interior of the bladder. This is the instrument system  160 A carrying the needle end effector  160 .  FIG. 3K  also illustrates the other instrument system  150 A carrying the hooked end effector  150 . Both of these instrument systems are shown in relative proximity to each other and can be used to perform any one of a number of different procedures. For example, the instrument systems may be used to close the sphincter at the base of the ureter tube  186  that couples to the kidney  187 .  
         [0073]      FIG. 3L  is a further illustration of the use of the instrument systems of the invention in closing the sphincter leading into the stomach  190  at the gastro-esophageol juncture. This is a procedure that is useable to reduce acid reflux that can occur in some patients. By reducing the size of the port at that point acids from the stomach are impeded from backing up into the esophagus. Thus, in  FIG. 3L  the aforementioned instrument systems  150 A and  160 A are used to perform a sewing or suturing operation so as to constrict the sphincter at the area  192  illustrated in  FIG. 3L . The instrument system  150 A carries the hook end effector  150  while the instrument system  160 A carries the needle end effector  160 . Both the instrument systems may be operated in the same manner as described previously in connection with other procedures that have been described herein.  
         [0074]      FIG. 4  is an exploded perspective view of another version of the cable drive mechanism and tool.  FIG. 5  is a top plan view of the rigid instrument insert itself.  FIG. 4  is an exploded perspective view of the cable drive mechanism and instrument illustrating the de-coupling concepts at the slave station S. A section of the surgical tabletop T which supports the rigid post  19  is shown. The drive unit  8  is supported from the side of the tabletop by an L-shaped brace  210  that carries an attaching member  212 . The brace  210  is suitably secured to the table T. The drive unit  8  is secured to the attaching member  212  by means of a clamp  214 . Similarly, the rigid support rod  19  is secured to the attaching member  212  by means of another clamping mechanism  216 .  
         [0075]     Also in  FIG. 4  the instrument  14  is shown detached from (or not yet attached to) support post  19  at bracket  25 . The instrument  14  along with cables  21  and  22  and lightweight housing section  856  provide a relatively small and lightweight decoupleable slave unit that is readily manually engageable (insertable) into the patient at the guide tube  24 .  
         [0076]     After insertion, the instrument assembly, with attached cables  21 ,  22  and housing  856 , is attached to the support post  19  by means of the knob  26  engaging a threaded hole in base  452  of adapter  15 . At the other end of the support post  19 , bracket  216  has a knob  213  that is tightened when the support rod  19  is in the desired position. The support rod  19 , at its vertical arm  19 A, essentially moves up and down through the clamp  216 . Similarly, the mounting bracket  25  can move along the horizontal arm  19 B of the support rod to be secured at different positions therealong. A further clamp  214  supports and enables the drive unit  8  to be moved to different positions along the attaching member  212 .  FIG. 4  also shows the coupler  230  which is pivotally coupled from base piece  234  by means of the pivot pin  232 . The coupler  230  is for engaging with and supporting the proximal end of the instrument insert  16 .  
         [0077]     The first housing section  855  also carries oppositely disposed thumb screws  875  (see  FIG. 4 ). These may be threaded through flanges  876 . When loosened, these set screws enable the second housing section  856  to engage with the first housing section  855 . For this purpose, there is provided a slot  878  illustrated in  FIG. 4 . Once the second housing section  856  is engaged with the first housing section  855 , then the thumb screws  875  may be tightened to hold the two housing sections together, at the same time facilitating engagement between the coupler disks  862  and the coupler spindles  860 .  
         [0078]     As illustrated in  FIG. 4 , the two housing sections  855  and  856  are separable from each other so that the relatively compact slave unit can be engaged and disengaged from the motor array, particularly from the first housing section  855  that contains the motors  800 . The first housing section  855 , as described previously, contains the motors  800  and their corresponding coupler disks  862 . In  FIG. 4 , the second housing section  856  primarily accommodates and supports the coupler spindles  860  and the cabling extending from each of the spindles to the cable bundles  21  and  22  depicted in  FIG. 4 .  
         [0079]      FIG. 4  also shows details of the adaptor including the carriage  226  supported on rails  224 . The carriage  226  holds the base piece  234  that, in turn, supports the instrument insert. The coupler  230  of the adaptor provides mechanical drive to the instrument insert. The carriage and rails are pivoted at  225  to provide one degree of freedom, while the in and out motion of the carriage provides another degree of freedom to the instrument.  
         [0080]     As shown in  FIG. 5 , each wheel of the instrument coupler  300  has two cables  376  that are affixed to the wheel and wrapped about opposite sides at its base. The lower cable rides over one of the idler pulleys or capstans (e.g., capstan  34 ), which routes the cables toward the center of the instrument stem  301 . It is desirable to maintain the cables near the center of the instrument stem. The closer the cables are to the central axis of the stem, the less disturbance motion on the cables when the insert stem is rotated. The cables may then be routed through fixed-length plastic tubes that are affixed to the proximal end of the stem section  301  and the distal end of the stem section  302 . The tubes maintain constant length pathways for the cables as they move within the instrument stem.  
         [0081]     The instrument coupler  300  is also provided with a registration slot  350  at its distal end. The slot  350  engages with a registration pin  352  supported between the bars  270  and  272  of base piece  234 . The coupler  300  is also provided with a clamping slot  355  on its proximal end for accommodating the threaded portion of the clamping knob  327  (on adapter coupler  230 ). The knob  327  affirmatively engages and interconnects the couplers  230  and  300 .  
         [0082]     In operation, once the surgeon has selected a particular instrument insert  16 , it is inserted into the adapter  15 . The proximal stem  301 , having the distal stem  302  and the tool  18  at the distal end, extend through the adapter guide tube  24 .  FIG. 4  shows the tool  18  extending out of the guide tube  24  when the surgical instrument  16  is fully inserted into the adaptor  15 . When it is fully inserted, the tab  281  on the axial wheel  306  engages with the mating detent  280  in pulley  279 . Also, the registration slot  350  engages with the registration pin  352 . Then the coupler  230  is pivoted over the base  300  of the instrument insert  16 . As this pivoting occurs, the respective wheels of the coupler  230  and the coupler  300  interengage so that drive can occur from the coupler  230  to the insert  16 . The knob  327  is secured down so that the two couplers  230  and  300  remain in fixed relative positions.  
         [0083]      FIG. 6  is a perspective view of one embodiment of the flexible instrument system  500  illustrated in  FIG. 1 .  FIG. 7  is an enlarged detailed perspective view of the end effector that may be used with the flexible instrument system.  FIG. 1  depicts flexible instrument system  500  supported from support bracket  502 , which extends to the operating table. Usually the support bracket is supported from the side of the operating table and may be adjustable in position relative to the operating table, to dispose system  500  in a convenient position over or relative to the patient. In one embodiment, bracket  502  is secured to the operating table at one end. The other end of bracket  502  supports the entire flexible instrument by means of a two-piece structure similar to that described in copending U.S. Provisional Application Ser. No. 60/279,087 filed Mar. 27, 2001 the entire teachings of which are concorporated herein by reference. A knob may be provided on support base  504 , not shown in  FIG. 1 . Once the support base  504  is fixed to the support bracket  502 , then the flexible instrument system is maintained in a fixed position at base  504 , providing a stable and steady structure during the medical procedure. Like the rigid system in  FIG. 1 , system  500  can be positioned at an acute angle with respect to the operating table or can be arranged at other convenient positions depending upon the surgical procedure being performed.  
         [0084]     Flexible instrument system  500  illustrated in  FIG. 6  comprises flexible instrument  510  having a shaft  528  extending to mechanically drivable mechanism  526 , which interlocks with base (or receiver)  506 . Base  506  is supported on carriage  508 . Carriage  508 , in turn, is adapted for linear translation and supported by elongated rails  512  and  514 . Rails  512  and  514  terminate at one end via end piece  516  which provides further support. Support base  504  terminates rails  512  and  514  at their other end. Carriage  508  includes bearings or bushings  509  that support the carriage from rails  512  and  514 .  
         [0085]     Flexible instrument system  500  employs two separate cable bundles for mechanically driving the flexible instrument along rails  512  and  514 . Pulley  521  (dotted outline), residing within carriage control module  520 , receives a first pair of cables  518 . Pulley  521  also receives a second set of cables, which runs through carriage  508  to a further pulley  522  supported by end piece  516 . The second set of cables controls the translational motion of carriage  508  and terminates at point  519 .  
         [0086]      FIG. 6  also shows a set of cables  524  for driving control elements, e.g. pulleys within receiver  506 . These control elements move the shaft and the tool in several degrees-of-freedom. Arrow J 1  indicates the linear translation via module  520 . Rotational arrow J 2  indicates rotation of flexible shaft  528  of flexible instrument  510  about the inner axis parallel with the shaft length. Arrow J 3  represents the flexing or bending of flexible shaft  528  at controlled flexible segment  530 . In this embodiment, flexible segment  530  is positioned directly adjacent tool  534  at the distal end of shaft  528 . Arrow J 4  represents the pivot action of a wrist joint, which links tool  534  to shaft  528 , about axis  532 . In this embodiment, tool  534  is exemplified as a grasper, and arrows J 5  and J 6  represent the opening and closing actions of the tool jaws. Motions indicated by arrows J 2 -J 6  are controlled from cabling  524  originating at receiver  506 .  
         [0087]      FIG. 7  provides an enlarged perspective view of the distal end of shaft  528  including flexible segment  530  and tool  534 . The segment  530  corresponds to the section  500 B illustrated in  FIG. 3 , while the end effector  534  corresponds to the end effector  500 A illustrated in  FIG. 3 . Tool  534  comprises upper grip or jaw  602  and lower grip or jaw  603 , both supported from link  601 . Base  600  is affixed to or integral with flexible shaft  528 . Link  601  is rotatably connected to base  600  about axis  532 . A pivot pin may be provided for this connection. Upper and lower jaws  602  and  603  are rotatably connected to link  601  about axis  536  and again, a pivot pin can provide this connection.  
         [0088]      FIG. 7  shows eight cables at  538  extending through the hollow inside of shaft  528  for control of tool  534  and flexible segment  530 . Two of these cables operate the bend of flexible segment  530 , two cables operate one of the jaws  602 , two cables operate the other of the jaws  603  and the last two cables operate the wrist action about the axis  532 . All of these cables travel through the hollow shaft  528  and through appropriate holes in flexible segment  530  e.g. wire  525 , as well as holes in base  600 . Each of these pairs of cables operates in concert to open and close jaws, pivot about the wrist, and bend flexible segment  530 .  
         [0089]     One pair of cables travels through shaft  528  and through appropriate holes in the base  600 , wrapping around a curved surface of the link  601  and then attaching to the link. Tension on this pair of cables rotates the link  601  along with the upper and lower grips or jaws  602  and  603  about axis  532 .  
         [0090]     Two other pairs of cables also extend through the shaft  528  and through holes in the base and then pass between fixed posts  612 . These posts constrain the cables to pass substantially through axis  532 , which defines rotation of link  601 . This construction essentially allows free rotation of link  601  with minimal length changes in the cables passing to jaws  602  and  603 . Thus, the cables actuating jaws  602  and  603  are essentially decoupled from the motion of link  601  and are not effected by any rotation of link  601 . Cables controlling jaw movement terminate on jaws  602  and  603 . These cables permit independent operation of the jaws  602  and  603  in respective clockwise and counter clockwise directions with respect to axis  536 . A similar set of cables is present on the under-side of the link  601  (not shown). Each of the jaws  602  and  603 , as well as the link  601 , may be constructed of metal. Alternatively, link  601  may be constructed of a hard plastic material. Base  600  may also be constructed of a plastic material and may be integral with shaft  528 .  
         [0091]     Bending of flexible segment  530  is provided via diametrically disposed slots  662 , which define spaced ribs  664 . Flexible segment  530  also has a longitudinally extending wall  665  through which cabling may extend, particularly for the operation of the tool. One of the pairs of cables of bundle  538  controlling flexible segment  530  terminates where base  600  intercouples with shaft  528 . This pair of cables works in concert to cause bending as indicated by arrow J 3 , i.e. in a direction orthogonal to the pivoting provided at wrist axis  532 . The flexible segment  530  may also be provided with additional degrees of freedom by controlling bending in two axes, direction J 3  that is illustrated and a direction orthogonal thereto.  
         [0092]      FIGS. 8, 9  and  10  show different embodiments that can be used with either instrument but that are illustrated, in particular, for the rigid instrument system.  FIG. 8  illustrates the construction of one form of a tool.  FIG. 8  is a perspective view. The tool  18  is comprised of four members including a base  600 , link  601 , upper grip or jaw  602  and lower grip or jaw  603 . The base  600  is affixed to the flexible stem section  302  (see  FIG. 5 ). The flexible stem may be constructed of a ribbed plastic. This flexible section is used so that the instrument will readily bend through the curved part of the guide tube  24 .  
         [0093]     The link  601  is rotatably connected to the base  600  about axis  604 .  FIG. 8  illustrates a pivot pin  620  at axis  604 . The upper and lower jaws  602  and  603  are rotatably connected by pivot pin  624  to the link  601  about axis  605 , where axis  605  is essentially perpendicular to axis  604 .  
         [0094]     Six cables  606 - 611  actuate the four members  600 - 603  of the tool. Cable  606  travels through the insert stem (section  302 ) and through a hole in the base  600 , wraps around curved surface  626  on link  601 , and then attaches on link  601  at  630 . Tension on cable  606  rotates the link  601 , and attached upper and lower grips  602  and  603 , about axis  604 . Cable  607  provides the opposing action to cable  606 , and goes through the same routing pathway, but on the opposite sides of the insert. Cable  607  may also attach to link  601  generally at  630 .  
         [0095]     Cables  608  and  610  also travel through the stem  301 ,  302  and though holes in the base  600 . The cables  608  and  610  then pass between two fixed posts  612 . These posts constrain the cables to pass substantially through the axis  604 , which defines rotation of the link  601 . This construction essentially allows free rotation of the link  601  with minimal length changes in cables  608 - 611 . In other words, the cables  608 - 611 , which actuate the jaws  602  and  603 , are essentially decoupled from the motion of link  601 . Cables  608  and  610  pass over rounded sections and terminate on jaws  602  and  603 , respectively. Tension on cables  608  and  610  rotate jaws  602  and  603  counter-clockwise about axis  605 . Finally, as shown in  FIG. 8 , the cables  609  and  611  pass through the same routing pathway as cables  608  and  610 , but on the opposite side of the instrument. These cables  609  and  611  provide the clockwise motion to jaws  602  and  603 , respectively. At the jaws  602  and  603 , as depicted in  FIG. 8 , the ends of cables  608 - 611  may be secured at  635 , for example by the use of an adhesive such as epoxy glue, or the cables could be crimped to the jaws.  
         [0096]     Reference is now made to  FIG. 9 .  FIG. 9  is a side elevation view of a needle driver version of end effector. This embodiment employs an over-center camming arrangement so that the jaw is not only closed, but is done so at a forced closure.  
         [0097]     In  FIG. 9 , similar reference characters are employed with respect to the embodiment of  FIG. 8 . Thus, there is provided a base  600 , a link  601 , an upper jaw  650  and a lower jaw  652 . The base  600  is affixed to the flexible stem section  302 . Cabling  608 - 611  operate the end jaws. Linkages  654  and  656  provide the over-center camming operation. The two embodiments of  FIGS. 8 and 9  employ a fixed wrist pivot. An alternate construction is illustrated in  FIG. 10  in which there is provided, in place of a wrist pivot, a flexible or bending section. This type of bendable section may be used with either flexible or rigid instrument systems.  
         [0098]      FIG. 10  is a perspective view of an embodiment of a flexible or bendable wrist just proximal to the tool.  FIG. 10  illustrates the manner in which the previously disclosed tools may be used with a flexible or bendable segment of the instrument shaft, whether used with a rigid shaft body or a flexible shaft body or combinations thereof. One of the advantages is that only a single cable needs to be coupled to the tool for actuation thereof. The pitch and yaw of the tool is controlled at the flexible section  100  shown in  FIG. 10 . This arrangement also lends itself to making the tool disposable or at the very least detachable from the instrument body such as for substitution of another tool. Because the construction becomes more simplified at the tip of the instrument, it makes it possible to construct a tool that is readily detachable from the instrument.  
         [0099]     In  FIG. 10  there is disclosed one embodiment of a tool, illustrated in conjunction with a flexible shaft or tube having a remotely controllable bending or flexing section  100 . The medical instrument may comprise an elongated shaft, such as shaft section  110 , having proximal and distal ends; and a tool, such as graspers  102  and  104 , supported from the distal end of the elongated shaft and useable in performing a medical procedure on a subject. The tool is actuated preferably by a single tendon or cable that extends through the flexible section  100 . In order to provide the pitch and yaw action at the tool, the bending or flexing section  100  is constructed so as to have orthogonal bending by using four cables separated at 90.degree. intervals and by using a center support with ribs and slots about the entire periphery. Refer to the ribs  112  that define corresponding slots  114 . The ribs define at each of their centers a center support passage  118  that has extending therethrough the cable  136 . The bending section  100  is at the end of tube section  110 . The section  110  may be flexible itself, may be smooth as shown, or may be fluted.  
         [0100]     The bending section  100  has alternating ridges  120  to provide universal bending. This version enables bending in orthogonal directions by means of four cables  106 ,  107 ,  116  and  117 . The operation of cables  106  and  107  provides flexing in one degree-of-freedom while an added orthogonal degree-of-freedom is provided by operation of cables  116  and  117 . Each of the cables  106 ,  107 ,  116 , and  117  have at their terminating ends respective balls  106 A,  107 A,  116 A, and  117 A that may be held in corresponding recesses in a distal end wall  119  of the flexible section  100 .  
         [0101]     The bending section  100 , as indicated previously, includes a series of spaced ribs  112  disposed, in parallel, with the plane of each rib extending orthogonal to the longitudinal axis of the section  100 . At the proximal end of the bendable section an end rib connects to the shaft section  110 , while at the distal end there is provided the distal end wall  119  that supports the ends of the cables. Each of the ribs  112  are held in spaced relationship by means of the alternating ridges  120 . As depicted in  FIG. 10  these ribs are identified as horizontal ribs  120 A, alternating with vertical ribs  120 B. This structure has been found to provide excellent support at the center passage for the actuating cable  136 , while also providing enhanced flexibility in orthogonal directions of bending or flexing.  
         [0102]     The grippers  102  and  104  are supported for opening and closing by means of a pivot pin  135  that extends along a pivot axis. These grippers may be supported in link  140 . Refer to the exploded perspective view of  FIG. 10  showing the pin  135 , and grippers  102  and  104 . The pin  135  may be supported at its ends in opposite sides of link  140 .  
         [0103]     Reference is now made to  FIGS. 11-14  for an illustration of different end effector devices that can be used with the instrument systems described herein.  FIG. 11  shows a clip applier  410 .  FIG. 12  shows a cutting jaw  420 .  FIG. 13  shows a device  430  for applying a solution or agent to an operative site.  FIG. 14  shows a syringe type device  440  useable as an end effector.  
         [0104]     The surgical robotic system, as illustrated in  FIGS. 15-17 , although preferably used to perform minimally invasive surgery, may also be used to perform other procedures as well, such as open or endoscopic surgical procedure.  FIG. 15  is a perspective view at the slave station of the system of  FIG. 1  illustrating the interchangeable instrument concepts as applied in a dual instrument system.  FIG. 16  is a cross-sectional view through the storage chamber and as taken along line  16 - 16  of  FIG. 15 .  FIG. 17  is a longitudinal cross-sectional view, as taken along line  17 - 17  of  FIG. 15 , and showing both a stored articulating instrument and a stored fluid dispensing.  
         [0105]     Reference is now made to  FIG. 15  which is a perspective view illustrating the instrument  14  and the adaptor  15  at the slave station S. This instrument system is secured in the manner illustrated in  FIG. 1  to the rigid post  502  that supports the surgical instrument by way of a mounting bracket.  FIG. 15  also shows several cables that may be separated into five sets for controlling different motions and actions at the slave station. These are individual cables of the aforementioned bundles  21  and  22  referred to in  FIG. 4 .  FIG. 15  also illustrates the support yoke  220  that is secured to the mounting bracket  31 , the pivot piece  222 , and support rails  224  for the carriage  226 . The rails are supported in end pieces  241  and  262  with the end piece  241  attached to the pivot piece  222 . The pivot piece  222  pivots relative to the support yoke  220  about pivot pin  225 . A base piece  234  is supported under the carriage  226  by means of the support post  228 . The support post  228  in essence supports the entire instrument assembly, including the adaptor  15  and the instrument  14 .  
         [0106]     As indicated previously, the support yoke  220  is supported in a fixed position from the mounting bracket  31 . The support yoke  220  may be considered as having an upper leg  236  and a lower leg  238 . In the opening  239  between these legs  236  and  238  is arranged the pivot piece  222 . Cabling extends into the support yoke  220 . This is illustrated in  FIG. 15  by the cable set  501 . Associated with the pivot piece  222  and the carriage  226  are pulleys (not shown) that receive the cabling for control of two degrees-of-freedom. This control from the cable set  501  includes pivoting of the entire instrument assembly about the pivot pin  225 . This action pivots the guide tube  24  essentially in a single plane. This pivoting is preferably about an incision of the patient which is placed directly under, and in line with, the pivot pin  225 . Other cables of set  501  control the carriage  226  in a linear path in the direction of the arrow  227 . See also the cables  229  extending between the carriage  226  and the end pieces  241  and  262 . The carriage moves the instrument and guide tube  24  back and forth in the direction of the operative site OS. Incidentally, in  FIG. 15  the instrument is in its fully advanced state with the tool at the operative site OS.  
         [0107]     The base piece  234  is the main support for the interchangeable instrument apparatus of the invention. The base piece  234  supports the guide tube  24 , the instrument storage chamber  540 , and the instrument driver  550 . The instrument driver  550  is supported from another carriage, depicted in  FIGS. 15 and 17  as the carriage  552 , and that, in turn, is supported for translation on the carriage rails  554 . The rails  554  are supported at opposite ends at end pieces  556  and  558 , in a manner similar to the support for the other carriage  226 . A support post  560  interconnects the carriage  552  with the instrument driver housing  570 .  
         [0108]     With further reference to  FIG. 15 , and as mentioned previously, there are a number of cable sets from bundles  21  and  22  coupled to and for controlling certain actions of the instrument system. Mention has been made of the cable set  501  for controlling instrument pivoting and translation, as previously explained. In addition,  FIG. 15  depicts four other cable sets  503 ,  505 ,  507 , and  509 . Cable set  503  controls rotation of the guide tube  24 . Cable set  505  controls the carriage  552 , and, in turn, the extending and retracting of the instrument driver for instrument exchange. Cable set  507  controls rotation of the instrument through rotation of the instrument driver. Finally, cable set  509  controls the tool via the instrument driver and instrument. There is also one other set of control cables not specifically illustrated in  FIG. 15  that controls the indexing motor  565 , to be discussed in further detail later.  
         [0109]      FIG. 17  shows a cross-sectional view through the interchangeable instrument portion of the overall instrument system. This clearly illustrates the internal cable and pulley arrangement for the various motion controls. There is a pulley  301  driven from the cable set  503  that controls rotation of the guide tube  24 . There is also a pulley  303  driven from cable set  505 , along with a companion pulley  305  that provides control for the carriage  552 .  FIG. 17  also illustrates another pulley  307  driven from cable set  507 , and for controlling the rotation of the instrument driver  550 , and, in turn, the selected instrument.  
         [0110]      FIG. 17  illustrates the guide tube  24  supported from the base piece  234 . The guide tube  24  is hollow, has a curved distal end as illustrated in  FIG. 15 , and is adapted to receive the individual instruments or work sections  541  (articulating) or  590  (fluid-filled) disposed in the instrument storage chamber  540 , as well as the instrument driver  550 . Refer to  FIG. 17  for an illustration of the instrument and instrument driver positioned in the guide tube  24 .  FIG. 17  shows the instrument driver  550  in its rest or disengaged position. The proximal end  24 A of the guide tube  24  is supported in the base piece  234  by means of a pair of bearings  235  so that the guide tube  24  is free to rotate in the base piece  234 . This rotation is controlled from the pulley  237  which is secured to the outer surface of the guide tube  24  by means of a set screw  231 . The pulley  237  is controlled to rotate by means of the cabling  310  that intercouples the pulleys  301  and  237  and that is an extension of the cabling  503 . Thus, by means of the cable and pulley arrangement, and by means of the rotational support of the guide tube  24 , the rotational position of the guide tube  24  is controlled from cable set  503 . Of course, this controlled rotation is effected from the master station via the controller  9 , as depicted in the system view of  FIG. 1 , and as a function of the movements made by the surgeon at the user interface  15 .  
         [0111]     As indicated before the proximal end  24 A of the guide tube  24  is supported from the base piece  234 . The distal end of the guide tube  24 , which is adapted to extend through the patient incision, is disposed at the operative site OS illustrated about the instrument member  20  in  FIG. 15 , and where a medical or surgical procedure is to be performed. In the system shown in  FIG. 15  the distal end of the guide tube  24  is curved at  24 B. In this way by rotating the guide tube  24  about its longitudinal axis there is provided a further degree-of-freedom so as to place the distal end of the instrument at any position in three-dimensional space. The rotation of the guide tube  24  enables an orbiting of the instrument end about the axis of the guide tube  24 . The guide tube  24  is preferably rigid and constructed of a metal such as aluminum.  
         [0112]      FIG. 17  also illustrates a cross-section of the instrument storage chamber  540  including the storage magazine  549 , and showing two of the six instrument passages  542  in the storage magazine  549 . The instrument storage chamber may also be referred to herein as an instrument retainer. In  FIG. 17  one of the fluid retaining instruments  590  is about to be engaged by the instrument driver  550 . The other articulating type instrument  541  is in place (storage or rest position) in the instrument storage chamber  540 , and out of the path of the instrument driver  550 . The instrument  541  carries a gripper tool, but other instruments may also be carried such as a scissors. Because these instruments are adapted to pass to the guide tube  24  and be positioned at the distal end  24 B thereof, the body  548  of each instrument is flexible so as to be able to curve with the curvature of the guide tube  24 .  
         [0113]     Although reference is made herein to the separate instrument and instrument driver, such as illustrated in  FIG. 17 , once they are engaged they function as a single piece instrument member. Accordingly reference is also made herein to the instrument driver  550  as a “driver section” of the overall one piece instrument member, and the instrument  541  or  590  as a “working section” of the instrument member. The instrument member has also been previously discussed as having a “coupling section” or “interface section”, which is defined between the working section and the driver section where the cables interlock by means of an engaging hook arrangement. This is shown in  FIG. 17  at  559 .  
         [0114]     The carriage  552  illustrated in  FIG. 17  is moved linearly by the cables  555  that extend between pulleys  303  and  305 . These cables attach to the carriage  552 . The carriage movement is controlled from cable set  505 . It is the movement of the carriage  552  that drives the instrument driver (driver section)  550 . The instrument driver  550 , in its rest or disengaged position, is supported between the instrument driver housing  570  and the wall  562  that is used for support of the instrument storage chamber  540 . The instrument magazine  549  is rotationally supported by means of the axle or shaft  547 , with the use of bushings or bearings, not shown. This support is between walls  562  and  563 .  
         [0115]      FIG. 17  shows the very distal end  525  of the instrument driver (transporter)  550  supported at wall  562 . In the rest position of the instrument driver  550  the driver is out of engagement with the instruments and the magazine  549 , thus permitting rotation of the instrument storage chamber  540 . The proximal end  526  of the instrument driver  550  is supported at the instrument driver housing  570 . It may be rotationally supported by means of a bushing  527 . The instrument driver  550  is supported for rotation, but rotation is only enabled once the driver has engaged the instrument and preferably is at the operative site. The rotation of the instrument driver  550  is controlled from cable set  507  by way of the pulley  307 .  
         [0116]     In  FIG. 15  the cable set  509  is illustrated as controlling the instrument motions including tool actuation. These cables control a series of pulleys shown in  FIG. 17  as pulleys  529 . As indicted in  FIG. 17  these pulleys control cabling that extends through the instrument driver and the instrument for control of instrument and tool motions when articulating type tools are selected. The cables that are controlled from these pulleys may control three degrees-of-freedom of the instrument, including pivoting at the wrist and two for gripper action. The same engagement arrangement can be used in this second embodiment of the invention including the mating hook arrangement, interlocked at interface  559  when the instrument driver and instrument are engaged.  
         [0117]     In one version of the invention a rotating member may be used for control of actuating rods. In the illustrated embodiment of the invention a different arrangement is used that includes a lead screw type of mechanism. This mechanism  591  is illustrated in  FIG. 17  next to the pulleys  529 . This mechanism includes a drive nut  593  having an internal threaded passage for receiving the actuating rod  592 . The actuating rod  592  also has a threaded outer surface and further includes an elongated slot or keyway  594 . An anti-rotation key  595  is fixed in position and is adapted to be received in the keyway  594 . This engagement between the key  595  and the actuating rod  592 , prevents rotation of the actuating rod  592 . However, the threaded engagement between the drive nut  593  and the outer threads of the actuating rod  592  enable linear (screw advance) translation of the actuating rod  592 . This linear translation of the actuating rod initiates dispensing from the fluid-filled instrument by actuating the instrument member piston.  
         [0118]     The drive nut  593  is journaled to the housing  570 , but is free to rotate relative to the housing. A bearing  596  is provided to enable rotation of the drive nut  593  relative to the housing  570 . The cable set  511  couples about the drive nut  593  to cause rotation thereof. Because the key  595  is fixed in position, then the actuating rod  592  can only move linearly in the direction of the arrow  597 . The linear translation of the actuating rod  592  is transferred, via the driver  550 , to the actuating rod of the instrument member. This action is, in turn, transferred to the dispensing piston of the syringe member  590 . For further details refer to the pending applications referred to before and incorporated by reference herein.  
         [0119]      FIG. 17  shows one fluid-filled instrument  590 . The cable control via the cable set  511  can provide precise movement of the actuating rod  592  so that all or any portion of the liquid in the dispensing member can be ejected at the appropriate body site. If less than all the liquid is ejected then the instrument can be returned to the storage magazine in readiness for a subsequent use. By keeping track of the degrees of rotation of the drive nut  593 , one can ascertain how much of the liquid has been dispensed and how much remains in the syringe member.  
         [0120]      FIG. 18  is schematic diagram of the catheter system of the present invention as deployed through the urethra for a surgical procedure in the bladder.  FIG. 18  provides a schematic cross-sectional diagram illustrating a surgical procedure where catheter K 1  enters a natural body orifice, such as the urethra for carrying out procedures in, for example, the bladder. In  FIG. 18  catheter K 1  is shown extending into bladder B 1 . In this example, the computer controlled segment, identified as operative, bendable or flexible segment O in  FIG. 18 , is positioned at a more proximal section of catheter K 1 . Bladder B 1 , being an open cavity, does not have lumens leading from the urethra that would naturally guide a catheter towards any particular operative site. Upon entering bladder B 1 , catheter K 1  can bend in any direction including the direction of the operative site. In this embodiment, because of the more proximal positioning of operative segment O, a surgeon can controllably bend the distal end of catheter K towards the operative site. In the embodiment shown in  FIG. 18 , the distal end of the catheter, labeled P 1 , can be rigid or be “passively” flexible, i.e. made of a flexible material and not necessarily controlled for flexure under remote computer control.  FIG. 18  also shows another instrument system preferably a rigid instrument system including an instrument C extending through an incision D. The instrument shaft carries an end effector C 1  that may be a set of jaws. Similarly, the bendable instrument K 1  may carry an end effector C 2 . These instruments are coordinated in their action so that they can operate together in performing a surgical procedure. Refer also to the previous discussion regarding  FIG. 3K .  
         [0121]     Refer now to  FIG. 19  for added details of the bladder procedure referenced in  FIGS. 3K and 18 . This drawing also shows the cross-section through the wall WI of the bladder B 1 , illustrating the ureter tube T 1  that extends through the muscle wall to the kidney. This also shows an inside instrument system  11  with a corresponding end effector, as well as an outside instrument system  12  that likewise carries an end effector. These end effectors may be for sewing or for other purposes depending upon the particular procedure that is to be performed. The inside instrument system is usually flexible, while the outside instrument system may be either flexible or rigid.  
         [0122]     Reference to a rigid instrument system usually refers to an instrument in which there is a shaft that is primarily rigid and usually meant for insertion into the patient through a small incision such as a laparoscopic incision. However, rigid instruments may also be used to some extent within a natural body orifice. Flexible shaft instruments may be used through a natural body orifice, by percutaneous entry, through an incision or by other means for entry into the patient.  
         [0123]      FIG. 20  shows still another instrument system that may be used for suturing, sewing or other surgical procedures in a body cavity or vessel such as in the cavity  193  illustrated. The instrument system  194  uses a single instrument arrangement that actually has two or more work areas. By way of example in  FIG. 20  there is, at the very distal end of the instrument system  194 , an active work element  195 . This may be the same as the instrument end effector  160  illustrated in  FIG. 3K  or may be a set of jaws. In addition to the active work element  195  the instrument system is also provided with an intermediate work element  197 . This is another end effector that is adapted to cooperate with the end effector  195  in performing a surgical procedure. For sewing the end effector  197  may be a hook end effector previously described, or it may be an anvil construction. The end effectors shown in  FIG. 20  may also be of other types such as, but not limited to, graspers, needle drivers, cauterizing tools, scalpels, etc. The instrument system shown in  FIG. 20  is simple in construction using only a single controlled instrument member. Preferably the shaft of the instrument system is curved back upon itself as illustrated at  198  in  FIG. 20 . This construction enables the one instrument system to be used for performing a complete surgical procedure such as passing a suture through a fold of tissue as illustrated in  FIG. 20 .  
         [0124]     Another concept relates to arthroscopic procedures, but could also apply to other medical procedures. This relates to the use of a single flexible instrument that might be used in, for example, a knee operation through a single entry point, rather than present instrumentation that uses multiple instruments and associated multiple incisions. The procedures described herein are also advantageous in that they can be carried out without requiring open incisions, thus lessening recovery times.  
         [0125]     The following are some of the additional features that characterize these inventions and relating to the use of multiple instruments, particularly multiple instruments of different types and adapted for different locations of access to anatomic parts of the body.  
         [0126]     (A) The use of instruments intralumenally minimizes the number of incisions that have to be made in a particular procedure.  
         [0127]     (B) The intralumenal instrument can be used as a “locator” to assist in locating the extralumenal instrument. For example, one can locate the coronary vessel (often hidden by fat and muscle, and not on the heart surface) for anastomosis by means of the intralumenal instrument.  
         [0128]     (C) Provides for multiple instruments in a small space. For example, in bowel anastomosis/resection two instruments may be used intralumenally and one used extralumenally.  
         [0129]     (D) Provides for internal and external control of a surgical procedure. For example, in the repair of a failed AAA stent (see  FIG. 3G ), the intralumenal instrument stabilizes the stent, bringing the loose stent against the vessel wall, while the extralumenal instrument performs an anchoring through the vessel wall.  
         [0130]     (E) In all of the above the instruments are preferably computer controllable from a master station with an input device and in coordination with each other. For that purpose the instruments are provided with sensors so each knows the position of the other, and their accurate manipulation can thus be controlled.  
         [0131]     (F) The control of operations described herein such as sewing or suturing techniques employs algorithms when operation is substantially totally computer controlled. These algorithms can control such parameters as stitch patterns, stitch tension, stitch spacing, tightness and precision of the stitching.  
         [0132]     While this invention has been particularly shown and described with references to preferred embodiments thereof, it will be understood by those skilled in the art that various changes in form and details may be made therein without departing from the scope of the invention encompassed by the appended claims.