Patent Description:
Medical procedures, such as laparoscopy, may involve accessing and visualizing an internal region of a patient. In a laparoscopic procedure, a medical instrument can be inserted into the internal region through a laparoscopic access port.

In certain procedures, a robotically-enabled medical system may be used to control the insertion and/or manipulation of the medical instrument and end effector. The robotically-enabled medical system may include a robotic arm or any other instrument positioning device. The robotically-enabled medical system may also include a controller used to control the positioning of the instrument during the procedure.

<CIT> describes a surgical tool including a tool shaft, and end effector and a wrist that couples the end effector to the tool shaft. The tool includes a drive mechanism configured to effect movement of one or both of the wrist and the end effector in yaw and pitch via independent actuation of four independent cable ends of two or more independent cables that extend between the drive mechanism and the wrist. <CIT> describes a working head for a manually or motor-actuated medical-surgical manipulator, comprising a base part, a tilting body which is designed to be pivotable about a first pin opposite and on this base part, and a tilting body which is arranged on the tilting body and can be pivoted about a second pin, which is orthogonal to the tilting body the first pin is arranged, pivotally designed tool. The tool consists of a first and a second tool part, these tool parts having actuating rollers. The pivoting movements of the tool and the tilting body are carried out by means of traction means, and the working head is also provided with guide rollers, over which the traction means are guided in part. Furthermore, the tilting body of the working head is designed in such a way that it has sliding guides with sliding surfaces.

In a first aspect, a surgical instrument comprises a surgical effector having multiple degrees of movement, a wrist coupled to the surgical effector, the wrist including a distal clevis, a proximal clevis, and at least a first pulley, and at least two cable segments extending through the wrist to the surgical effector to actuate the surgical effector in the multiple degrees of movement, the at least two cable segments engaging opposing sides of the first pulley. The at least two cable segments are independent from one another. The proximal clevis comprises proximal redirect surfaces configured to redirect the at least two cable segments towards the first pulley.

The surgical instrument may further include one or more of the following features in any combination: (a) wherein the multiple degrees of movement of the surgical effector includes rotation about a pitch axis and wherein the first pulley also rotates about the pitch axis; (b) wherein the surgical effector has at least N degrees of freedom of movement which are controlled by N+<NUM> cable segments extending through the wrist to the surgical effector; (c) wherein the surgical effector has at least three degrees of movement and the surgical system includes at least four cable segments; (d) wherein the three degrees of movement include a first yaw angle, a second yaw angle and a pitch angle of the surgical effector; (e) wherein the wrist includes at least two pulleys aligned along a pitch axis of the surgical effector; (f) wherein the at least two pulleys are positioned adjacent to one another; (g) wherein the at least two pulleys are spaced apart from each other and offset from a central axis of the wrist; (h) wherein the at least two pulleys are the only pulleys in the wrist aligned with the pitch axis; (i) wherein the first pulley is part of a proximal set of pulleys; (j) wherein the surgical instrument further comprises a distal set of pulleys relative to the proximal set of pulleys; (k) wherein one or more redirect surfaces are formed between the proximal set of pulleys and distal set of pulleys; (<NUM>) wherein the at least two cable segments that engage opposite sides of the first pulley are not part of the same cable; (m) wherein the at least two cable segments that engage opposite sides of the first pulley are independently moveable from one another; (n) wherein the at least two cable segments that engage opposite sides of the first pulley are independently actuatable from one another; and/or (o) wherein the one or more redirect surfaces are stationary.

In another aspect, a surgical instrument comprises a wrist comprising a first pulley that rotates about a pitch axis, a surgical effector with at least two degrees of freedom of movement, one of the degrees of movement comprising rotation about the pitch axis, and at least a first and second cable segment extending through the wrist for actuating the surgical effector in the at least two degrees of freedom of movement, the first and second cable segments both engaging the first pulley. The first cable and the second cable are independent from one another.

In another aspect, a surgical instrument comprises a wrist including one or more pulleys, and a surgical effector with N degrees of movement, at least one of the N degrees of movement comprising rotation about a pitch axis extending through the wrist, wherein at least N+<NUM> cable segments extending through the wrist to actuate the surgical effector in the N degrees of movement, and wherein at least two of the N+<NUM> cable segments sharing one of the pulleys in the wrist.

The surgical instrument may further include one or more of the following features in any combination: (a) wherein the wrist includes a distal clevis and a proximal clevis; (b) wherein the one or more pulleys are part of a first set of pulleys, and wherein the wrist includes a second set of pulleys positioned distal to the first set of pulleys; (c) wherein the distal clevis of the wrist includes redirect surfaces between the first and the second set of pulleys; and/or (d) wherein the redirect surfaces are stationary surfaces.

In another aspect, a surgical system comprises a robotic arm, a surgical effector coupled to the robotic arm, the surgical effector having multiple degrees of movement, a wrist positioned between the surgical effector and the robotic arm,; the wrist including at least a first pulley, and at least two cable segments extending through the wrist to the surgical effector to actuate the surgical effector in the multiple degrees of movement, the at least two cable segments engaging opposing sides of the first pulley. The at least two cable segments are independent from one another.

In another aspect, a surgical system comprises a surgical instrument comprising a surgical effector, a wrist coupled to the surgical effector, the wrist comprising a proximal clevis and a distal clevis, wherein the distal clevis comprises one or more stationary redirect surfaces, and at least two cable segments extending through the wrist to the surgical effector to actuate the surgical effector, wherein the at least two cable segments engage the one or more stationary redirect surfaces in the distal clevis.

The surgical system may further include one or more of the following features in any combination: (a) wherein the surgical instrument further comprises one or more pulleys in the proximal clevis and one or more pulleys in the distal clevis; (b) wherein the stationary redirect surfaces are positioned between the one or more pulleys in the proximal clevis and the one or more pulleys in the distal clevis; (c) wherein the one or more redirect stationary surfaces in the distal clevis are part of one or more surfaces that form a perimeter of a slot; and/or (d) wherein the surgical instrument further comprises one or more stationary redirect surfaces in the proximal clevis.

A method of actuating a surgical effector in multiple degrees of movement, the method comprises (i) advancing or retracting a first cable segment extending about a first side of a first pulley in a wrist that is coupled to the surgical effector to actuate the surgical effector in a first degree of movement, and (ii) advancing or retracting a second cable segment extending about a second side of the first pulley to actuate the surgical effector in a second degree of movement. The method is not explicitly recited in the wording of the claims and does not form part of the claimed invention, which is defined by independent claim <NUM>.

The method may further include rotating the surgical effector about a pitch axis that extends through an axis of the first pulley by advancing or retracting the first cable segment and by advancing or retracting the second pulley segment.

Aspects of the present disclosure may be integrated into a robotically-enabled medical system capable of performing a variety of medical procedures, including both minimally invasive, such as laparoscopy, and non-invasive, such as endoscopy, procedures. Among endoscopy procedures, the system may be capable of performing bronchoscopy, ureteroscopy, gastroscopy, etc..

In addition to performing the breadth of procedures, the system may provide additional benefits, such as enhanced imaging and guidance to assist the physician. Additionally, the system may provide the physician with the ability to perform the procedure from an ergonomic position without the need for awkward arm motions and positions. Still further, the system may provide the physician with the ability to perform the procedure with improved ease of use such that one or more of the instruments of the system can be controlled by a single user.

Various embodiments will be described below in conjunction with the drawings for purposes of illustration. It should be appreciated that many other implementations of the disclosed concepts are possible, and various advantages can be achieved with the disclosed implementations. Headings are included herein for reference and to aid in locating various sections. These headings are not intended to limit the scope of the concepts described with respect thereto. Such concepts may have applicability throughout the entire specification.

The robotically-enabled medical system may be configured in a variety of ways depending on the particular procedure. <FIG> illustrates an embodiment of a cart-based robotically-enabled system <NUM> arranged for a diagnostic and/or therapeutic bronchoscopy procedure. During a bronchoscopy, the system <NUM> may comprise a cart <NUM> having one or more robotic arms <NUM> to deliver a medical instrument, such as a steerable endoscope <NUM>, which may be a procedure-specific bronchoscope for bronchoscopy, to a natural orifice access point (i.e., the mouth of the patient positioned on a table in the present example) to deliver diagnostic and/or therapeutic tools. As shown, the cart <NUM> may be positioned proximate to the patient's upper torso in order to provide access to the access point. Similarly, the robotic arms <NUM> may be actuated to position the bronchoscope relative to the access point. The arrangement in <FIG> may also be utilized when performing a gastro-intestinal (GI) procedure with a gastroscope, a specialized endoscope for GI procedures. <FIG> depicts an example embodiment of the cart in greater detail.

With continued reference to <FIG>, once the cart <NUM> is properly positioned, the robotic arms <NUM> may insert the steerable endoscope <NUM> into the patient robotically, manually, or a combination thereof. As shown, the steerable endoscope <NUM> may comprise at least two telescoping parts, such as an inner leader portion and an outer sheath portion, each portion coupled to a separate instrument driver from the set of instrument drivers <NUM>, each instrument driver coupled to the distal end of an individual robotic arm. This linear arrangement of the instrument drivers <NUM>, which facilitates coaxially aligning the leader portion with the sheath portion, creates a "virtual rail" <NUM> that may be repositioned in space by manipulating the one or more robotic arms <NUM> into different angles and/or positions. The virtual rails described herein are depicted in the Figures using dashed lines, and accordingly the dashed lines do not depict any physical structure of the system. Translation of the instrument drivers <NUM> along the virtual rail <NUM> telescopes the inner leader portion relative to the outer sheath portion or advances or retracts the endoscope <NUM> from the patient. The angle of the virtual rail <NUM> may be adjusted, translated, and pivoted based on clinical application or physician preference. For example, in bronchoscopy, the angle and position of the virtual rail <NUM> as shown represents a compromise between providing physician access to the endoscope <NUM> while minimizing friction that results from bending the endoscope <NUM> into the patient's mouth.

The endoscope <NUM> may be directed down the patient's trachea and lungs after insertion using precise commands from the robotic system until reaching the target destination or operative site. In order to enhance navigation through the patient's lung network and/or reach the desired target, the endoscope <NUM> may be manipulated to telescopically extend the inner leader portion from the outer sheath portion to obtain enhanced articulation and greater bend radius. The use of separate instrument drivers <NUM> also allows the leader portion and sheath portion to be driven independent of each other.

For example, the endoscope <NUM> may be directed to deliver a biopsy needle to a target, such as, for example, a lesion or nodule within the lungs of a patient. The needle may be deployed down a working channel that runs the length of the endoscope to obtain a tissue sample to be analyzed by a pathologist. Depending on the pathology results, additional tools may be deployed down the working channel of the endoscope for additional biopsies. After identifying a nodule to be malignant, the endoscope <NUM> may endoscopically deliver tools to resect the potentially cancerous tissue. In some instances, diagnostic and therapeutic treatments can be delivered in separate procedures. In those circumstances, the endoscope <NUM> may also be used to deliver a fiducial to "mark" the location of the target nodule as well. In other instances, diagnostic and therapeutic treatments may be delivered during the same procedure.

The system <NUM> may also include a movable tower <NUM>, which may be connected via support cables to the cart <NUM> to provide support for controls, electronics, fluidics, optics, sensors, and/or power to the cart <NUM>. Placing such functionality in the tower <NUM> allows for a smaller form factor cart <NUM> that may be more easily adjusted and/or re-positioned by an operating physician and his/her staff. Additionally, the division of functionality between the cart / table and the support tower <NUM> reduces operating room clutter and facilitates improving clinical workflow. While the cart <NUM> may be positioned close to the patient, the tower <NUM> may be stowed in a remote location to stay out of the way during a procedure.

In support of the robotic systems described above, the tower <NUM> may include component(s) of a computer-based control system that stores computer program instructions, for example, within a non-transitory computer-readable storage medium such as a persistent magnetic storage drive, solid state drive, etc. The execution of those instructions, whether the execution occurs in the tower <NUM> or the cart <NUM>, may control the entire system or sub-system(s) thereof. For example, when executed by a processor of the computer system, the instructions may cause the components of the robotics system to actuate the relevant carriages and arm mounts, actuate the robotics arms, and control the medical instruments. For example, in response to receiving the control signal, the motors in the joints of the robotics arms may position the arms into a certain posture.

The tower <NUM> may also include a pump, flow meter, valve control, and/or fluid access in order to provide controlled irrigation and aspiration capabilities to the system that may be deployed through the endoscope <NUM>. These components may also be controlled using the computer system of tower <NUM>. In some embodiments, irrigation and aspiration capabilities may be delivered directly to the endoscope <NUM> through separate cable(s).

The tower <NUM> may include a voltage and surge protector designed to provide filtered and protected electrical power to the cart <NUM>, thereby avoiding placement of a power transformer and other auxiliary power components in the cart <NUM>, resulting in a smaller, more moveable cart <NUM>.

The tower <NUM> may also include support equipment for the sensors deployed throughout the robotic system <NUM>. For example, the tower <NUM> may include opto-electronics equipment for detecting, receiving, and processing data received from the optical sensors or cameras throughout the robotic system <NUM>. In combination with the control system, such opto-electronics equipment may be used to generate real-time images for display in any number of consoles deployed throughout the system, including in the tower <NUM>. Similarly, the tower <NUM> may also include an electronic subsystem for receiving and processing signals received from deployed electromagnetic (EM) sensors. The tower <NUM> may also be used to house and position an EM field generator for detection by EM sensors in or on the medical instrument.

The tower <NUM> may also include a console <NUM> in addition to other consoles available in the rest of the system, e.g., console mounted on top of the cart. The console <NUM> may include a user interface and a display screen, such as a touchscreen, for the physician operator. Consoles in system <NUM> are generally designed to provide both robotic controls as well as pre-operative and real-time information of the procedure, such as navigational and localization information of the endoscope <NUM>. When the console <NUM> is not the only console available to the physician, it may be used by a second operator, such as a nurse, to monitor the health or vitals of the patient and the operation of system, as well as provide procedure-specific data, such as navigational and localization information. In other embodiments, the console <NUM> is housed in a body that is separate from the tower <NUM>.

The tower <NUM> may be coupled to the cart <NUM> and endoscope <NUM> through one or more cables or connections (not shown). In some embodiments, the support functionality from the tower <NUM> may be provided through a single cable to the cart <NUM>, simplifying and de-cluttering the operating room. In other embodiments, specific functionality may be coupled in separate cabling and connections. For example, while power may be provided through a single power cable to the cart, the support for controls, optics, fluidics, and/or navigation may be provided through a separate cable.

<FIG> provides a detailed illustration of an embodiment of the cart from the cart-based robotically-enabled system shown in <FIG>. The cart <NUM> generally includes an elongated support structure <NUM> (often referred to as a "column"), a cart base <NUM>, and a console <NUM> at the top of the column <NUM>. The column <NUM> may include one or more carriages, such as a carriage <NUM> (alternatively "arm support") for supporting the deployment of one or more robotic arms <NUM> (three shown in <FIG>). The carriage <NUM> may include individually configurable arm mounts that rotate along a perpendicular axis to adjust the base of the robotic arms <NUM> for better positioning relative to the patient. The carriage <NUM> also includes a carriage interface <NUM> that allows the carriage <NUM> to vertically translate along the column <NUM>.

The carriage interface <NUM> is connected to the column <NUM> through slots, such as slot <NUM>, that are positioned on opposite sides of the column <NUM> to guide the vertical translation of the carriage <NUM>. The slot <NUM> contains a vertical translation interface to position and hold the carriage at various vertical heights relative to the cart base <NUM>. Vertical translation of the carriage <NUM> allows the cart <NUM> to adjust the reach of the robotic arms <NUM> to meet a variety of table heights, patient sizes, and physician preferences. Similarly, the individually configurable arm mounts on the carriage <NUM> allow the robotic arm base <NUM> of robotic arms <NUM> to be angled in a variety of configurations.

In some embodiments, the slot <NUM> may be supplemented with slot covers that are flush and parallel to the slot surface to prevent dirt and fluid ingress into the internal chambers of the column <NUM> and the vertical translation interface as the carriage <NUM> vertically translates. The slot covers may be deployed through pairs of spring spools positioned near the vertical top and bottom of the slot <NUM>. The covers are coiled within the spools until deployed to extend and retract from their coiled state as the carriage <NUM> vertically translates up and down. The spring-loading of the spools provides force to retract the cover into a spool when carriage <NUM> translates towards the spool, while also maintaining a tight seal when the carriage <NUM> translates away from the spool. The covers may be connected to the carriage <NUM> using, for example, brackets in the carriage interface <NUM> to ensure proper extension and retraction of the cover as the carriage <NUM> translates.

The column <NUM> may internally comprise mechanisms, such as gears and motors, that are designed to use a vertically aligned lead screw to translate the carriage <NUM> in a mechanized fashion in response to control signals generated in response to user inputs, e.g., inputs from the console <NUM>.

The robotic arms <NUM> may generally comprise robotic arm bases <NUM> and end effectors <NUM>, separated by a series of linkages <NUM> that are connected by a series of joints <NUM>, each joint comprising an independent actuator, each actuator comprising an independently controllable motor. Each independently controllable joint represents an independent degree of freedom available to the robotic arm. Each of the arms <NUM> have seven joints, and thus provide seven degrees of freedom. A multitude of joints result in a multitude of degrees of freedom, allowing for "redundant" degrees of freedom. Redundant degrees of freedom allow the robotic arms <NUM> to position their respective end effectors <NUM> at a specific position, orientation, and trajectory in space using different linkage positions and joint angles. This allows for the system to position and direct a medical instrument from a desired point in space while allowing the physician to move the arm joints into a clinically advantageous position away from the patient to create greater access, while avoiding arm collisions.

The cart base <NUM> balances the weight of the column <NUM>, carriage <NUM>, and arms <NUM> over the floor. Accordingly, the cart base <NUM> houses heavier components, such as electronics, motors, power supply, as well as components that either enable movement and/or immobilize the cart. For example, the cart base <NUM> includes rollable wheel-shaped casters <NUM> that allow for the cart to easily move around the room prior to a procedure. After reaching the appropriate position, the casters <NUM> may be immobilized using wheel locks to hold the cart <NUM> in place during the procedure.

Positioned at the vertical end of column <NUM>, the console <NUM> allows for both a user interface for receiving user input and a display screen (or a dual-purpose device such as, for example, a touchscreen <NUM>) to provide the physician user with both pre-operative and intra-operative data. Potential pre-operative data on the touchscreen <NUM> may include pre-operative plans, navigation and mapping data derived from pre-operative computerized tomography (CT) scans, and/or notes from pre-operative patient interviews. Intra-operative data on display may include optical information provided from the tool, sensor and coordinate information from sensors, as well as vital patient statistics, such as respiration, heart rate, and/or pulse. The console <NUM> may be positioned and tilted to allow a physician to access the console from the side of the column <NUM> opposite carriage <NUM>. From this position, the physician may view the console <NUM>, robotic arms <NUM>, and patient while operating the console <NUM> from behind the cart <NUM>. As shown, the console <NUM> also includes a handle <NUM> to assist with maneuvering and stabilizing cart <NUM>.

<FIG> illustrates an embodiment of a robotically-enabled system <NUM> arranged for ureteroscopy. In a ureteroscopic procedure, the cart <NUM> may be positioned to deliver a ureteroscope <NUM>, a procedure-specific endoscope designed to traverse a patient's urethra and ureter, to the lower abdominal area of the patient. In a ureteroscopy, it may be desirable for the ureteroscope <NUM> to be directly aligned with the patient's urethra to reduce friction and forces on the sensitive anatomy in the area. As shown, the cart <NUM> may be aligned at the foot of the table to allow the robotic arms <NUM> to position the ureteroscope <NUM> for direct linear access to the patient's urethra. From the foot of the table, the robotic arms <NUM> may insert the ureteroscope <NUM> along the virtual rail <NUM> directly into the patient's lower abdomen through the urethra.

After insertion into the urethra, using similar control techniques as in bronchoscopy, the ureteroscope <NUM> may be navigated into the bladder, ureters, and/or kidneys for diagnostic and/or therapeutic applications. For example, the ureteroscope <NUM> may be directed into the ureter and kidneys to break up kidney stone build up using a laser or ultrasonic lithotripsy device deployed down the working channel of the ureteroscope <NUM>. After lithotripsy is complete, the resulting stone fragments may be removed using baskets deployed down the ureteroscope <NUM>.

<FIG> illustrates an embodiment of a robotically-enabled system similarly arranged for a vascular procedure. In a vascular procedure, the system <NUM> may be configured such that the cart <NUM> may deliver a medical instrument <NUM>, such as a steerable catheter, to an access point in the femoral artery in the patient's leg. The femoral artery presents both a larger diameter for navigation as well as a relatively less circuitous and tortuous path to the patient's heart, which simplifies navigation. As in a ureteroscopic procedure, the cart <NUM> may be positioned towards the patient's legs and lower abdomen to allow the robotic arms <NUM> to provide a virtual rail <NUM> with direct linear access to the femoral artery access point in the patient's thigh / hip region. After insertion into the artery, the medical instrument <NUM> may be directed and inserted by translating the instrument drivers <NUM>. Alternatively, the cart may be positioned around the patient's upper abdomen in order to reach alternative vascular access points, such as, for example, the carotid and brachial arteries near the shoulder and wrist.

Embodiments of the robotically-enabled medical system may also incorporate the patient's table. Incorporation of the table reduces the amount of capital equipment within the operating room by removing the cart, which allows greater access to the patient. <FIG> illustrates an embodiment of such a robotically-enabled system arranged for a bronchoscopy procedure. System <NUM> includes a support structure or column <NUM> for supporting platform <NUM> (shown as a "table" or "bed") over the floor. Much like in the cart-based systems, the end effectors of the robotic arms <NUM> of the system <NUM> comprise instrument drivers <NUM> that are designed to manipulate an elongated medical instrument, such as a bronchoscope <NUM> in <FIG>, through or along a virtual rail <NUM> formed from the linear alignment of the instrument drivers <NUM>. In practice, a C-arm for providing fluoroscopic imaging may be positioned over the patient's upper abdominal area by placing the emitter and detector around table <NUM>.

<FIG> provides an alternative view of the system <NUM> without the patient and medical instrument for discussion purposes. As shown, the column <NUM> may include one or more carriages <NUM> shown as ring-shaped in the system <NUM>, from which the one or more robotic arms <NUM> may be based. The carriages <NUM> may translate along a vertical column interface <NUM> that runs the length of the column <NUM> to provide different vantage points from which the robotic arms <NUM> may be positioned to reach the patient. The carriage(s) <NUM> may rotate around the column <NUM> using a mechanical motor positioned within the column <NUM> to allow the robotic arms <NUM> to have access to multiples sides of the table <NUM>, such as, for example, both sides of the patient. In embodiments with multiple carriages, the carriages may be individually positioned on the column and may translate and/or rotate independent of the other carriages. While carriages <NUM> need not surround the column <NUM> or even be circular, the ring-shape as shown facilitates rotation of the carriages <NUM> around the column <NUM> while maintaining structural balance. Rotation and translation of the carriages <NUM> allows the system to align the medical instruments, such as endoscopes and laparoscopes, into different access points on the patient. In other embodiments (not shown), the system <NUM> can include a patient table or bed with adjustable arm supports in the form of bars or rails extending alongside it. One or more robotic arms <NUM> (e.g., via a shoulder with an elbow joint) can be attached to the adjustable arm supports, which can be vertically adjusted. By providing vertical adjustment, the robotic arms <NUM> are advantageously capable of being stowed compactly beneath the patient table or bed, and subsequently raised during a procedure.

The arms <NUM> may be mounted on the carriages through a set of arm mounts <NUM> comprising a series of joints that may individually rotate and/or telescopically extend to provide additional configurability to the robotic arms <NUM>. Additionally, the arm mounts <NUM> may be positioned on the carriages <NUM> such that, when the carriages <NUM> are appropriately rotated, the arm mounts <NUM> may be positioned on either the same side of table <NUM> (as shown in <FIG>), on opposite sides of table <NUM> (as shown in <FIG>), or on adjacent sides of the table <NUM> (not shown).

The column <NUM> structurally provides support for the table <NUM>, and a path for vertical translation of the carriages. Internally, the column <NUM> may be equipped with lead screws for guiding vertical translation of the carriages, and motors to mechanize the translation of said carriages based the lead screws. The column <NUM> may also convey power and control signals to the carriage <NUM> and robotic arms <NUM> mounted thereon.

The table base <NUM> serves a similar function as the cart base <NUM> in cart <NUM> shown in <FIG>, housing heavier components to balance the table/bed <NUM>, the column <NUM>, the carriages <NUM>, and the robotic arms <NUM>. The table base <NUM> may also incorporate rigid casters to provide stability during procedures. Deployed from the bottom of the table base <NUM>, the casters may extend in opposite directions on both sides of the base <NUM> and retract when the system <NUM> needs to be moved.

Continuing with <FIG>, the system <NUM> may also include a tower (not shown) that divides the functionality of system <NUM> between table and tower to reduce the form factor and bulk of the table. As in earlier disclosed embodiments, the tower may provide a variety of support functionalities to table, such as processing, computing, and control capabilities, power, fluidics, and/or optical and sensor processing. The tower may also be movable to be positioned away from the patient to improve physician access and de-clutter the operating room. Additionally, placing components in the tower allows for more storage space in the table base for potential stowage of the robotic arms. The tower may also include a master controller or console that provides both a user interface for user input, such as keyboard and/or pendant, as well as a display screen (or touchscreen) for pre-operative and intra-operative information, such as real-time imaging, navigation, and tracking information. In some embodiments, the tower may also contain holders for gas tanks to be used for insufflation.

In some embodiments, a table base may stow and store the robotic arms when not in use. <FIG> illustrates a system <NUM> that stows robotic arms in an embodiment of the table-based system. In system <NUM>, carriages <NUM> may be vertically translated into base <NUM> to stow robotic arms <NUM>, arm mounts <NUM>, and the carriages <NUM> within the base <NUM>. Base covers <NUM> may be translated and retracted open to deploy the carriages <NUM>, arm mounts <NUM>, and arms <NUM> around column <NUM>, and closed to stow to protect them when not in use. The base covers <NUM> may be sealed with a membrane <NUM> along the edges of its opening to prevent dirt and fluid ingress when closed.

<FIG> illustrates an embodiment of a robotically-enabled table-based system configured for a ureteroscopy procedure. In a ureteroscopy, the table <NUM> may include a swivel portion <NUM> for positioning a patient off-angle from the column <NUM> and table base <NUM>. The swivel portion <NUM> may rotate or pivot around a pivot point (e.g., located below the patient's head) in order to position the bottom portion of the swivel portion <NUM> away from the column <NUM>. For example, the pivoting of the swivel portion <NUM> allows a C-arm (not shown) to be positioned over the patient's lower abdomen without competing for space with the column (not shown) below table <NUM>. By rotating the carriage <NUM> (not shown) around the column <NUM>, the robotic arms <NUM> may directly insert a ureteroscope <NUM> along a virtual rail <NUM> into the patient's groin area to reach the urethra. In a ureteroscopy, stirrups <NUM> may also be fixed to the swivel portion <NUM> of the table <NUM> to support the position of the patient's legs during the procedure and allow clear access to the patient's groin area.

In a laparoscopic procedure, through small incision(s) in the patient's abdominal wall, minimally invasive instruments may be inserted into the patient's anatomy. In some embodiments, the minimally invasive instruments comprise an elongated rigid member, such as a shaft, which is used to access anatomy within the patient. After inflation of the patient's abdominal cavity, the instruments may be directed to perform surgical or medical tasks, such as grasping, cutting, ablating, suturing, etc. In some embodiments, the instruments can comprise a scope, such as a laparoscope. <FIG> illustrates an embodiment of a robotically-enabled table-based system configured for a laparoscopic procedure. As shown in <FIG>, the carriages <NUM> of the system <NUM> may be rotated and vertically adjusted to position pairs of the robotic arms <NUM> on opposite sides of the table <NUM>, such that instruments <NUM> may be positioned using the arm mounts <NUM> to be passed through minimal incisions on both sides of the patient to reach his/her abdominal cavity.

To accommodate laparoscopic procedures, the robotically-enabled table system may also tilt the platform to a desired angle. <FIG> illustrates an embodiment of the robotically-enabled medical system with pitch or tilt adjustment. As shown in <FIG>, the system <NUM> may accommodate tilt of the table <NUM> to position one portion of the table at a greater distance from the floor than the other. Additionally, the arm mounts <NUM> may rotate to match the tilt such that the arms <NUM> maintain the same planar relationship with table <NUM>. To accommodate steeper angles, the column <NUM> may also include telescoping portions <NUM> that allow vertical extension of column <NUM> to keep the table <NUM> from touching the floor or colliding with base <NUM>.

<FIG> provides a detailed illustration of the interface between the table <NUM> and the column <NUM>. Pitch rotation mechanism <NUM> may be configured to alter the pitch angle of the table <NUM> relative to the column <NUM> in multiple degrees of freedom. The pitch rotation mechanism <NUM> may be enabled by the positioning of orthogonal axes <NUM>, <NUM> at the column-table interface, each axis actuated by a separate motor <NUM>, <NUM> responsive to an electrical pitch angle command. Rotation along one screw <NUM> would enable tilt adjustments in one axis <NUM>, while rotation along the other screw <NUM> would enable tilt adjustments along the other axis <NUM>. In some embodiments, a ball joint can be used to alter the pitch angle of the table <NUM> relative to the column <NUM> in multiple degrees of freedom.

For example, pitch adjustments are particularly useful when trying to position the table in a Trendelenburg position, i.e., position the patient's lower abdomen at a higher position from the floor than the patient's lower abdomen, for lower abdominal surgery. The Trendelenburg position causes the patient's internal organs to slide towards his/her upper abdomen through the force of gravity, clearing out the abdominal cavity for minimally invasive tools to enter and perform lower abdominal surgical or medical procedures, such as laparoscopic prostatectomy.

<FIG> illustrate isometric and end views of another embodiment of a table-based surgical robotics system <NUM>. The surgical robotics system <NUM> includes one or more adjustable arm supports <NUM> that can be configured to support one or more robotic arms (see, for example, <FIG>) relative to a table <NUM>. In the illustrated embodiment, a single adjustable arm support <NUM> is shown, though an additional arm support can be provided on an opposite side of the table <NUM>. The adjustable arm support <NUM> can be configured so that it can move relative to the table <NUM> to adjust and/or vary the position of the adjustable arm support <NUM> and/or any robotic arms mounted thereto relative to the table <NUM>. For example, the adjustable arm support <NUM> may be adjusted one or more degrees of freedom relative to the table <NUM>. The adjustable arm support <NUM> provides high versatility to the system <NUM>, including the ability to easily stow the one or more adjustable arm supports <NUM> and any robotics arms attached thereto beneath the table <NUM>. The adjustable arm support <NUM> can be elevated from the stowed position to a position below an upper surface of the table <NUM>. In other embodiments, the adjustable arm support <NUM> can be elevated from the stowed position to a position above an upper surface of the table <NUM>.

The adjustable arm support <NUM> can provide several degrees of freedom, including lift, lateral translation, tilt, etc. In the illustrated embodiment of <FIG>, the arm support <NUM> is configured with four degrees of freedom, which are illustrated with arrows in <FIG>. A first degree of freedom allows for adjustment of the adjustable arm support <NUM> in the z-direction ("Z-lift"). For example, the adjustable arm support <NUM> can include a carriage <NUM> configured to move up or down along or relative to a column <NUM> supporting the table <NUM>. A second degree of freedom can allow the adjustable arm support <NUM> to tilt. For example, the adjustable arm support <NUM> can include a rotary joint, which can allow the adjustable arm support <NUM> to be aligned with the bed in a Trendelenburg position. A third degree of freedom can allow the adjustable arm support <NUM> to "pivot up," which can be used to adjust a distance between a side of the table <NUM> and the adjustable arm support <NUM>. A fourth degree of freedom can permit translation of the adjustable arm support <NUM> along a longitudinal length of the table.

The surgical robotics system <NUM> in <FIG> can comprise a table supported by a column <NUM> that is mounted to a base <NUM>. The base <NUM> and the column <NUM> support the table <NUM> relative to a support surface. A floor axis <NUM> and a support axis <NUM> are shown in <FIG>.

The adjustable arm support <NUM> can be mounted to the column <NUM>. In other embodiments, the arm support <NUM> can be mounted to the table <NUM> or base <NUM>. The adjustable arm support <NUM> can include a carriage <NUM>, a bar or rail connector <NUM> and a bar or rail <NUM>. In some embodiments, one or more robotic arms mounted to the rail <NUM> can translate and move relative to one another.

The carriage <NUM> can be attached to the column <NUM> by a first joint <NUM>, which allows the carriage <NUM> to move relative to the column <NUM> (e.g., such as up and down a first or vertical axis <NUM>). The first joint <NUM> can provide the first degree of freedom ("Z-lift") to the adjustable arm support <NUM>. The adjustable arm support <NUM> can include a second joint <NUM>, which provides the second degree of freedom (tilt) for the adjustable arm support <NUM>. The adjustable arm support <NUM> can include a third joint <NUM>, which can provide the third degree of freedom ("pivot up") for the adjustable arm support <NUM>. An additional joint <NUM> (shown in <FIG>) can be provided that mechanically constrains the third joint <NUM> to maintain an orientation of the rail <NUM> as the rail connector <NUM> is rotated about a third axis <NUM>. The adjustable arm support <NUM> can include a fourth joint <NUM>, which can provide a fourth degree of freedom (translation) for the adjustable arm support <NUM> along a fourth axis <NUM>.

<FIG> illustrates an end view of the surgical robotics system 140A with two adjustable arm supports 105A, 105B mounted on opposite sides of a table <NUM>. A first robotic arm 142A is attached to the bar or rail 107A of the first adjustable arm support 105B. The first robotic arm 142A includes a base 144A attached to the rail 107A. The distal end of the first robotic arm 142A includes an instrument drive mechanism 146A that can attach to one or more robotic medical instruments or tools. Similarly, the second robotic arm 142B includes a base 144B attached to the rail 107B. The distal end of the second robotic arm 142B includes an instrument drive mechanism 146B. The instrument drive mechanism 146B can be configured to attach to one or more robotic medical instruments or tools.

In some embodiments, one or more of the robotic arms 142A, 142B comprises an arm with seven or more degrees of freedom. In some embodiments, one or more of the robotic arms 142A, 142B can include eight degrees of freedom, including an insertion axis (<NUM>-degree of freedom including insertion), a wrist (<NUM>-degrees of freedom including wrist pitch, yaw and roll), an elbow (<NUM>-degree of freedom including elbow pitch), a shoulder (<NUM>-degrees of freedom including shoulder pitch and yaw), and base 144A, 144B (<NUM>-degree of freedom including translation). In some embodiments, the insertion degree of freedom can be provided by the robotic arm 142A, 142B, while in other embodiments, the instrument itself provides insertion via an instrument-based insertion architecture.

The end effectors of the system's robotic arms comprise (i) an instrument driver (alternatively referred to as "instrument drive mechanism" or "instrument device manipulator") that incorporate electro-mechanical means for actuating the medical instrument and (ii) a removable or detachable medical instrument, which may be devoid of any electro-mechanical components, such as motors. This dichotomy may be driven by the need to sterilize medical instruments used in medical procedures, and the inability to adequately sterilize expensive capital equipment due to their intricate mechanical assemblies and sensitive electronics. Accordingly, the medical instruments may be designed to be detached, removed, and interchanged from the instrument driver (and thus the system) for individual sterilization or disposal by the physician or the physician's staff. In contrast, the instrument drivers need not be changed or sterilized, and may be draped for protection.

<FIG> illustrates an example instrument driver. Positioned at the distal end of a robotic arm, instrument driver <NUM> comprises of one or more drive units <NUM> arranged with parallel axes to provide controlled torque to a medical instrument via drive shafts <NUM>. Each drive unit <NUM> comprises an individual drive shaft <NUM> for interacting with the instrument, a gear head <NUM> for converting the motor shaft rotation to a desired torque, a motor <NUM> for generating the drive torque, an encoder <NUM> to measure the speed of the motor shaft and provide feedback to the control circuitry, and control circuity <NUM> for receiving control signals and actuating the drive unit. Each drive unit <NUM> being independent controlled and motorized, the instrument driver <NUM> may provide multiple (four as shown in <FIG>) independent drive outputs to the medical instrument. In operation, the control circuitry <NUM> would receive a control signal, transmit a motor signal to the motor <NUM>, compare the resulting motor speed as measured by the encoder <NUM> with the desired speed, and modulate the motor signal to generate the desired torque.

For procedures that require a sterile environment, the robotic system may incorporate a drive interface, such as a sterile adapter connected to a sterile drape, that sits between the instrument driver and the medical instrument. The chief purpose of the sterile adapter is to transfer angular motion from the drive shafts of the instrument driver to the drive inputs of the instrument while maintaining physical separation, and thus sterility, between the drive shafts and drive inputs. Accordingly, an example sterile adapter may comprise of a series of rotational inputs and outputs intended to be mated with the drive shafts of the instrument driver and drive inputs on the instrument. Connected to the sterile adapter, the sterile drape, comprised of a thin, flexible material such as transparent or translucent plastic, is designed to cover the capital equipment, such as the instrument driver, robotic arm, and cart (in a cart-based system) or table (in a table-based system). Use of the drape would allow the capital equipment to be positioned proximate to the patient while still being located in an area not requiring sterilization (i.e., non-sterile field). On the other side of the sterile drape, the medical instrument may interface with the patient in an area requiring sterilization (i.e., sterile field).

<FIG> illustrates an example medical instrument with a paired instrument driver. Like other instruments designed for use with a robotic system, medical instrument <NUM> comprises an elongated shaft <NUM> (or elongate body) and an instrument base <NUM>. The instrument base <NUM>, also referred to as an "instrument handle" due to its intended design for manual interaction by the physician, may generally comprise rotatable drive inputs <NUM>, e.g., receptacles, pulleys or spools, that are designed to be mated with drive outputs <NUM> that extend through a drive interface on instrument driver <NUM> at the distal end of robotic arm <NUM>. When physically connected, latched, and/or coupled, the mated drive inputs <NUM> of instrument base <NUM> may share axes of rotation with the drive outputs <NUM> in the instrument driver <NUM> to allow the transfer of torque from drive outputs <NUM> to drive inputs <NUM>. In some embodiments, the drive outputs <NUM> may comprise splines that are designed to mate with receptacles on the drive inputs <NUM>.

The elongated shaft <NUM> is designed to be delivered through either an anatomical opening or lumen, e.g., as in endoscopy, or a minimally invasive incision, e.g., as in laparoscopy. The elongated shaft <NUM> may be either flexible (e.g., having properties similar to an endoscope) or rigid (e.g., having properties similar to a laparoscope) or contain a customized combination of both flexible and rigid portions. When designed for laparoscopy, the distal end of a rigid elongated shaft may be connected to an end effector extending from a jointed wrist formed from a clevis with at least one degree of freedom and a surgical tool or medical instrument, such as, for example, a grasper or scissors, that may be actuated based on force from the tendons as the drive inputs rotate in response to torque received from the drive outputs <NUM> of the instrument driver <NUM>. When designed for endoscopy, the distal end of a flexible elongated shaft may include a steerable or controllable bending section that may be articulated and bent based on torque received from the drive outputs <NUM> of the instrument driver <NUM>.

Torque from the instrument driver <NUM> is transmitted down the elongated shaft <NUM> using tendons along the shaft <NUM>. These individual tendons, such as pull wires, may be individually anchored to individual drive inputs <NUM> within the instrument handle <NUM>. From the handle <NUM>, the tendons are directed down one or more pull lumens along the elongated shaft <NUM> and anchored at the distal portion of the elongated shaft <NUM>, or in the wrist at the distal portion of the elongated shaft. During a surgical procedure, such as a laparoscopic, endoscopic or hybrid procedure, these tendons may be coupled to a distally mounted end effector, such as a wrist, grasper, or scissor. Under such an arrangement, torque exerted on drive inputs <NUM> would transfer tension to the tendon, thereby causing the end effector to actuate in some way. In some embodiments, during a surgical procedure, the tendon may cause a joint to rotate about an axis, thereby causing the end effector to move in one direction or another. Alternatively, the tendon may be connected to one or more jaws of a grasper at distal end of the elongated shaft <NUM>, where tension from the tendon cause the grasper to close.

In endoscopy, the tendons may be coupled to a bending or articulating section positioned along the elongated shaft <NUM> (e.g., at the distal end) via adhesive, control ring, or other mechanical fixation. When fixedly attached to the distal end of a bending section, torque exerted on drive inputs <NUM> would be transmitted down the tendons, causing the softer, bending section (sometimes referred to as the articulable section or region) to bend or articulate. Along the non-bending sections, it may be advantageous to spiral or helix the individual pull lumens that direct the individual tendons along (or inside) the walls of the endoscope shaft to balance the radial forces that result from tension in the pull wires. The angle of the spiraling and/or spacing there between may be altered or engineered for specific purposes, wherein tighter spiraling exhibits lesser shaft compression under load forces, while lower amounts of spiraling results in greater shaft compression under load forces, but also exhibits limits bending. On the other end of the spectrum, the pull lumens may be directed parallel to the longitudinal axis of the elongated shaft <NUM> to allow for controlled articulation in the desired bending or articulable sections.

In endoscopy, the elongated shaft <NUM> houses a number of components to assist with the robotic procedure. The shaft may comprise of a working channel for deploying surgical tools (or medical instruments), irrigation, and/or aspiration to the operative region at the distal end of the shaft <NUM>. The shaft <NUM> may also accommodate wires and/or optical fibers to transfer signals to/from an optical assembly at the distal tip, which may include of an optical camera. The shaft <NUM> may also accommodate optical fibers to carry light from proximally-located light sources, such as light emitting diodes, to the distal end of the shaft.

At the distal end of the instrument <NUM>, the distal tip may also comprise the opening of a working channel for delivering tools for diagnostic and/or therapy, irrigation, and aspiration to an operative site. The distal tip may also include a port for a camera, such as a fiberscope or a digital camera, to capture images of an internal anatomical space. Relatedly, the distal tip may also include ports for light sources for illuminating the anatomical space when using the camera.

In the example of <FIG>, the drive shaft axes, and thus the drive input axes, are orthogonal to the axis of the elongated shaft. This arrangement, however, complicates roll capabilities for the elongated shaft <NUM>. Rolling the elongated shaft <NUM> along its axis while keeping the drive inputs <NUM> static results in undesirable tangling of the tendons as they extend off the drive inputs <NUM> and enter pull lumens within the elongated shaft <NUM>. The resulting entanglement of such tendons may disrupt any control algorithms intended to predict movement of the flexible elongated shaft during an endoscopic procedure.

<FIG> illustrates an alternative design for an instrument driver and instrument where the axes of the drive units are parallel to the axis of the elongated shaft of the instrument. As shown, a circular instrument driver <NUM> comprises four drive units with their drive outputs <NUM> aligned in parallel at the end of a robotic arm <NUM>. The drive units, and their respective drive outputs <NUM>, are housed in a rotational assembly <NUM> of the instrument driver <NUM> that is driven by one of the drive units within the assembly <NUM>. In response to torque provided by the rotational drive unit, the rotational assembly <NUM> rotates along a circular bearing that connects the rotational assembly <NUM> to the non-rotational portion <NUM> of the instrument driver. Power and controls signals may be communicated from the non-rotational portion <NUM> of the instrument driver <NUM> to the rotational assembly <NUM> through electrical contacts may be maintained through rotation by a brushed slip ring connection (not shown). In other embodiments, the rotational assembly <NUM> may be responsive to a separate drive unit that is integrated into the non-rotatable portion <NUM>, and thus not in parallel to the other drive units. The rotational mechanism <NUM> allows the instrument driver <NUM> to rotate the drive units, and their respective drive outputs <NUM>, as a single unit around an instrument driver axis <NUM>.

Like earlier disclosed embodiments, an instrument <NUM> may comprise an elongated shaft portion <NUM> and an instrument base <NUM> (shown with a transparent external skin for discussion purposes) comprising a plurality of drive inputs <NUM> (such as receptacles, pulleys, and spools) that are configured to receive the drive outputs <NUM> in the instrument driver <NUM>. Unlike prior disclosed embodiments, instrument shaft <NUM> extends from the center of instrument base <NUM> with an axis substantially parallel to the axes of the drive inputs <NUM>, rather than orthogonal as in the design of <FIG>.

When coupled to the rotational assembly <NUM> of the instrument driver <NUM>, the medical instrument <NUM>, comprising instrument base <NUM> and instrument shaft <NUM>, rotates in combination with the rotational assembly <NUM> about the instrument driver axis <NUM>. Since the instrument shaft <NUM> is positioned at the center of instrument base <NUM>, the instrument shaft <NUM> is coaxial with instrument driver axis <NUM> when attached. Thus, rotation of the rotational assembly <NUM> causes the instrument shaft <NUM> to rotate about its own longitudinal axis. Moreover, as the instrument base <NUM> rotates with the instrument shaft <NUM>, any tendons connected to the drive inputs <NUM> in the instrument base <NUM> are not tangled during rotation. Accordingly, the parallelism of the axes of the drive outputs <NUM>, drive inputs <NUM>, and instrument shaft <NUM> allows for the shaft rotation without tangling any control tendons.

<FIG> illustrates an instrument having an instrument based insertion architecture in accordance with some embodiments. The instrument <NUM> can be coupled to any of the instrument drivers discussed above. The instrument <NUM> comprises an elongated shaft <NUM>, an end effector <NUM> connected to the shaft <NUM>, and a handle <NUM> coupled to the shaft <NUM>. The elongated shaft <NUM> comprises a tubular member having a proximal portion <NUM> and a distal portion <NUM>. The elongated shaft <NUM> comprises one or more channels or grooves <NUM> along its outer surface. The grooves <NUM> are configured to receive one or more wires or cables <NUM> therethrough. One or more cables <NUM> thus run along an outer surface of the elongated shaft <NUM>. In other embodiments, cables <NUM> can also run through the elongated shaft <NUM>. Manipulation of the one or more cables <NUM> (e.g., via an instrument driver) results in actuation of the end effector <NUM>.

The instrument handle <NUM>, which may also be referred to as an instrument base, may generally comprise an attachment interface <NUM> having one or more mechanical inputs <NUM>, e.g., receptacles, pulleys or spools, that are designed to be reciprocally mated with one or more torque couplers on an attachment surface of an instrument driver.

In some embodiments, the instrument <NUM> comprises a series of pulleys or cables that enable the elongated shaft <NUM> to translate relative to the handle <NUM>. In other words, the instrument <NUM> itself comprises an instrument-based insertion architecture that accommodates insertion of the instrument, thereby minimizing the reliance on a robot arm to provide insertion of the instrument <NUM>. In other embodiments, a robotic arm can be largely responsible for instrument insertion.

Any of the robotic systems described herein can include an input device or controller for manipulating an instrument attached to a robotic arm. In some embodiments, the controller can be coupled (e.g., communicatively, electronically, electrically, wirelessly and/or mechanically) with an instrument such that manipulation of the controller causes a corresponding manipulation of the instrument e.g., via master slave control.

<FIG> is a perspective view of an embodiment of a controller <NUM>. In the present embodiment, the controller <NUM> comprises a hybrid controller that can have both impedance and admittance control. In other embodiments, the controller <NUM> can utilize just impedance or passive control. In other embodiments, the controller <NUM> can utilize just admittance control. By being a hybrid controller, the controller <NUM> advantageously can have a lower perceived inertia while in use.

In the illustrated embodiment, the controller <NUM> is configured to allow manipulation of two medical instruments, and includes two handles <NUM>. Each of the handles <NUM> is connected to a gimbal <NUM>. Each gimbal <NUM> is connected to a positioning platform <NUM>.

As shown in <FIG>, each positioning platform <NUM> includes a SCARA arm (selective compliance assembly robot arm) <NUM> coupled to a column <NUM> by a prismatic joint <NUM>. The prismatic joints <NUM> are configured to translate along the column <NUM> (e.g., along rails <NUM>) to allow each of the handles <NUM> to be translated in the z-direction, providing a first degree of freedom. The SCARA arm <NUM> is configured to allow motion of the handle <NUM> in an x-y plane, providing two additional degrees of freedom.

In some embodiments, one or more load cells are positioned in the controller. For example, in some embodiments, a load cell (not shown) is positioned in the body of each of the gimbals <NUM>. By providing a load cell, portions of the controller <NUM> are capable of operating under admittance control, thereby advantageously reducing the perceived inertia of the controller while in use. In some embodiments, the positioning platform <NUM> is configured for admittance control, while the gimbal <NUM> is configured for impedance control. In other embodiments, the gimbal <NUM> is configured for admittance control, while the positioning platform <NUM> is configured for impedance control. Accordingly, for some embodiments, the translational or positional degrees of freedom of the positioning platform <NUM> can rely on admittance control, while the rotational degrees of freedom of the gimbal <NUM> rely on impedance control.

Traditional endoscopy may involve the use of fluoroscopy (e.g., as may be delivered through a C-arm) and other forms of radiation-based imaging modalities to provide endoluminal guidance to an operator physician. In contrast, the robotic systems contemplated by this disclosure can provide for non-radiation-based navigational and localization means to reduce physician exposure to radiation and reduce the amount of equipment within the operating room. As used herein, the term "localization" may refer to determining and/or monitoring the position of objects in a reference coordinate system. Technologies such as pre-operative mapping, computer vision, real-time EM tracking, and robot command data may be used individually or in combination to achieve a radiation-free operating environment. In other cases, where radiation-based imaging modalities are still used, the pre-operative mapping, computer vision, real-time EM tracking, and robot command data may be used individually or in combination to improve upon the information obtained solely through radiation-based imaging modalities.

<FIG> is a block diagram illustrating a localization system <NUM> that estimates a location of one or more elements of the robotic system, such as the location of the instrument, in accordance to an example embodiment. The localization system <NUM> may be a set of one or more computer devices configured to execute one or more instructions. The computer devices may be embodied by a processor (or processors) and computer-readable memory in one or more components discussed above. By way of example and not limitation, the computer devices may be in the tower <NUM> shown in <FIG>, the cart shown in <FIG>, the beds shown in <FIG>, etc..

As shown in <FIG>, the localization system <NUM> may include a localization module <NUM> that processes input data <NUM>-<NUM> to generate location data <NUM> for the distal tip of a medical instrument. The location data <NUM> may be data or logic that represents a location and/or orientation of the distal end of the instrument relative to a frame of reference. The frame of reference can be a frame of reference relative to the anatomy of the patient or to a known object, such as an EM field generator (see discussion below for the EM field generator).

The various input data <NUM>-<NUM> are now described in greater detail. Pre-operative mapping may be accomplished through the use of the collection of low dose CT scans. Pre-operative CT scans are reconstructed into three-dimensional images, which are visualized, e.g. as "slices" of a cutaway view of the patient's internal anatomy. When analyzed in the aggregate, image-based models for anatomical cavities, spaces and structures of the patient's anatomy, such as a patient lung network, may be generated. Techniques such as center-line geometry may be determined and approximated from the CT images to develop a three-dimensional volume of the patient's anatomy, referred to as model data <NUM> (also referred to as "preoperative model data" when generated using only preoperative CT scans). The use of center-line geometry is discussed in <CIT>, the contents of which are herein incorporated in its entirety. Network topological models may also be derived from the CT-images, and are particularly appropriate for bronchoscopy.

In some embodiments, the instrument may be equipped with a camera to provide vision data <NUM>. The localization module <NUM> may process the vision data to enable one or more vision-based location tracking. For example, the preoperative model data may be used in conjunction with the vision data <NUM> to enable computer vision-based tracking of the medical instrument (e.g., an endoscope or an instrument advance through a working channel of the endoscope). For example, using the preoperative model data <NUM>, the robotic system may generate a library of expected endoscopic images from the model based on the expected path of travel of the endoscope, each image linked to a location within the model. Intra-operatively, this library may be referenced by the robotic system in order to compare real-time images captured at the camera (e.g., a camera at a distal end of the endoscope) to those in the image library to assist localization.

Other computer vision-based tracking techniques use feature tracking to determine motion of the camera, and thus the endoscope. Some features of the localization module <NUM> may identify circular geometries in the preoperative model data <NUM> that correspond to anatomical lumens and track the change of those geometries to determine which anatomical lumen was selected, as well as the relative rotational and/or translational motion of the camera. Use of a topological map may further enhance vision-based algorithms or techniques.

Optical flow, another computer vision-based technique, may analyze the displacement and translation of image pixels in a video sequence in the vision data <NUM> to infer camera movement. Examples of optical flow techniques may include motion detection, object segmentation calculations, luminance, motion compensated encoding, stereo disparity measurement, etc. Through the comparison of multiple frames over multiple iterations, movement and location of the camera (and thus the endoscope) may be determined.

The localization module <NUM> may use real-time EM tracking to generate a real-time location of the endoscope in a global coordinate system that may be registered to the patient's anatomy, represented by the preoperative model. In EM tracking, an EM sensor (or tracker) comprising of one or more sensor coils embedded in one or more locations and orientations in a medical instrument (e.g., an endoscopic tool) measures the variation in the EM field created by one or more static EM field generators positioned at a known location. The location information detected by the EM sensors is stored as EM data <NUM>. The EM field generator (or transmitter), may be placed close to the patient to create a low intensity magnetic field that the embedded sensor may detect. The magnetic field induces small currents in the sensor coils of the EM sensor, which may be analyzed to determine the distance and angle between the EM sensor and the EM field generator. These distances and orientations may be intra-operatively "registered" to the patient anatomy (e.g., the preoperative model) in order to determine the geometric transformation that aligns a single location in the coordinate system with a position in the pre-operative model of the patient's anatomy. Once registered, an embedded EM tracker in one or more positions of the medical instrument (e.g., the distal tip of an endoscope) may provide real-time indications of the progression of the medical instrument through the patient's anatomy.

Robotic command and kinematics data <NUM> may also be used by the localization module <NUM> to provide localization data <NUM> for the robotic system. Device pitch and yaw resulting from articulation commands may be determined during pre-operative calibration. Intra-operatively, these calibration measurements may be used in combination with known insertion depth information to estimate the position of the instrument. Alternatively, these calculations may be analyzed in combination with EM, vision, and/or topological modeling to estimate the position of the medical instrument within the network.

As <FIG> shows, a number of other input data can be used by the localization module <NUM>. For example, although not shown in <FIG>, an instrument utilizing shape-sensing fiber can provide shape data that the localization module <NUM> can use to determine the location and shape of the instrument.

The localization module <NUM> may use the input data <NUM>-<NUM> in combination(s). In some cases, such a combination may use a probabilistic approach where the localization module <NUM> assigns a confidence weight to the location determined from each of the input data <NUM>-<NUM>. Thus, where the EM data may not be reliable (as may be the case where there is EM interference) the confidence of the location determined by the EM data <NUM> can be decrease and the localization module <NUM> may rely more heavily on the vision data <NUM> and/or the robotic command and kinematics data <NUM>.

As discussed above, the robotic systems discussed herein may be designed to incorporate a combination of one or more of the technologies above. The robotic system's computer-based control system, based in the tower, bed and/or cart, may store computer program instructions, for example, within a non-transitory computer-readable storage medium such as a persistent magnetic storage drive, solid state drive, or the like, that, upon execution, cause the system to receive and analyze sensor data and user commands, generate control signals throughout the system, and display the navigational and localization data, such as the position of the instrument within the global coordinate system, anatomical map, etc..

<FIG> illustrates a side view of an embodiment of a surgical instrument <NUM>. The surgical instrument <NUM> can comprise an elongate shaft <NUM>, a handle <NUM>, a wrist <NUM>, and a surgical effector <NUM>. <FIG> illustrates an enlarged view of an example surgical effector of a surgical instrument, such as the surgical instrument <NUM> of <FIG> with certain components being shown as transparent.

Existing surgical instruments have included one or more pulleys within a wrist of an instrument wherein each of the pulleys are engaged by a single cable segment. <CIT> discloses such a surgical instrument with a wrist having one or more pulleys, wherein each pulley is engaged by a single cable segment.

In contrast, the following embodiments of the present disclosure relate to a novel surgical instrument comprising one or more pulleys that are shared by at least two cable segments. By sharing at least two cable segments on a pulley, the size of the surgical instrument can be reduced by eliminating the number of pulleys on the surgical instrument. For example, in certain embodiments, the outer diameter of the surgical instrument can be reduced to less than <NUM>, such as between <NUM> and <NUM>. In other embodiments, by eliminating the number of pulleys on the surgical instrument, additional components can be added to the surgical instrument without increasing the diameter of the instrument. For example, a working lumen can be added to the surgical instrument in the space previously occupied by a pulley that has been removed as a result of the pulley sharing configurations described herein. In certain circumstances, having cable segments share a pulley can result in increased friction. However, it has been found that in loading situations of the embodiments described herein, the cable segments that are under the most tension are on separate pulleys; as such, the increased friction can be managed while achieving the advantages of the size reduction described above. Along with the reduction in the number of pulleys, the surgical instrument described herein can also include redirect surfaces to direct the cable segments through the surgical instrument. These redirect surfaces can be used instead of pulleys, which can further reduce the size of the surgical instrument. In some embodiments, the redirect surfaces can be stationary. In some embodiments, the redirect surfaces can be found within a distal clevis of the instrument, which is also novel, as discussed below.

As shown in <FIG>, the surgical instrument <NUM> can comprise the wrist <NUM> and the surgical effector <NUM>, the elongate shaft <NUM>, a proximal clevis <NUM>, a distal clevis <NUM>, proximal pulleys <NUM> and distal pulleys <NUM>. The wrist <NUM> can be mechanically coupled to the surgical effector <NUM>. The distal clevis <NUM> can be located distally in relation to the proximal clevis <NUM>. Likewise, the distal pulleys <NUM> can be located distally in relation to the proximal pulleys <NUM>. The surgical effector <NUM> can be coupled to a robotic arm and can actuate in multiple degrees of movement. In the illustrated embodiment, the surgical effector <NUM> has degrees of movement about a pitch axis <NUM> and a yaw axis <NUM> as will be described in more detail below. In some embodiments, the surgical effector <NUM> can have N+<NUM> cable segments and N degrees of freedom of movement. For example, the surgical effector <NUM> can be a two degree-of-freedom wrist, pivotable around the pitch axis <NUM> and the yaw axis <NUM>. In some embodiments, as shown in <FIG>, the surgical effector <NUM> can comprise at least four cable segments to control at least three degrees of freedom, such as, for example, pitch, yaw and grip. In some embodiments, at least two cable segments independent from one another can engage opposing sides of at least one pulley of the proximal pulleys <NUM> or the distal pulleys <NUM>.

<FIG> and <FIG> show illustrations of the surgical wrist <NUM> with housing removed. As shown in greater detail in <FIG>, the wrist <NUM> can comprise four cable segments including a first cable segment <NUM>, a second cable segment <NUM>, a third cable segment <NUM> and a fourth cable segment <NUM>. In some embodiments, the cable segments can be portions of the same cable. For example, the first cable segment <NUM> and the second cable segment <NUM> can be portions of the same cable. Likewise, in some embodiments, the third cable segment <NUM> and the fourth cable segment <NUM> can be portions of the same cable. In some embodiments, the first cable segment <NUM> and the second cable segment <NUM> can be separated by a medial crimp. Likewise, in some embodiments, the third cable segment <NUM> and the fourth cable segment <NUM> can be separated by a medial crimp. The cable segments can extend through the elongate shaft <NUM> and extend through the proximal clevis <NUM>. The cable segments then can engage at least a portion of the proximal pulleys <NUM> and extend towards the distal clevis <NUM>. The cable segments then can engage at least a portion of the distal pulleys <NUM>. Each of the cable segments <NUM>, <NUM>, <NUM>, <NUM> can engage the proximal redirect surfaces <NUM> and distal redirect surfaces <NUM> as shown in <FIG>, and the proximal pulleys <NUM> and the distal pulleys <NUM> as shown in <FIG>. As shown in <FIG>, the proximal pulleys <NUM> can comprise two pulleys 220a, 220b that are each shared by two cable segments.

As shown in <FIG>, the proximal clevis <NUM> can mechanically attached to the distal end of the elongate shaft <NUM>. The proximal clevis <NUM> can comprise proximal redirect surfaces <NUM>, as shown in <FIG>, that redirect the cable segments towards the proximal pulleys <NUM>. The proximal redirect surfaces <NUM> of the proximal clevis <NUM> can reduce, or in some cases, prevent tangling or shearing of the cable segments <NUM>, <NUM>, <NUM>, <NUM>. The proximal redirect surfaces <NUM> can reduce the amount of friction between the cable segments and the proximal clevis <NUM>. The distal clevis <NUM> can be disposed in part between the proximal pulleys <NUM> and the distal pulleys <NUM>. In some embodiments, the distal clevis <NUM> can be mechanically coupled to both the proximal pulleys <NUM> and the distal pulleys <NUM>.

<FIG> shows a side view of the wrist <NUM>, showing additional detail of the interaction between the cable segments <NUM>, <NUM>, <NUM>, <NUM> and the proximal pulleys <NUM> and the distal pulleys <NUM>. <FIG> shows another side view of the wrist <NUM>, with additional detail showing the interaction between the cable segments <NUM>, <NUM>, <NUM>, <NUM> and a proximal clevis <NUM> and a distal clevis <NUM>. In the present embodiment, the proximal pulleys <NUM> and the distal pulleys <NUM> each can comprise two pulleys. In other embodiments, the proximal pulleys <NUM> and the distal pulleys <NUM> each comprise two or more pulleys (such as three, four, five or six). In some embodiments, the two pulleys 220a, 220b of the proximal pulleys <NUM> can be adjacent to one another and aligned along the pitch axis <NUM>. In some embodiments, each of the two pulleys 220a, 220b of the proximal pulleys <NUM> can be offset from a central axis <NUM> of the wrist <NUM> such that a working lumen is positioned between the pulleys. The working lumen can, for example, accommodate one or more electrical cables, suction irrigation tubes, or other tubular members. In some embodiments, the working lumen can be between. <NUM> and <NUM>. In some embodiments, the two pulleys 222a, 222b of the distal pulleys <NUM> can be adjacent to one another and aligned along the yaw axis <NUM>. In some embodiments, each of the two pulleys 222a, 222b of the distal pulleys <NUM> can be offset from the central axis <NUM> of the wrist <NUM> such that a working lumen is positioned between the pulleys.

As shown in <FIG> and <FIG>, each pulley of the proximate pulleys <NUM> can be shared by two cable segments. For example, as shown in <FIG>, the first cable segment <NUM> and the second cable segment <NUM> can be routed on a first side of the proximal pulleys <NUM> while the third cable segment <NUM> and the fourth cable segment <NUM> can be routed on a second side of the proximal pulleys <NUM>. In such a configuration, the first cable segment <NUM> and the third cable segment <NUM> advantageously engage the first pulley 220a of the proximal pulleys <NUM>, while the second cable segment <NUM> and the fourth cable segment <NUM> advantageously engage the second pulley 220b of the proximal pulleys <NUM>. In other words, the first pulley 220a is shared by the first cable segment <NUM> and the third cable segment <NUM> (which would not be considered as part of the same cable), while the second pulley 220b is shared by the second cable segment <NUM> and the fourth cable segment <NUM> (which would not be considered as part of the same cable). Note that since the first cable segment <NUM> and the third cable segment <NUM> would not be viewed as part of the same cable, and the second cable segment <NUM> and the fourth cable segment <NUM> would not be viewed as part of the same cable, an aspects of the novelty of certain embodiments described herein involves a pulley that is shared by a first cable segment or cable that is separate, independent and/or independently actuated from a second cable segment or cable. In some embodiments, the term "independently actuated" can mean that the cable segments (e.g., the first cable segment <NUM> and the third cable segment <NUM>) can move independently and/or at different rates from one another. In some embodiments, the independent cable segments move in equal but opposite mounts about the distal pulleys and/or proximal pulleys. In some embodiments, neither of the cables or cable segments that are shared around a proximal pulley engage with or intersect with one another. In some embodiments, neither of the cables or cable segments that are shared around a proximal pulley are directly connected to one another, such as via a crimp. Such pulley sharing configuration allows the wrist <NUM> to have less pulleys for the same degree of freedom of movement, which can allow the wrist <NUM> and the elongate shaft <NUM> to have a smaller outer diameter (e.g., less than <NUM> in certain embodiments and between <NUM> and <NUM> in certain embodiments) and/or for additional components to be added to the surgical instrument in the place of the removed pulleys such as, for example, a working lumen that can extend between the distal pulleys 222a, 222b and/or proximal pulleys 220a, 220b.

The cable segments can be further configured so that retracting or advancing a cable segment can actuate the surgical effector <NUM> to move in a first degree of movement. In one embodiment, shown in <FIG>, <FIG>, <FIG> and <FIG>, the surgical effector <NUM> can have three degrees of movement created by rotation of the proximal pulleys <NUM> and the distal pulleys <NUM> about the pitch axis <NUM> and the yaw axis <NUM>, respectively. The surgical effector <NUM> of the illustrated embodiment includes a first forceps half 208a and a second forceps half 208b that are operatively connected to the first pulley 222a and the second pulley 222b of the distal pulleys <NUM>, respectively. Thus rotation of the first pulley 222a of the distal pulleys <NUM> about the yaw axis <NUM> can cause rotation of the first forceps half 208a about the yaw axis <NUM>. Similarly, rotation of the second pulley 222b of the distal pulleys <NUM> about the yaw axis <NUM> can cause rotation of the second forceps half 208b about the yaw axis <NUM>. In some embodiments, pitch motion of the surgical effector <NUM> can be actuated by a combination of cable segment actuations, such as an even lengthening of cable segments <NUM>, <NUM> matched with an even shortening of cable segments <NUM>, <NUM>, which can cause the distal clevis to rotate about the pitch axis <NUM>. In other embodiments, the surgical effector <NUM> can be actuated about the pitch axis <NUM> when the proximal pulleys <NUM> are rotated about the pitch axis <NUM>.

In the embodiment shown in <FIG>, <FIG>, <FIG>, and <FIG>, the rotation of the proximal pulleys <NUM> and the distal pulleys <NUM> is caused by retracting or advancing the cable segments <NUM>, <NUM>, <NUM>, <NUM>. In certain embodiments, an input controller can be coupled to each of the four cable segments <NUM>, <NUM>, <NUM>, <NUM>. In such arrangements, the first input controller can advance/retract the first cable segment <NUM>; the second input controller can advance/retract the second cable segment <NUM>; the third input controller can advance/retract the third cable segment <NUM>; and, the fourth input controller can advance/retract the fourth cable segment <NUM>. The first cable segment <NUM> and the third cable segment <NUM> can share the first pulley 220a of the proximal pulleys <NUM> while the second cable segment <NUM> and the fourth cable segment <NUM> can share the second pulley 220b of the proximal pulleys <NUM>. With this configuration, as noted earlier, the outer diameter of the surgical effector <NUM> and the surgical wrist <NUM> can be reduced and in certain embodiments reduced to a diameter that is less than <NUM>, such as between <NUM> and <NUM>.

<FIG> and <FIG> illustrate the surgical effector <NUM> in an example "neutral" state, i.e., the first yaw angle <NUM>, the second yaw angle <NUM>, and the pitch angle <NUM> are not offset from the central axis <NUM>, with no cable segments being advanced or retracted. The first yaw angle <NUM> can be manipulated by advancing/retracting the first cable segment <NUM> and retracting/advancing the second cable segment <NUM>.

<FIG> illustrates the two forceps halves 208a and 208b of the surgical effector <NUM> rotated at the first yaw angle <NUM> and the second yaw angle <NUM> about the yaw axis <NUM>. <FIG> and <FIG> demonstrate the potential yaw and pitch movement of the surgical effector <NUM> in accordance with some embodiments. As shown in <FIG>, advancing the first cable <NUM> and/or retracting the second cable <NUM> causes the first pulley 220a of the distal pulleys <NUM> and the first forceps half 208a to rotate about the yaw axis <NUM> such that the first yaw angle <NUM> increases. On the other hand, retracting the first cable segment <NUM> and/or advancing the second cable segment <NUM> causes the first pulley 220a of the distal pulleys <NUM> and the first forceps half 208a to rotate about the yaw axis <NUM> such that the first yaw angle <NUM> decreases. Similarly, the second yaw angle <NUM> can be manipulated by advancing/retracting the third cable <NUM> and retracting/advancing the fourth cable <NUM>. Advancing the third cable <NUM> and/or retracting the fourth cable <NUM> causes the second pulley 220b of the distal pulleys <NUM> and the second forceps half 208b to rotate about the yaw axis <NUM> such that the second yaw angle <NUM> increases. On the other hand, retracting the third cable <NUM> and/or advancing the fourth cable <NUM> causes the second pulley 220b of the distal pulleys <NUM> and the second forceps half 208b to rotate about the yaw axis <NUM> such that the second yaw angle <NUM> decreases.

<FIG> illustrates the surgical effector <NUM> rotated at the pitch angle <NUM> about the pitch axis <NUM>. As shown in <FIG>, the pitch angle <NUM> of the surgical effector <NUM> can be manipulated by retracting/advancing the first cable segment <NUM> and the second cable segment <NUM> and advancing/retracting the third cable segment <NUM> and the fourth cable segment <NUM>. On the other hand, advancing both the first cable segment <NUM> and the second cable segment <NUM> and retracting both the third cable segment <NUM> and the fourth cable segment <NUM> can cause the proximal pulleys <NUM> to rotate about the yaw axis such that the pitch angle <NUM> decreases.

The above description is a configuration controlling the degrees of freedom in which each movement can be asynchronous and controlled independently. However, in certain robotic surgical operations the degrees of freedom can be changed simultaneously. One skilled in the art will note that simultaneous motion about the three controllable degrees of freedom can be accomplished by a more complex control scheme for advancing and retracting the four cable segments <NUM>, <NUM>, <NUM>, <NUM>. In some embodiments, the four cable segments <NUM>, <NUM>, <NUM>, <NUM> are formed of a metal, while in other embodiments, the four cable segments are formed of a non-metal. In one embodiment, this control scheme involves a computer-based control system that stores computer program instructions of a master device configured to interpret the motions of the user into corresponding actions of the surgical effector <NUM> at the surgical site. The computer program may be configured to measure the electric load required to rotate the input controllers to compute the length and/or movement of the cable segments. The computer program may be further configured to compensate for changes in cable segment elasticity, such as if the cables are a polymer, by increasing/decreasing the amount of rotation needed for the input controllers to change the length of a cable segment. The tension may be adjusted by increasing or decreasing the rotation of all the input controllers in coordination. The tension can be increased by simultaneously increasing rotation, and the tension can be decreased by simultaneously decreasing rotation. The computer program may be further configured to maintain a minimum level of tension in the cables. If the tension in any of the cables is sensed to drop below a lower minimum tension threshold, then the computer program may increase rotation of all input controllers in coordination until the cable tension in all cables is above the lower minimum tension threshold. If the tension in all of the cables is sensed to rise above an upper minimum tension threshold, then the computer program may decrease rotation of all input controllers in coordination until the cable tension in any of the cables is below the upper minimum tension threshold. The computer program may be further configured to recognize the grip strength of the operator based on the load of the motors actuating the input controllers coupled to the cable segments, particularly in a situation where the working members are holding on to an object or are pressed together. More generally, the computer program may be further configured to further control the translation and rotation of the surgical instrument via the robotic arm, which in certain embodiments can include an instrument driver <NUM> with drive outputs <NUM> as described above with reference to <FIG>. Torque received from the drive outputs <NUM> of the instrument driver <NUM> can be used to separately and/or independently actuate cable segments <NUM>, <NUM>, <NUM>, <NUM>. In certain embodiments, each of the drive outputs <NUM> can be used to actuate a single cable segment.

<FIG> shows a top perspective view of an embodiment of a distal clevis <NUM>. The distal clevis <NUM> can comprise two arms <NUM> and distal redirect surfaces <NUM>. The distal clevis <NUM> and the distal redirect surfaces <NUM> can be configured to be formed between the proximate pulleys <NUM> and the distal pulleys <NUM> as shown in <FIG> and <FIG>. Optionally, the distal redirect surface <NUM> of the distal clevis <NUM> can be positioned between a first set of pulleys (for example, the proximate pulleys <NUM>) and a second set of pulleys (for example, the distal pulleys <NUM>). The two arms <NUM> can extend distally from side portions of the distal clevis <NUM> towards the surgical effector <NUM> (not shown). Each of the two arms <NUM> can be configured to comprise an opening <NUM> that extends through a width of the two arms <NUM>. The openings <NUM> can be positioned and configured such that an elongate rod <NUM> can be inserted into the openings <NUM> and the distal pulleys <NUM>, as shown in <FIG> and <FIG>. The elongate rod <NUM> and the openings <NUM> can be configured to define a rotation axis for the distal pulleys <NUM>. In some embodiments, the rotation axis associated with the distal clevis <NUM> and the distal pulleys <NUM> can be a yaw axis <NUM>, as shown in <FIG>.

The distal redirect surfaces <NUM> can comprise one or more surfaces extending about or around slots, recesses or openings <NUM> extending through a bottom portion of the distal clevis <NUM>, as shown in <FIG>. In some embodiments, the distal redirect surfaces <NUM> are part of one or more surfaces that form a perimeter of the one or more openings <NUM> of the distal clevis <NUM>. The distal redirect surfaces <NUM> can be angled, curved or sloped such that they can reduce friction between the cable segments <NUM>, <NUM>, <NUM>, <NUM> and the distal clevis <NUM> when the cable segments are retracted or advanced to actuate the surgical effector <NUM> as described above. In some embodiments, the distal redirect surfaces are configured to increase cable life by maximizing a radius of curvature. The distal redirect surfaces <NUM> can also be configured to prevent the cable segments <NUM>, <NUM>, <NUM>, <NUM> from tangling or twisting. In some embodiments, the distal redirect surfaces <NUM> can be stationary. In some embodiments, the distal redirect surfaces <NUM> can be non-stationary. In some embodiments, the distal redirect surfaces <NUM> can comprise of at least one moveable component such as a rotatable ball or surface configured to engage the cable segments <NUM>, <NUM>, <NUM>, <NUM>. In some embodiments, the cable segments can be configured to engage at least a portion of the distal redirect surfaces <NUM>. In some embodiments, the cable segments can be configured to engage the entire portion of distal redirect surfaces <NUM>. In some embodiments, the distal redirect surfaces <NUM> of the distal clevis <NUM> may be coated with a material to reduce friction between the distal redirect surfaces <NUM> and the cable segments.

As shown in <FIG>, the cable segments <NUM>, <NUM>, <NUM>, <NUM> extend through the distal clevis <NUM> toward the distal pulleys <NUM> (not shown). <FIG> illustrates an embodiment of a configuration of the cable segments <NUM>, <NUM>, <NUM>, <NUM> after extending through the distal clevis <NUM> and the distal redirect surfaces <NUM>. After extending through the distal redirect surfaces <NUM>, the cable segments extend around the distal pulleys <NUM>. In some embodiments, as shown in <FIG>, the cable segments <NUM>, <NUM>, <NUM>, <NUM> actively engage at least a portion of a plurality of grooves of the distal pulleys <NUM> (not shown). In some embodiments, the cable segments actively engage the entire portion of the plurality of grooves of the distal pulley <NUM>. As shown in <FIG> and <FIG>, each of the plurality of grooves of the distal pulleys <NUM> can be configured to engage two cable segments. For example, in the embodiment shown in <FIG> and <FIG>, the first cable segment <NUM> and the second cable segment <NUM> engage the first pulley 222a of the distal pulleys <NUM> while the third cable segment <NUM> and the fourth cable segment <NUM> engage the second pulley 222b of the distal pulleys <NUM>. In some embodiments, the cable segments <NUM>, <NUM>, <NUM>, <NUM> can be configured such that they do not intersect one another. The cable segments <NUM>, <NUM>, <NUM>, <NUM> can be further configured so that retracting or advancing a cable segment extending about a first side of a first pulley of the distal pulley <NUM> operatively coupled to the surgical effector <NUM> actuates the surgical effector <NUM> in a first degree of movement, and advancing or retracting a second cable segment extending about a second side of the first pulley of the distal pulley <NUM> actuates the surgical effector <NUM> in a second degree of movement.

<FIG> shows a top view of an embodiment of a proximal clevis <NUM>. The proximal clevis <NUM> can comprise of two arms <NUM> and proximal redirect surfaces <NUM>. The proximal clevis <NUM> and the proximal redirect surfaces <NUM> can be configured to be formed between the elongate shaft <NUM> (not shown) and the proximal pulleys <NUM> (not shown). The two arms <NUM> can extend distally from side portions of the proximal clevis <NUM> towards the surgical effector <NUM>, as shown in <FIG>. Each of the two arms <NUM> can be configured to have an opening <NUM> that extends through a width of the two arms <NUM>, as shown in <FIG>. The openings <NUM> can be positioned and configured such that a first elongate rod <NUM> can be inserted into the openings <NUM> and the proximal pulleys <NUM> as shown in <FIG> and <FIG>. The first elongate rod <NUM> and the openings <NUM> can be configured to define a rotation axis for the distal pulleys <NUM>. In some embodiments, the rotation axis associated with the proximal clevis <NUM> and the proximal pulleys <NUM> can be a pitch axis <NUM>, as shown in <FIG>.

The proximal redirect surfaces <NUM> can comprise one or more surfaces extending about or around slots, recesses or openings <NUM> extending through a bottom portion of the proximal clevis <NUM>. In some embodiments, the proximal redirect surfaces <NUM> can be part of one or more surfaces that form a perimeter of one or more openings <NUM> of the proximal clevis <NUM>. The proximal redirect surfaces <NUM> can be angled, curved or sloped such that they can reduce friction between the cable segments <NUM>, <NUM>, <NUM>, <NUM> and the proximal clevis <NUM> when the cable segments are retracted or advanced to actuate the surgical effector <NUM> as described above. The proximal redirect surfaces <NUM> can also be configured to prevent the cable segments <NUM>, <NUM>, <NUM>, <NUM> from tangling or twisting. In some embodiments, the proximal redirect surfaces <NUM> can be stationary. In some embodiments, the proximal redirect surfaces <NUM> can be non-stationary. For example, the proximal redirect surfaces <NUM> can comprise of at least one moveable components such as rotatable balls or surfaces configured to engage the cable segments <NUM>, <NUM>, <NUM>, <NUM>. In some embodiments, the cable segments <NUM>, <NUM>, <NUM>, <NUM> can be configured to engage at least a portion of the proximal redirect surfaces <NUM>. In some embodiments, the cable segments can be configured to engage the entire portion of proximal redirect surfaces <NUM>.

As shown in <FIG>, the cable segments <NUM>, <NUM>, <NUM>, <NUM> can be configured to extend through the proximal clevis <NUM> toward the proximal pulleys <NUM> (not shown in <FIG>). <FIG>, <FIG> and <FIG> illustrate an embodiment of a configuration of the cable segments <NUM>, <NUM>, <NUM>, <NUM> after extending through the proximal clevis <NUM> and the proximal redirect surfaces <NUM>. After extending through the proximal redirect surfaces <NUM>, the cable segments can be configured to extend around the proximal pulleys <NUM>. In some embodiments, the cable segments <NUM>, <NUM>, <NUM>, <NUM> can be configured to actively engage at least a portion of a plurality of grooves of the proximal pulleys <NUM>. In some embodiments, the cable segments <NUM>, <NUM>, <NUM>, <NUM> can be configured to actively engage the entire portion of the plurality of grooves of the proximal pulleys <NUM>. As shown in <FIG>, each of the plurality of grooves of the proximal pulleys <NUM> can be configured to engage two cable segments. In some embodiments, the cable segments <NUM>, <NUM>, <NUM>, <NUM> can be configured such that they do not intersect another. The cable segments <NUM>, <NUM>, <NUM>, <NUM> can be further configured so that retracting or advancing a cable segment extending about a first side of a first pulley of the proximal pulley <NUM> operatively coupled to the surgical effector <NUM> actuates the surgical effector <NUM> in a first degree of movement, and advancing or retracting a second cable segment extending about a second side of the first pulley of the distal pulley <NUM> actuates the surgical effector <NUM> in a second degree of movement.

<FIG> illustrates a side view of the proximal clevis <NUM>. The proximal clevis con comprise the proximal redirect surfaces <NUM>. The proximal redirect surfaces <NUM> can be configured to redirect the cable segments <NUM>, <NUM>, <NUM>, <NUM> from substantially near the center of the proximal clevis <NUM> and the elongated shaft <NUM> (not shown) to the grooves of the proximal pulleys <NUM>. In some embodiments, the proximal redirect surfaces <NUM> of the proximal clevis <NUM> can comprise one or more movable surfaces. In some embodiments, the proximal redirect surfaces <NUM> of the proximal clevis <NUM> can be coated with a material to reduce friction between the proximal redirect surface <NUM> and the cable segments. In some embodiments, the cable segments can be configured to engage at least a portion of the proximal redirect surfaces <NUM>. In some embodiments, the cable segments can be configured to engage the entire portion of proximal redirect surfaces <NUM>.

Implementations disclosed herein provide system, methods, and apparatus for robotically-enabled medical systems. Various implementations described herein include robotically-enabled medical systems with a wrist comprising one or more pulleys shared by cable segments.

It should be noted that the terms "couple," "coupling," "coupled" or other variations of the word couple as used herein may indicate either an indirect connection or a direct connection. For example, if a first component is "coupled" to a second component, the first component may be either indirectly connected to the second component via another component or directly connected to the second component.

The robotic motion actuation functions described herein may be stored as one or more instructions on a processor-readable or computer-readable medium. The term "computer-readable medium" refers to any available medium that can be accessed by a computer or processor. By way of example, and not limitation, such a medium may comprise random access memory (RAM), read-only memory (ROM), electrically erasable programmable read-only memory (EEPROM), flash memory, compact disc read-only memory (CD-ROM) or other optical disk storage, magnetic disk storage or other magnetic storage devices, or any other medium that can be used to store desired program code in the form of instructions or data structures and that can be accessed by a computer. It should be noted that a computer-readable medium may be tangible and non-transitory. As used herein, the term "code" may refer to software, instructions, code or data that is/are executable by a computing device or processor.

As used herein, the term "plurality" denotes two or more. For example, a plurality of components indicates two or more components.

Claim 1:
A surgical instrument (<NUM>) comprising:
a surgical effector (<NUM>) having multiple degrees of movement;
a wrist (<NUM>) coupled to the surgical effector, the wrist including a distal clevis (<NUM>), a proximal clevis (<NUM>), and at least a first pulley (<NUM>); and
at least two cable segments (<NUM>, <NUM>, <NUM>, <NUM>) extending through the wrist to the surgical effector to actuate the surgical effector in the multiple degrees of movement, the at least two cable segments engaging opposing sides of the first pulley, wherein the at least two cable segments are independent from one another,
characterized in that the proximal clevis comprises proximal redirect surfaces (<NUM>) configured to redirect the at least two cable segments towards the first pulley.