Patent Description:
The present disclosure is directed to medical procedures and methods for manipulating tissue during medical procedures. More particularly, the present disclosure is directed to systems and methods for manipulating tissue by controlling a virtual tissue control point displayed in a user interface.

Minimally invasive medical techniques are intended to reduce the amount of extraneous tissue that is damaged during diagnostic or surgical procedures, thereby reducing patient recovery time, discomfort, and harmful side effects. Such minimally invasive techniques may be performed through natural orifices in a patient anatomy or through one or more surgical incisions. Through these natural orifices or incisions, clinicians may insert medical tools to reach a target tissue location. Minimally invasive medical tools include instruments such as therapeutic instruments, diagnostic instruments, and surgical instruments. Minimally invasive medical tools may also include imaging instruments such as endoscopic instruments that provide a user with a field of view within the patient anatomy.

Some minimally invasive medical tools may be teleoperated, otherwise remotely operated, or otherwise computer-assisted. During a medical procedure, the clinician may need to manipulate tissue to retract the tissue, expose a target area, inspect a hidden region of tissue, or perform some other action. When manipulating the tissue, the clinician may need to consider a variety of parameters including the direction of motion, the magnitude of motion, operator instrument orientation, instrument collision avoidance, multi-instrument interference, and range of motion limits. Systems and methods are needed for simplifying and improving the clinician's experience during the process of manipulating tissue.

<CIT> discloses , a method for controlling a robotic surgical tool. The method for controlling a robotic surgical tool includes moving a monitor displaying an image of a robotic surgical tool; sensing motion of the monitor; and translating the sensed motion of the monitor into motion of the robotic surgical tool.

The embodiments of the invention are summarized by the claims that follow the detailed description.

In one example embodiment, an apparatus comprises a display system, an instrument physically associated with tissue and a control system. The display system displays an image of the tissue in a user interface. The control system is communicatively coupled to the display system. The control system is configured to display a tissue control point over the image; receive an input that moves the tissue control point within the user interface; and operate the instrument responsive to the received input, the operation causing movement of the instrument to thereby manipulate the tissue.

It will nevertheless be understood that no limitation of the scope of the disclosure is intended. In the following detailed description of the aspects of the invention, numerous specific details are set forth in order to provide a thorough understanding of the disclosed embodiments. However, as would be appreciated by one skilled in the art, embodiments of this disclosure may be practiced without these specific details. In other instances well known methods, procedures, components, and circuits have not been described in detail so as not to unnecessarily obscure aspects of the embodiments of the invention.

Any alterations and further modifications to the described devices, instruments, methods, and any further application of the principles of the present disclosure are fully contemplated as would normally occur to one skilled in the art to which the disclosure relates. In addition, dimensions provided herein are for specific examples and it is contemplated that different sizes, dimensions, and/or ratios may be utilized to implement the concepts of the present disclosure. To avoid needless descriptive repetition, one or more components or actions described in accordance with one illustrative embodiment may be used or omitted as applicable from other illustrative embodiments. For the sake of brevity, the numerous iterations of these combinations will not be described separately. For simplicity, in some instances the same reference numbers are used throughout the drawings to refer to the same or like parts.

The embodiments below will describe various instruments and portions of instruments in terms of their state in three-dimensional space. As used herein, the term "position" refers to the location of an object or a portion of an object in a three-dimensional space (e.g., three degrees of translational freedom along Cartesian X, Y, Z coordinates). As used herein, the term "orientation" refers to the rotational placement of an object or a portion of an object (three degrees of rotational freedom - e.g., roll, pitch, and yaw). As used herein, the term "pose" refers to the position of an object or a portion of an object in at least one degree of translational freedom and to the orientation of that object or portion of the object in at least one degree of rotational freedom (up to six total degrees of freedom).

Referring now to the drawings, <FIG>, <FIG>, and <FIG> together provide an overview of a medical system <NUM> that may be used in, for example, medical procedures including diagnostic, therapeutic, or surgical procedures. The medical system <NUM> is located in a medical environment <NUM>. The medical environment <NUM> is depicted as an operating room in <FIG>. In other embodiments, the medical environment <NUM> may be an emergency room, a medical training environment, a medical laboratory, or some other type of environment in which any number of medical procedures or medical training procedures may take place. In still other embodiments, the medical environment <NUM> may include an operating room and a control area located outside of the operating room.

In one or more embodiments, the medical system <NUM> may be a teleoperational medical system that is under the teleoperational control of a surgeon. In alternative embodiments, the medical system <NUM> may be under the partial control of a computer programmed to perform the medical procedure or sub-procedure. In still other alternative embodiments, the medical system <NUM> may be a fully automated medical system that is under the full control of a computer programmed to perform the medical procedure or sub-procedure with the medical system <NUM>. One example of the medical system <NUM> that may be used to implement the systems and techniques described in this disclosure is the da Vinci® Surgical System manufactured by Intuitive Surgical, Inc. of Sunnyvale, California.

As shown in <FIG>, the medical system <NUM> generally includes an assembly <NUM>, which may be mounted to or positioned near an operating table O on which a patient P is positioned. The assembly <NUM> may be referred to as a patient side cart, a surgical cart, or a surgical robot. In one or more embodiments, the assembly <NUM> may be a teleoperational assembly. The teleoperational assembly may be referred to as, for example, a teleoperational arm cart. A medical instrument system <NUM> and an endoscopic imaging system <NUM> are operably coupled to the assembly <NUM>. An operator input system <NUM> allows a surgeon S or other type of clinician to view images of or representing the surgical site and to control the operation of the medical instrument system <NUM> and/or the endoscopic imaging system <NUM>.

The medical instrument system <NUM> may comprise one or more medical instruments. In embodiments in which the medical instrument system <NUM> comprises a plurality of medical instruments, the plurality of medical instruments may include multiple of the same medical instrument and/or multiple different medical instruments. Similarly, the endoscopic imaging system <NUM> may comprise one or more endoscopes. In the case of a plurality of endoscopes, the plurality of endoscopes may include multiple of the same endoscope and/or multiple different endoscopes.

The operator input system <NUM> may be located at a surgeon's control console, which may be located in the same room as operating table O. In some embodiments, the surgeon S and the operator input system <NUM> may be located in a different room or a completely different building from the patient P. The operator input system <NUM> generally includes one or more control device(s) for controlling the medical instrument system <NUM>. The control device(s) may include one or more of any number of a variety of input devices, such as hand grips, joysticks, trackballs, data gloves, trigger-guns, foot pedals, hand-operated controllers, voice recognition devices, touch screens, body motion or presence sensors, and other types of input devices.

In some embodiments, the control device(s) will be provided with the same degrees of freedom as the medical instrument(s) of the medical instrument system <NUM> to provide the surgeon with telepresence, which is the perception that the control device(s) are integral with the instruments so that the surgeon has a strong sense of directly controlling instruments as if present at the surgical site. In other embodiments, the control device(s) may have more or fewer degrees of freedom than the associated medical instruments and still provide the surgeon with telepresence. In some embodiments, the control device(s) are manual input devices that move with six degrees of freedom, and which may also include an actuatable handle for actuating instruments (for example, for closing grasping jaw end effectors, applying an electrical potential to an electrode, delivering a medicinal treatment, and actuating other types of instruments).

The assembly <NUM> supports and manipulates the medical instrument system <NUM> while the surgeon S views the surgical site through the operator input system <NUM>. An image of the surgical site may be obtained by the endoscopic imaging system <NUM>, which may be manipulated by the assembly <NUM>. The assembly <NUM> may comprise endoscopic imaging systems <NUM> and may similarly comprise multiple medical instrument systems <NUM> as well. The number of medical instrument systems <NUM> used at one time will generally depend on the diagnostic or surgical procedure to be performed and on space constraints within the operating room, among other factors. The assembly <NUM> may include a kinematic structure of one or more non-servo controlled links (e.g., one or more links that may be manually positioned and locked in place, generally referred to as a set-up structure) and a manipulator. When the manipulator takes the form of a teleoperational manipulator, the assembly <NUM> is a teleoperational assembly. The assembly <NUM> includes a plurality of motors that drive inputs on the medical instrument system <NUM>. In an embodiment, these motors move in response to commands from a control system (e.g., control system <NUM>). The motors include drive systems which when coupled to the medical instrument system <NUM> may advance a medical instrument into a naturally or surgically created anatomical orifice. Other motorized drive systems may move the distal end of said medical instrument in multiple degrees of freedom, which may include three degrees of linear motion (e.g., linear motion along the X, Y, Z Cartesian axes) and three degrees of rotational motion (e.g., rotation about the X, Y, Z Cartesian axes). Additionally, the motors may be used to actuate an articulable end effector of the medical instrument for grasping tissue in the jaws of a biopsy device or the like. Medical instruments of the medical instrument system <NUM> may include end effectors having a single working member such as a scalpel, a blunt blade, an optical fiber, or an electrode. Other end effectors may include, for example, forceps, graspers, scissors, or clip appliers.

The medical system <NUM> also includes a control system <NUM>. The control system <NUM> includes at least one memory <NUM> and at least one processor <NUM> for effecting control between the medical instrument system <NUM>, the operator input system <NUM>, and other auxiliary systems <NUM> which may include, for example, imaging systems, audio systems, fluid delivery systems, display systems, illumination systems, steering control systems, irrigation systems, and/or suction systems. A clinician may circulate within the medical environment <NUM> and may access, for example, the assembly <NUM> during a set up procedure or view a display of the auxiliary system <NUM> from the patient bedside.

Though depicted as being external to the assembly <NUM> in <FIG>, the control system <NUM> may, in some embodiments, be contained wholly within the assembly <NUM>. The control system <NUM> also includes programmed instructions (e.g., stored on a non-transitory, computer-readable medium) to implement some or all of the methods described in accordance with aspects disclosed herein. While the control system <NUM> is shown as a single block in the simplified schematic of <FIG>, the control system <NUM> may include two or more data processing circuits with one portion of the processing optionally being performed on or adjacent the assembly <NUM>, another portion of the processing being performed at the operator input system <NUM>, and the like.

Any of a wide variety of centralized or distributed data processing architectures may be employed. Similarly, the programmed instructions may be implemented as a number of separate programs or subroutines, or they may be integrated into a number of other aspects of the systems described herein, including teleoperational systems. In one embodiment, the control system <NUM> supports wireless communication protocols such as Bluetooth, IrDA, HomeRF, IEEE <NUM>, DECT, and Wireless Telemetry.

The control system <NUM> is in communication with a database <NUM> which may store one or more clinician profiles, a list of patients and patient profiles, a list of procedures to be performed on said patients, a list of clinicians scheduled to perform said procedures, other information, or combinations thereof. A clinician profile may comprise information about a clinician, including how long the clinician has worked in the medical field, the level of education attained by the clinician, the level of experience the clinician has with the medical system <NUM> (or similar systems), or any combination thereof.

The database <NUM> may be stored in the memory <NUM> and may be dynamically updated. Additionally or alternatively, the database <NUM> may be stored on a device such as a server or a portable storage device that is accessible by the control system <NUM> via an internal network (e.g., a secured network of a medical facility or a teleoperational system provider) or an external network (e.g. the Internet). The database <NUM> may be distributed throughout two or more locations. For example, the database <NUM> may be present on multiple devices which may include the devices of different entities and/or a cloud server. Additionally or alternatively, the database <NUM> may be stored on a portable user-assigned device such as a computer, a mobile device, a smart phone, a laptop, an electronic badge, a tablet, a pager, and other similar user devices.

In some embodiments, control system <NUM> may include one or more servo controllers that receive force and/or torque feedback from the medical instrument system <NUM>. Responsive to the feedback, the servo controllers transmit signals to the operator input system <NUM>. The servo controller(s) may also transmit signals instructing assembly <NUM> to move the medical instrument system(s) <NUM> and/or endoscopic imaging system <NUM> which extend into an internal surgical site within the patient body via openings in the body. Any suitable conventional or specialized servo controller may be used. A servo controller may be separate from, or integrated with, assembly <NUM>. In some embodiments, the servo controller and assembly <NUM> are provided as part of a teleoperational arm cart positioned adjacent to the patient's body.

The control system <NUM> can be coupled with the endoscopic imaging system <NUM> and can include a processor to process captured images for subsequent display, such as to a surgeon on the surgeon's control console, or on another suitable display located locally and/or remotely. For example, where a stereoscopic endoscope is used, the control system <NUM> can process the captured images to present the surgeon with coordinated stereo images of the surgical site. Such coordination can include alignment between the opposing images and can include adjusting the stereo working distance of the stereoscopic endoscope.

In alternative embodiments, the medical system <NUM> may include more than one assembly <NUM> and/or more than one operator input system <NUM>. The exact number of assemblies <NUM> will depend on the surgical procedure and the space constraints within the operating room, among other factors. The operator input systems <NUM> may be collocated or they may be positioned in separate locations. Multiple operator input systems <NUM> allow more than one operator to control one or more assemblies <NUM> in various combinations. The medical system <NUM> may also be used to train and rehearse medical procedures.

<FIG> is a perspective view of one embodiment of an assembly <NUM> which may be referred to as a patient side cart, surgical cart, teleoperational arm cart, or surgical robot. The assembly <NUM> shown provides for the manipulation of three surgical tools 30a, 30b, and 30c (e.g., medical instrument systems <NUM>) and an imaging device <NUM> (e.g., endoscopic imaging system <NUM>), such as a stereoscopic endoscope used for the capture of images of the site of the procedure. The imaging device may transmit signals over a cable <NUM> to the control system <NUM>. Manipulation is provided by teleoperative mechanisms having a number of joints. The imaging device <NUM> and the surgical tools 30a-c can be positioned and manipulated through incisions in the patient so that a kinematic remote center is maintained at the incision to minimize the size of the incision. Images of the surgical site can include images of the distal ends of the surgical tools 30a-c when they are positioned within the field-of-view of the imaging device <NUM>.

The assembly <NUM> includes a drivable base <NUM>. The drivable base <NUM> is connected to a telescoping column <NUM>, which allows for adjustment of the height of arms <NUM>. The arms <NUM> may include a rotating joint <NUM> that both rotates and moves up and down. Each of the arms <NUM> may be connected to an orienting platform <NUM>. The arms <NUM> may be labeled to facilitate trouble shooting. For example, each of the arms <NUM> may be emblazoned with a different number, letter, symbol, other identifier, or combinations thereof. The orienting platform <NUM> may be capable of <NUM> degrees of rotation. The assembly <NUM> may also include a telescoping horizontal cantilever <NUM> for moving the orienting platform <NUM> in a horizontal direction.

In the present example, each of the arms <NUM> connects to a manipulator arm <NUM>. The manipulator arms <NUM> may connect directly to a medical instrument, e.g., one of the surgical tools 30a-c. The manipulator arms <NUM> may be teleoperatable. In some examples, the arms <NUM> connecting to the orienting platform <NUM> may not be teleoperatable. Rather, such arms <NUM> may be positioned as desired before the surgeon S begins operation with the teleoperative components. Throughout a surgical procedure, medical instruments may be removed and replaced with other instruments such that instrument to arm associations may change during the procedure.

Endoscopic imaging systems (e.g., endoscopic imaging system <NUM> and imaging device <NUM>) may be provided in a variety of configurations including rigid or flexible endoscopes. Rigid endoscopes include a rigid tube housing a relay lens system for transmitting an image from a distal end to a proximal end of the endoscope. Flexible endoscopes transmit images using one or more flexible optical fibers. Digital image based endoscopes have a "chip on the tip" design in which a distal digital sensor such as a one or more charge-coupled device (CCD) or a complementary metal oxide semiconductor (CMOS) device store image data. Endoscopic imaging systems may provide two- or three- dimensional images to the viewer. Two-dimensional images may provide limited depth perception. Three-dimensional stereo endoscopic images may provide the viewer with more accurate depth perception. Stereo endoscopic instruments employ stereo cameras to capture stereo images of the patient anatomy. An endoscopic instrument may be a fully sterilizable assembly with the endoscope cable, handle and shaft all rigidly coupled and hermetically sealed.

<FIG> is a perspective view of an embodiment of the operator input system <NUM> at the surgeon's control console. The operator input system <NUM> includes a left eye display <NUM> and a right eye display <NUM> for presenting the surgeon S with a coordinated stereo view of the surgical environment that enables depth perception. The left and right eye displays <NUM>, <NUM> may be components of a display system <NUM>. In other embodiments, the display system <NUM> may include one or more other types of displays.

The operator input system <NUM> further includes one or more input control devices <NUM>, which in turn cause the assembly <NUM> to manipulate one or more instruments of the endoscopic imaging system <NUM> and/or medical instrument system <NUM>. The input control devices <NUM> can provide the same degrees of freedom as their associated instruments to provide the surgeon S with telepresence, or the perception that the input control devices <NUM> are integral with said instruments so that the surgeon has a strong sense of directly controlling the instruments. To this end, position, force, and tactile feedback sensors (not shown) may be employed to transmit position, force, and tactile sensations from the medical instruments, e.g., surgical tools 30a-c, or imaging device <NUM>, back to the surgeon's hands through the input control devices <NUM>. Input control devices <NUM> are foot pedals that receive input from a user's foot. Aspects of the operator input system <NUM>, the assembly <NUM>, and the auxiliary systems <NUM> may be adjustable and customizable to meet the physical needs, skill level, or preferences of the surgeon S.

During a medical procedure performed using the medical system <NUM>, the surgeon S or another clinician may need to manipulate tissue to retract the tissue, expose a target area, inspect a hidden region of tissue, or perform some other action. For example, the surgeon S may need to use the surgical tool 30a to retract the tissue but the instrument may be partially or fully outside the field of view of the endoscopic imaging system <NUM>. Thus, the surgeon S may be unable to readily observe whether or not movement of the surgical tool 30a would cause a collision with the surgical tool 30b, the surgical tool 30c, or one of the manipulator arms <NUM>. Further, the surgeon S may need to contort his or her wrist in order to take control of the surgical tool 30a. Thus, it may be desirable to have methods and systems that improve the surgeon S's experience of manipulating tissue during a medical procedure.

The various embodiments described below provide methods and systems that allow the surgeon S to more easily and directly manipulate tissue within the field of view of the endoscopic imaging system <NUM> using an instrument (e.g. one of the surgical tools 30a, 30b, or 30c). In one or more embodiments, the display system <NUM> may display a tissue control point (e.g. tissue control point <NUM> in <FIG> below) over an image representing the field of view of the endoscopic imaging system <NUM>. The surgeon S may manipulate the tissue control point <NUM> using the operator input system <NUM> and the control system <NUM> may process this input to thereby control operation of the instrument. The use of the tissue control point <NUM> simplifies the steps needed by the surgeon S to manipulate the tissue in a desired manner. Further, using the tissue control point <NUM> allows the surgeon S to control operation of the instrument to thereby manipulate tissue in the field of view of the endoscopic imaging system <NUM> even when the instrument is partially or fully out of the field of view.

<FIG> is a representational diagram of a tissue control point <NUM> that is collocated with the tissue <NUM> to be controlled using the tissue control point <NUM>. This diagram depicts a boundary <NUM> that represents the field of view of the endoscopic imaging system <NUM>. This field of view would be displayed as an image of the tissue <NUM> in a user interface on the display system <NUM>. The image may be an image of or an image representing the field of view of the endoscopic imaging system <NUM>.

The diagram further depicts an instrument <NUM>, an instrument <NUM>, and an instrument <NUM>, each of which is engaged with the tissue. Each of the instrument <NUM>, the instrument <NUM>, and the instrument <NUM> may be an example of one type of instrument that may be in a medical instrument system, such as medical instrument system <NUM> in <FIG>. For example, in one embodiment, the instrument <NUM>, the instrument <NUM>, and the instrument <NUM> may be surgical tools 30a, 30b, and 30c in <FIG>. The instrument <NUM> may be used to manipulate the tissue <NUM> during the medical procedure. The instrument <NUM> may be used to perform tasks such as, for example, retraction, countertraction, or a combination thereof. For example, the instrument <NUM> may be implemented as a retractor, a grasper, forceps, clamps, or some other type of auxiliary instrument.

The tissue control point <NUM> may be movable within the user interface displayed on the display system <NUM> in <FIG> relative to the image of the tissue and may be movable with a selected number of degrees of freedom. For example, the tissue control point <NUM> may be translatable, rotatable, or both. In one or more embodiment, the tissue control point <NUM> is implemented as a graphical element (e.g. a movable indicator) that indicates the number of degrees of freedom with which the tissue control point <NUM> may be moved. In some embodiments, the tissue control point <NUM> may be translated or rotated in any direction relative to the user interface.

In one embodiment, the tissue control point <NUM> is represented using a four-headed arrow cursor. This four-headed arrow cursor indicates that the tissue control point <NUM> is movable in four translational directions (e.g. left, right, up, and down). The tissue control point <NUM> may be used to control the instrument <NUM>. As depicted, the instrument <NUM> may be located outside the boundary <NUM> representing the field of view of the endoscopic imaging system <NUM>. The tissue control point <NUM> enables the surgeon S or other clinician to control operation of the instrument <NUM> even when the instrument <NUM> is not visible in the field of view, and thereby not displayed in the user interface. An offset <NUM> is present between the tip <NUM> and the tissue control point <NUM>. The offset <NUM> is represented by a dotted-line that extends between a tip <NUM> of the instrument <NUM> and the tissue control point <NUM>.

<FIG> is the representation diagram of the tissue <NUM> from <FIG> after the tissue <NUM> has been manipulated based on movement of the tissue control point <NUM>. As depicted, the tissue control point <NUM> has been translated upwards. Based on this movement, the control system <NUM> operates the instrument <NUM> to cause a corresponding movement of the instrument <NUM>, which thereby manipulates the tissue.

<FIG> is the representational diagram of the tissue control point <NUM> represented as a virtual object <NUM> (or virtual fixture) that is collocated with the tissue <NUM> to be controlled. In <FIG>, the virtual object <NUM> is depicted as a graphical line element. The proxy geometry <NUM> of the instrument <NUM> may be known to the control system <NUM>. The proxy geometry <NUM> may indicate the geometry of the jaws of the instrument <NUM>, the tip of the instrument <NUM>, or some other portion of the instrument <NUM>. In this embodiment, the proxy geometry <NUM> indicates the geometry of the jaws of the instrument <NUM>. A distance <NUM> is represented by a dotted-line that extends between the proxy geometry <NUM> and the virtual object <NUM>. When the proxy geometry <NUM> and virtual object <NUM> are not in contact, the distance <NUM> represents the closest distance between the proxy geometry <NUM> and the virtual object <NUM>. When the proxy geometry <NUM> and the virtual object <NUM> are in contact, the distance <NUM> represents a penetration depth, which may be used for rendering a restoring force.

<FIG> is a flowchart of a method <NUM> for manipulating tissue. The method <NUM> is illustrated in <FIG> as a set of operations or processes <NUM> through <NUM> and is described with continuing reference to <FIG>, <FIG>, <FIG>, and <FIG>. Not all of the illustrated processes <NUM> through <NUM> may be performed in all embodiments of method <NUM>. Additionally, one or more processes that are not expressly illustrated in <FIG> may be included before, after, in between, or as part of the processes <NUM> through <NUM>. In some embodiments, one or more of the processes <NUM> through <NUM> may be implemented, at least in part, in the form of executable code stored on non-transitory, tangible, machine-readable media that when run by one or more processors (e.g., the processors of control system) may cause the one or more processors to perform one or more of the processes.

At process <NUM>, the tissue control point <NUM> is displayed over the image of the tissue <NUM> in the user interface. The tissue control point <NUM> may be a graphical indicator that allows a user (e.g. the surgeon S) to control the instrument <NUM> engaged with the tissue <NUM> of the patient during the medical procedure to thereby manipulate the tissue <NUM>. The instrument <NUM> may be engaged with the tissue <NUM> by being physically associated with the tissue <NUM>. For example, the instrument may be touching the tissue <NUM>, grasping the tissue <NUM>, retracting the tissue <NUM>, applying a force to the tissue <NUM>, otherwise engaging the tissue <NUM>, or a combination thereof. The image of the tissue <NUM> may be provided by, for example, the endoscopic imaging system <NUM> in <FIG>. In other words, the image may present the field of view of the endoscopic imaging system <NUM>.

The tissue control point <NUM> is displayed over the image at a selected location over the tissue <NUM> in the image. In this manner, the tissue control point <NUM> may be considered virtually collocated with the tissue <NUM>. The selected location for the tissue control point <NUM> may be established based on a position of the instrument <NUM> relative to the tissue. In some cases, the instrument <NUM> may be visible in the image. In other cases, the instrument <NUM> may not be visible in the image. In other words, the instrument <NUM> may be out of a field of view of the endoscopic imaging system <NUM>. In cases where the instrument <NUM> is out of the field of view, the selected location for the tissue control point <NUM> relative to the image may be offset from a position of the instrument <NUM> or tip <NUM> of the instrument <NUM> relative to the tissue <NUM>.

At process <NUM>, an input is received that moves the tissue control point <NUM> within the user interface. This input may be received through the input control device <NUM> and processed by the control system <NUM>. In some embodiments, the input control device <NUM> may be a joystick. In other embodiments, the input control device <NUM> may include at least one of a touchscreen, a gesture tracking system, a gaze tracking system, a hand control device, a teleoperated device, a mouse, or some other type of input device such as described for input devices <NUM>, <NUM>.

Based on the received input, the control system <NUM> may move the tissue control point <NUM>. The tissue control point <NUM> may have a selected number of degrees of freedom. The number of degrees of freedom selected may be task-specific based on the types of corresponding movements that need to be provided for the instrument <NUM>. The human arm is considered to have seven degrees of freedom. In one embodiment, the number of degrees of freedom selected for the tissue control point <NUM> is less than the seven degrees of freedom provided by the human arm to thereby simplify the user interactions needed to achieve the desired movement of the instrument <NUM>.

In one embodiment, movement of the tissue control point <NUM> may include a left translation, a right translation, an upward translation, a downward translation, an inward translation, an outward translation, a rotation of the tissue control point, or a combination thereof. The translation of the tissue control point <NUM> depicted in <FIG> is an example of one type of movement of the tissue control point <NUM> based on the received input. In some embodiments, movement of the tissue control point <NUM> may include multiple translations in varying directions and/or the same direction. In other embodiments, the tissue control point <NUM> may be only translatable, only translatable along one axis, only rotatable, or limited in movement in some other manner. In one embodiment, when the instrument <NUM> has jaws that grasp the tissue <NUM>, movement of the tissue control point <NUM> may be restricted such that the tissue control point <NUM> cannot cause the jaws to open and release the tissue <NUM>.

At process <NUM>, the instrument <NUM>, which is physically associated with the tissue <NUM>, is operated based on the received input to thereby manipulate the tissue <NUM>. In one embodiment, operating the instrument <NUM> includes transforming the movement of the tissue control point <NUM> into a corresponding movement for the instrument <NUM> to thereby manipulate the tissue <NUM>. This transformation may take into account factors in addition to the movement of the tissue control point <NUM>.

For example, the transformation may include optimizing movement of the instrument <NUM> based on one or more secondary objectives. These secondary objectives may include optimizing a speed of movement, ensuring that the movement is within selected range of motion limits for the instrument <NUM>, avoiding collision with one or more other instruments or structures, creating sufficient working space between the instrument <NUM> and any neighboring instruments, avoiding selected areas or zones (e.g. keep-out zones), or a combination thereof. In one or more embodiments, the control system <NUM> determines the position of the instrument <NUM> and the manipulator arm (e.g. manipulator arm <NUM>) connected to the instrument relative to other instruments and manipulator arms. The control system <NUM> may compute a path of movement for the instrument <NUM> that both corresponds to the movement of the tissue control point <NUM> and prevents interaction of the different instruments and manipulator arms. The path of movement may include any number of translational movements, rotational movements, or combination thereof.

In some embodiments, the control system <NUM> may identify operational parameters for the instrument <NUM>. These operational parameters may include for example, a geometry, a minimum speed of movement, a maximum speed of movement, a range of motion, a number of degrees of freedom, other types of parameters, or a combination thereof for the instrument <NUM>. The control system <NUM> may compute a path of movement for the instrument <NUM> that takes into account these optional parameters. Further, the control system <NUM> may compute a path of movement for the instrument <NUM> that ensures that the instrument <NUM> does not enter selected areas or zones (e.g. keep-out zones).

In some embodiments, the control system <NUM> may impose limits on the amount of force the instrument <NUM> is allowed to exert. For example, the instrument <NUM> may be generally capable of exerting about <NUM> pounds of force at the tip <NUM> of the instrument <NUM>. The control system <NUM>, however, may limit the amount of force that can be exerted at the tip <NUM> of the instrument <NUM> to about <NUM> pounds of force.

In one or more embodiments, operating the instrument <NUM> at process <NUM> manipulates the tissue <NUM> by causing a corresponding movement of the tissue <NUM> that achieves both the intended movement of the instrument <NUM> as well as the secondary objectives. The corresponding movement of the tissue <NUM> may be, for example, a retraction of the tissue <NUM>, a translation of the tissue <NUM>, a twisting of the tissue <NUM>, a rotation of the tissue <NUM>, a deformation of the tissue <NUM>, or a combination thereof. In this manner, movement of the tissue control point <NUM> by the user through the input control device <NUM> may be transformed into a corresponding movement of the instrument <NUM> that results in the tissue <NUM> engaged with or near the instrument <NUM> being retracted, twisted, rotated, lifted, pushed down, pulled downwards, raised upwards, moved to the side, moved upwards, deformed, and/or otherwise manipulated.

In some embodiments, the control system <NUM> may use imaging data or sensor data to observe movement of the tissue <NUM> surrounding the tissue control point <NUM> and may update the one or more control laws used in controlling movement of the instrument <NUM> based on the movement of the tissue control point <NUM> to reduce errors in the observed movement of the tissue <NUM>. In other words, the control system <NUM> may use feedback in the form of imaging data or sensor data to reduce errors in the actual motion of the tissue <NUM> relative to the intended motion of the tissue <NUM> based on the movement of the tissue control point <NUM>.

At process <NUM>, which may be optional, a haptic feedback response is generated in response to operation of the instrument <NUM>. The haptic feedback response, which may be also referred to as a haptic communication or a kinesthetic response, may be a physical or mechanical stimulation through the application of forces, vibrations, motion, or a combination thereof to the user. The haptic feedback response may be generated based on a physical effect of the operation of the instrument <NUM> on the tissue <NUM> and may allow the user to receive information from the control system <NUM> in the form of a felt sensation on some part of the body. The haptic feedback response may, for example, allow the user to experience the stiffness, rigidity, or deformability of the tissue <NUM>. In some embodiments, the haptic feedback response may allow the user to experience traction and resistance of the tissue <NUM> to movement.

The haptic feedback response may be generated using a haptic device that generates tactile sensations that can be felt by the user. The haptic device may include at least one of a teleoperated device, a joystick, gloves, some other type of hand control device, some other type of tactile sensation generating device, or combination thereof. In some embodiments, the haptic device may be the input control device <NUM>. For example, the input control device <NUM> may reflect forces and torques generated from virtual-physical interactions through physical force. The virtual-physical interactions may be, for example, the encountering of constraints due to contact with virtual surfaces, virtual lines, virtual points, or a combination thereof.

<FIG> is an illustration of a method <NUM> for manipulating tissue. The method <NUM> is illustrated as a set of operations or processes <NUM> through <NUM> and is described with continuing reference to <FIG>, <FIG>, <FIG>, and <FIG>. Not all of the illustrated processes <NUM> through <NUM> may be performed in all embodiments of method <NUM>. Additionally, one or more processes that are not expressly illustrated in <FIG> may be included before, after, in between, or as part of the processes <NUM> through <NUM>. In some embodiments, one or more of the processes <NUM> through <NUM> may be implemented, at least in part, in the form of executable code stored on non-transitory, tangible, machine-readable media that when run by one or more processors (e.g., the processors of control system) may cause the one or more processors to perform one or more of the processes.

At process <NUM>, an initial location for the tissue control point <NUM> is virtually determined. Determining this initial location includes establishing a relationship between the tissue <NUM> to be controlled, the tissue control point <NUM>, and the instrument <NUM>. More specifically, determining this initial location includes establishing a relationship between the tissue <NUM> to be controlled, the tissue control point <NUM>, and a tip or end effector of the instrument <NUM>.

In one embodiment, the initial location for the tissue control point <NUM> may be determined or selected by the user. For example, the user may enter initial input that is used to determine the tissue control point <NUM>. The user may select the initial location using, for example, the tip <NUM> of the instrument <NUM> or some other teleoperated instrument or tool to contact a location on the surface of the tissue <NUM> and then engage a control. Engaging the control may include, for example, pressing a button on the input control device <NUM>. The initial location for the tissue control point may then be determined based on the location on the surface at which the tip <NUM> of the instrument <NUM> has engaged the tissue <NUM>. In some embodiments, the instrument <NUM> may be used to grasp the tissue <NUM>. The control system <NUM> may use the grasping force commanded to the instrument <NUM> for grasping the tissue <NUM> as a signal to establish and lock an offset between the tip <NUM> of the instrument <NUM> and the tissue control point <NUM>.

In response to the control being engaged, the control system <NUM> may then create and display the tissue control point <NUM> at a corresponding virtual location over the image. In other embodiments, the user may use the input control device <NUM> to manually move the tissue control point <NUM> in the user interface into the selected location on the image. In still other embodiments, the input control device <NUM> may track or detect the gaze of the user to determine where to position the tissue control point <NUM>. For example, the control system <NUM> may establish the tissue control point <NUM> at a location on the surface of the tissue <NUM> at which a gaze of the user is detected as being directed for a selected period of time. Gaze input from the left and right eyes of the user may be triangulated to produce a three-dimensional fixed location.

In one embodiment, the initial location or the tissue control point <NUM> may be determined by the control system <NUM>. For example, the control system <NUM> may generate a sparse or dense three-dimensional surface reconstruction of a surface of the tissue <NUM> based on imaging data received from an imaging system (e.g. a laser imaging system). The control system <NUM> may then identify the location on the surface of the tissue <NUM> connected to or that is engaged by the instrument <NUM> (e.g. the tip or end effector of the instrument <NUM>). The control system <NUM> may identify candidate points on the surface of the tissue <NUM> that are, for example, centrally located and most anterior in view and may then select the initial location for the tissue control point <NUM> based on the candidate points. The tissue control point <NUM> may be selected at a location that is visible in the field of view of the endoscopic imaging system <NUM>, is not occluded by other instruments, and is close or optimally centered with respect to controlling the instrument <NUM>.

In other embodiments, the three-dimensional surface reconstruction of the surface of the tissue <NUM> described above may be used in conjunction with the detected gaze from a single eye. For example, a vector for the gaze detected from the single eye may be intersected with the three-dimensional surface reconstruction to determine the location for the tissue control point <NUM>.

In some embodiments, the initial location of the tissue control point <NUM> may be computed from a color/depth segmentation of the image provided by the endoscopic imaging system <NUM>. For example, the control system <NUM> may segment a region of the image using color image segmentation or depth image segmentation. The control system <NUM> may then compute a centroid of the segmented region of the image as the initial location for the tissue control point <NUM>.

In other embodiments, a two-dimensional location may be determined for the tissue control point <NUM> within the image. The two-dimensional location may then be mapped to a three-dimensional location with respect to a field of view of the endoscopic imaging system <NUM> or other imaging device that provides the image. For example, stereoscopic images displayed in the left and right eye displays <NUM>, <NUM> may be processed to determine matching pixel locations in the left and right views. A depth may then be computed from the disparity between the left and right eye pixels and used to determine the three-dimensional location for the tissue control point <NUM>. Thus, the initial location for the tissue control point <NUM> may be determined with reference to a two-dimensional coordinate system or a three-dimensional coordinate system.

At process <NUM>, a selected mode is activated that locks a position of the instrument <NUM> with respect to a reference coordinate system. In one or more embodiments, the instrument <NUM> and the tissue control point <NUM> may be controlled using the same input control device <NUM> (e.g. the same joystick). Activating the selected mode configures the input control device <NUM> to ensure that the input received is used to control the tissue control point <NUM> and not the instrument <NUM>. When the selected mode is not activated, input received through the input control device <NUM> is used to control the instrument <NUM> and not the tissue control point <NUM>.

In other words, if a user has activated the selected mode, then the input control device <NUM> or some portion of the input control device <NUM> that is used to teleoperate the instrument <NUM> may be reconfigured such that input received through the input control device <NUM> or some portion of the input control device <NUM> may be used to control the tissue control point <NUM> rather than the instrument <NUM>. A user may then use the input control device <NUM> to move the tissue control point <NUM>, which in turn, causes corresponding operation of the instrument <NUM>.

At process <NUM>, input is received through the input control device <NUM> that moves the tissue control point <NUM> within the user interface. The translation of the tissue control point <NUM> depicted in <FIG> is an example of the movement of the tissue control point <NUM> that occurs at process <NUM>. At process <NUM>, movement of the tissue control point <NUM> is transformed into a corresponding movement of the instrument <NUM> to thereby manipulate the tissue <NUM>.

<FIG> is an illustration of a method <NUM> for virtually collocating the tissue control point <NUM> with the tissue <NUM> to be controlled. The method <NUM> is illustrated as a set of operations or processes <NUM> through <NUM> and is described with continuing reference to <FIG>, <FIG>, <FIG>, and <FIG>. Not all of the illustrated processes <NUM> through <NUM> may be performed in all embodiments of method <NUM>. Additionally, one or more processes that are not expressly illustrated in <FIG> may be included before, after, in between, or as part of the processes <NUM> through <NUM>. In some embodiments, one or more of the processes <NUM> through <NUM> may be implemented, at least in part, in the form of executable code stored on non-transitory, tangible, machine-readable media that when run by one or more processors (e.g., the processors of control system) may cause the one or more processors to perform one or more of the processes.

At process <NUM>, a position for the instrument <NUM> and a position for an imaging device that provides the image of the tissue are computed. In one embodiment, at process <NUM>, the position for the instrument <NUM> may be a position of a tip <NUM> of the instrument <NUM> computed using kinematic equations for the manipulator controlling the instrument <NUM>. Similarly, the position for the imaging device (e.g. the endoscopic imaging system <NUM>) may be a position of the tip of the imaging device computed using kinematic equations for the manipulator controlling the imaging device. A manipulator may be implemented as, for example, the manipulator arm <NUM> of the assembly <NUM> shown in <FIG>. The position for the tip <NUM> of instrument <NUM> may be represented by Ttip and the position for the imaging device may be represented by Timd. Ttip and Timd may be three-dimensional transformation matrices composed of three-dimensional position and three-dimensional rotation components.

At process <NUM>, a reference position for the tissue control point <NUM> is computed based on the position computed for the instrument <NUM> and an offset transformation. The offset transformation may be used to maintain an offset between the tip <NUM> of the instrument <NUM> and the tissue control point <NUM> to thereby allow the tissue control point <NUM> to become an extension of the kinematic chain of the manipulator arm <NUM> controlling the instrument <NUM>. Using the offset transformation allows the tissue control point <NUM> to be related to the instrument <NUM> in a reference coordinate system for the instrument <NUM> or the manipulator arm <NUM> controlling the instrument <NUM>. The reference position for the tissue control point <NUM> may be represented by TTCP and may be three-dimensional.

At process <NUM>, the reference position for the tissue control point <NUM> is transformed into an imaging device-based position based on the position computed for the imaging device. This imaging device-based position may be in an imaging device coordinate system (e.g. a coordinate system for the endoscopic imaging system <NUM>). The imaging device-based position may be in two-dimensions or three-dimensions. The imaging device-based position may be represented by TTCP_IM. At process <NUM>, the imaging device-based position is transformed into a display position. The display position may be in a display coordinate system for the user interface. The display position may be represented by TTCP_DC. In some embodiments, the display position may be or may be used to compute the location of the tissue control point <NUM> relative to the image displayed in the user interface. Thus, the tissue control point <NUM> may be related to the instrument <NUM> in a number of different relevant coordinate systems.

<FIG> is an illustration of a method <NUM> for generating a haptic feedback response based on movement of the tissue control point <NUM>. The method <NUM> is illustrated as a set of operations or processes <NUM> through <NUM> and is described with continuing reference to <FIG>, <FIG>, <FIG>, and <FIG>. Not all of the illustrated processes <NUM> through <NUM> may be performed in all embodiments of method <NUM>. Additionally, one or more processes that are not expressly illustrated in <FIG> may be included before, after, in between, or as part of the processes <NUM> through <NUM>. In some embodiments, one or more of the processes <NUM> through <NUM> may be implemented, at least in part, in the form of executable code stored on non-transitory, tangible, machine-readable media that when run by one or more processors (e.g., the processors of control system) may cause the one or more processors to perform one or more of the processes. In one or more embodiments, the processes <NUM> through <NUM> may be performed by the medical system <NUM>.

At process <NUM>, a position is computed for a tip of a first instrument <NUM> and a second instrument <NUM>. An input control device <NUM> may be used to control the second instrument <NUM>. In one embodiment, computing the positions at process <NUM> includes computing a position of the tips of the two instruments by computing, for example, the forward kinematics for the manipulator arms <NUM> connected to these instruments. In one or more embodiments, the input control device <NUM> includes, incorporates, or connects to a haptic device that provides haptic feedback. The position for the tip of the first instrument <NUM> may be represented by Ttip1 and the position for the tip of the second instrument <NUM> may be represented by Ttip2. In one or more embodiments, both Ttip1 and Ttip2 may be three-dimensional positions computed in a manipulator coordinate system using kinematic equations.

At process <NUM>, a reference position for the tissue control point <NUM> is computed based on the computed position of the tip of the first instrument <NUM> and an offset transformation. The offset transformation may be used to maintain an offset between the tip of the instrument <NUM> and the tissue control point <NUM> to thereby allow the tissue control point <NUM> to become an extension of the kinematic chain of the manipulator arm <NUM> controlling the instrument <NUM>. The reference position for the tissue control point <NUM> may be represented by TTCP and may be three-dimensional.

At process <NUM>, the reference position for the tissue control point <NUM> and the position of the tip of the second instrument <NUM> are transformed with respect to a common coordinate system for the medical environment <NUM> in which the medical procedure is being performed. In one embodiment, the common coordinate system may be referred to as a world coordinate system. The world position for the tissue control point <NUM> within the world coordinate system may be represented as TTCP_WC, while the world position for the tip of the second input control device <NUM> within the world coordinate system may be represented as Ttip2_WC. The world position for the tissue control point <NUM> may be the world position for the virtual object <NUM> representing the tissue control point <NUM>.

The proxy geometry <NUM> of the second instrument <NUM> and the geometry of the virtual object <NUM> representing the tissue control point <NUM> may be known. The proxy geometry <NUM> may be moved such that the proxy geometry <NUM> comes into contact with or otherwise engages the virtual object <NUM> that represents the tissue control point <NUM>. The proxy geometry <NUM> may be used to nudge, prod, or otherwise manipulate the virtual object <NUM>. The forces exerted on the virtual object <NUM> by the proxy geometry <NUM> may affect movement of the first instrument <NUM>, thereby causing manipulation of the tissue <NUM>.

In other examples, the virtual object <NUM> may be directly grasped and manipulated using the second instrument <NUM>. This type of control provides a natural and direct way of affecting the retracting instrument pose without having to change, for example, a control mode of the telemanipulation interface. In this manner, the user may perceive that they are using the second instrument <NUM> to directly move the tissue <NUM>.

At process <NUM>, the distance <NUM> between the world position for the virtual object <NUM> and the world position for the proxy geometry <NUM> for the instrument <NUM> is computed. As depicted in <FIG>, the proxy geometry <NUM> may be the geometry of the jaws of the instrument <NUM>. At process <NUM>, a determination is made as to whether the distance <NUM> is less than zero. The distance <NUM> is less than zero when there is virtual penetration or interpenetration indicating virtual contact between the proxy geometry <NUM> and the virtual object <NUM>. When this virtual contact exists, operation of the second instrument <NUM> affects the virtual object <NUM>, which may, in turn, affect the first instrument <NUM>, thereby causing manipulation of the tissue <NUM>. When contact between the proxy geometry <NUM> and the virtual object <NUM> has been lost, the distance <NUM> is not less than zero. Without this virtual contact, operation of the second instrument <NUM> does not affect the virtual object <NUM> and thus, does not affect the first instrument <NUM>. When the distance <NUM> is less than zero, the distance <NUM> may be referred to as a penetration depth. When the distance <NUM> is not less than zero, the distance <NUM> represents the closest distance between the proxy geometry <NUM> and the virtual object <NUM>.

Referring again to the process <NUM>, if the distance <NUM> is not less than zero, the method <NUM> returns to the process <NUM>, as described above. But if the distance <NUM> is less than zero, then at process <NUM>, a virtual force/torque is computed. The virtual force/torque may be virtual force/torque of the proxy geometry <NUM> on the tissue control point <NUM>. Haptic rendering may be used to provide stable virtual contact with the tissue control point <NUM> and avoid a slip-through problem that happens when penetration depth exceeds the thickness of the virtual object <NUM>.

After process <NUM> has been performed, sub-method <NUM> and sub-method <NUM> are performed. Sub-method <NUM> includes processes <NUM>-<NUM> for manipulating the tissue <NUM> via interaction with the tissue control point <NUM> and sub-method <NUM> includes processes <NUM>-<NUM> for providing haptic feedback to the user when interacting with the tissue control point <NUM>.

In sub-method <NUM>, at process <NUM>, the computed virtual force/torque is applied to the virtual object <NUM> representing the tissue control point <NUM>. The computed virtual force/torque is applied as a reaction force that moves the virtual object <NUM>. As previously described, the virtual object <NUM> geometrically represents the tissue control point <NUM> and may be virtually collocated with the tissue <NUM> in the user interface. This virtual object <NUM> may also be referred to as a simulated tissue control point body or a simulated TCP body.

At process <NUM>, the virtual object <NUM> transform is updated. This transform may be the transformation that determines how movement of the virtual object <NUM> by the proxy geometry <NUM> will affect the first instrument <NUM>. At process <NUM>, the first instrument <NUM> is operated based on the updated virtual object transform. Operation of the first instrument <NUM> manipulates the tissue <NUM>. In particular, at process <NUM>, a command for the first instrument <NUM> may be generated based the updated virtual object transform and then applied to (e.g. sent to) the first instrument <NUM>. In this manner, the second instrument <NUM> may be operated to move the proxy geometry <NUM> and thereby engage and apply a force/torque on the virtual object <NUM>. The force/torque applied to the virtual object <NUM> may, in turn, cause movement of the first instrument <NUM>, which causes manipulation of the tissue <NUM>. The force/torque may be integrated by a mass/damper virtual model to compute the corresponding velocity and change in position.

At process <NUM>, the virtual force/torque is transformed with respect to the instrument/manipulator coordinate system. At process <NUM>, the virtual force/torque is then transformed from the instrument/manipulator coordinate system to an input coordinate system. The input coordinate system is for the input control device <NUM>. At process <NUM>, the force/torque is then applied to the input control device <NUM>. Applying the force/torque to the input control device <NUM> produces a haptic feedback response that may be experienced by the user. For example, the user may feel a physical response to pushing, prodding, nudging, or other motion of the tissue <NUM> caused by operation of the first instrument <NUM> based on virtual movement of the virtual object <NUM> by the proxy geometry <NUM>.

In this manner, the tissue control point <NUM> may support familiar physical interactions by representing the tissue control point <NUM> as both a visual and haptic virtual object <NUM>. Movement of the second instrument <NUM> may move the proxy geometry <NUM> so as to impart forces on the virtual object <NUM> representing the tissue control point <NUM>. The force applied to the virtual object <NUM> may, in turn, induce movement of the first instrument <NUM>. The determination regarding the distance <NUM> made at process <NUM> may ensure that the simulated movement of the virtual object <NUM> only occurs while the proxy geometry <NUM> is in contact with the virtual object <NUM>. This ensures that tissue manipulation is continuously controlled by the second instrument <NUM> and ceases upon loss of contact between the proxy geometry <NUM> and the virtual object <NUM>.

The method <NUM> described above provides a way in which the surgeon S or other clinician may control operation of the first instrument <NUM> without switching modes on the input control device <NUM> that is being used to control the second instrument <NUM>. Rather, operation of the second instrument <NUM> may be used to virtually contact and impart forces on the virtual object <NUM>, which then causes movement or some other type of operation of the first instrument <NUM>.

Thus, the embodiments described above provide a method and apparatus for manipulating tissue using the tissue control point <NUM>. The control system <NUM> establishes a relationship between the tissue control point <NUM> and the instrument <NUM> such that translational motion of the tissue control point <NUM> causes a corresponding movement of the instrument <NUM> that also optionally takes into account other degrees of freedom to achieve secondary objectives, such as avoiding collisions with neighboring instruments. The use of the tissue control point <NUM> simplifies the steps needed by a surgeon to manipulate the tissue in a desired manner. Further, using the tissue control point <NUM> enables the surgeon to control operation of the instrument <NUM> to manipulate tissue in the field of view of the endoscopic imaging system <NUM> even when the instrument <NUM> is partially or fully out of the field of view.

One or more elements in embodiments of the invention may be implemented in software to execute on a processor of a computer system such as control processing system. When implemented in software, the elements of the embodiments of the invention are essentially the code segments to perform the necessary tasks. The program or code segments can be stored in a processor readable storage medium or device that may have been downloaded by way of a computer data signal embodied in a carrier wave over a transmission medium or a communication link. The processor readable storage device may include any medium that can store information including an optical medium, semiconductor medium, and magnetic medium. Processor readable storage device examples include an electronic circuit; a semiconductor device, a semiconductor memory device, a read only memory (ROM), a flash memory, an erasable programmable read only memory (EPROM); a floppy diskette, a CD-ROM, an optical disk, a hard disk, or other storage device. The code segments may be downloaded via computer networks such as the Internet, Intranet, etc..

Claim 1:
An apparatus comprising:
a display system (<NUM>) that displays an image of tissue (<NUM>) in a user interface;
an instrument (<NUM>) which may be engaged with the tissue by being physically associated with the tissue; and
a control system (<NUM>) communicatively coupled to the display system, the apparatus characterized by the control system being configured to:
display a tissue control point (<NUM>) over the image;
receive an input that moves the tissue control point within the user interface; and
operate the instrument responsive to the received input, the operation causing movement of the instrument to thereby manipulate the tissue.