EP1624790A4

EP1624790A4 - Endoluminal tool deployment system

Info

Publication number: EP1624790A4
Application number: EP04752537A
Authority: EP
Inventors: Brent R Wiltshire; Richard C Ewers; Rodney Brenneman; Eugene Chen; Vahid Saadat
Original assignee: USGI Medical Inc
Current assignee: USGI Medical Inc
Priority date: 2003-05-19
Filing date: 2004-05-17
Publication date: 2008-05-21
Also published as: WO2004103430A3; WO2004103430A2; JP2007511247A; EP1624790A2

Abstract

Systems, devices and methods are provided for endoscopic procedures involving tissue manipulations beyond the capabilities of traditional endoscopic instruments. Embodiments of the systems include an elongated main body (10) having a scope therethrough. Some embodiments of the systems include an elongated main body (10) which is rigidizable and/or torque transmitting to improve manipulation through passageways in the body.

Description

ENDOLUMINAL TOOL DEPLOYMENT SYSTEM

BACKGROUND OF THE INVENTION [0001] The present invention relates generally to medical devices, systems and methods. More particularly, the present invention relates to devices, systems and methods for use in endoscopic or laparoscopic procedures.

[0002] Endoscopy is a form of minimally invasive procedure wherein the interior of the body is accessed and visualized through an orifice in the body, such as the esophagus or rectum. Such access allows a surgeon or physician to view and/or treat internal portions of the orifice or internal tissues or organs which are accessible through the orifice. These procedures may be for diagnostic puφoses, such as visual inspection or the removal of a tissue sample for biopsy, or the procedure may be used for treatment puφoses, such as the removal of a polyp or tumor or the restructuring of tissue. While these procedures can be done using regular open surgery, endoscopy usually involves less pain, less risk, less scarring, and faster recovery of the patient.

[0003] Endoscopy is typically performed with the use of an endoscope, a small circular tube containing optical components. Traditional endoscopes comprise a small diameter "snake-like" insertion tube having a distal end which is inserted into the orifice to the desired internal location. Fiber optics extend through the insertion tube and terminate at the distal end to allow axial viewing from the distal end. Images of the internal location near the distal end of the endoscope are transmitted to a video monitor for the physician to view. A control handle allows the endoscopist to control the direction of the scope and in some cases, permits the actuation of air, water and suction utilities that may be required for the endoscopy procedure. [0004] Since endoscopes may be used to perform a treatment at an internal location, some endoscopes are equipped with a lumen through which a surgical instrument or tool may be passed. Generally, the lumen extends through the length of the insertion tube to the distal end so that the end effector of the inserted instrument pro trades from the distal end in the axial direction. Thus, the instrument is directed in parallel to the fiber optics so that the end effector is positioned along the line of view.

[0005] Such endoscopes have a number of constraints which limit their usefulness in performing diagnostic and surgical procedures. To begin, surgical instruments and tools are inserted axially through a working lumen in the endoscope. And, most of these endoscopes only allow axial and rotational movement of the tool beyond the distal end. This helps to maintain positioning of the tool within the field of view of the endoscope which is also directed axially. However, this limits the variety and complexity of procedures that may be performed. For example, procedures which involve tissue approximation pose great difficulty since only one portion of tissue maybe grasped at a time and lateral, rather than axial, movement may be required. Although steering of an axially inserted tool may be possible near the distal end, such steering typically positions the end effector of the tool out of the field of view of the axially directed scope. [0006] A similar minimally invasive procedure which overcomes some of these constraints is laparoscopy. In laparoscopy, the interior of the body is accessed and visualized through a small incision. When accessing the abdomen, the incision is usually made in the navel. Laparoscopy was initially used by gynecologists to diagnose and treat conditions relating to the female reproductive organs: uterus, fallopian tubes, and ovaries. It is now used for a wider range of procedures, including operations that in the past required open surgery, such as removal of the appendix (appendectomy) and gallbladder removal (cholecystectomy). Laparoscopy is performed with a device which allows the surgeon or physician to view and/or treat internal tissues or organs which are accessible through the incision. This device is the same or similar to an endoscope, sometimes referred to as a laparoscope. The device comprises a small diameter insertion tube having a distal end which is inserted into the incision to the desired internal location. Fiber optics extend through the insertion tube and terminate at the distal end to allow axial viewing from the distal end. Images of the internal location near the distal end are transmitted to a video monitor for the physician to view. Sometimes, access through an incision creates a shorter, straighter and more direct access path than through an orifice. Therefore, some laparoscopes may have a shorter and stiffer insertion tube than some endoscopes.

[0007] Although laparoscopes suffer from many of the same limitations as endoscopes, laparoscopy allows additional surgical instruments and tools to be inserted through separate incisions to perform procedures. Proper location of the incisions can allow instraments to be positioned in various directions. Therefore, movement and viewing is not limited to the axis of the laparoscope and simultaneous viewing of the tissues and the instruments may be more readily achieved during the procedure. However, these additional benefits are achieved at the cost of increased invasiveness. Access paths must be created for the instruments with the use of trocars requiring general anesthesia, risk of complications and infection, and increased overall recovery time for the access paths to heal. In addition, access may be difficult or contraindicated in some patients, particularly in the morbidly obese. [0008] Thus, it would be desired to provide an improved methods, devices and systems to perform minimally invasive procedures. Particularly, methods, devices and systems which would provide the benefits of endoscopy, such as lower invasiveness and access to deeply internal locations, with the benefits of laparoscopy, such as the use of multiple instruments with movement and viewing along various axes. The devices and systems would be reliable, convenient and easy to use with improved outcomes for patients due to reduction in invasiveness and therefore risk, cost and recovery time. At least some of these objectives will be met by the invention described hereinafter.

[0009] In addition, it would be desired to provide improved methods, devices and systems which would provide improve passage and manipulation through endovascular passageways. Typical endoscopes have a length in the range of 130 to 190cm and may be used to traverse a variety of tortuous paths within the body. For example, endoscopes may be used to access the lower gastrointestinal tract from entry through the anus, sometimes reaching as far as the cecum at the distal end of the colon. The upper gastrointestinal tract may be accessed through the esophagus to the stomach and the upper regions of the small intestine. Achieving access to any of these regions, particularly through the colon, involves tedious manipulation of the endoscope. Much of this manipulation involves torqueing of the endoscope. However, once a substantial length of the endoscope has passed into the body, torqueing becomes increasingly difficult. In addition, accessing such regions usually takes place through minimally supported lumens, such as the colon, which do not provide resistive strength or through open cavities, such as the stomach, which do not provide particular pathways for the endoscope. This also limits the use of endoscopic access to desired treatment locations.

[0010] Thus, it would be desired to provide improved methods, devices and systems to access desired freatment locations. Particularly, methods, devices and systems which would improve the ability to access desired treatment locations minimally invasively, particularly endoscopically or laparoscopically. The devices and systems would be reliable, convenient and easy to use with improved outcomes for patients due to reduction in invasiveness and therefore risk, cost and recovery time. At least some of these objectives will be met by the invention described hereinafter. BRIEF SUMMARY OF THE INVENTION [0011] The present invention provides systems, devices and methods for endoscopic procedures involving tissue manipulations beyond the capabilities of traditional endoscopic instraments. Some embodiments of the systems include an elongated main body which is rigidizable and/or torque transmitting to improve manipulation through passageways in the body. And, some embodiments of the systems include an elongated main body having a scope therethrough and at least one steerable tool arm which extends from the distal end of the main body. In these embodiments, the system typically includes two tool arms, each arm steerable to form a curve laterally outward which then bends laterally inward so that the arms form a an angular or boomerang shape. In addition, end effectors extend from the distal ends of each arm for use in manipulation of tissue. The angular shape brings the end effectors together in view of the scope for cooperative movements which are continuously visible by the surgeon through the scope. In addition, the tool arms may be steerable in any additional direction and may be rotateable to allow grasping, pulling, tugging, elevation and more complex manipulation of tissue. Thus, the systems and devices of the present invention provide many of the capabilities of open surgery or laparoscopic surgery with an endoscopic approach. In addition, the systems and devices of the present invention provide improvements in manipulation for accessing desired treatment locations. [0012] In a first aspect of the present invention, the tool arm(s) comprise a shaft having a proximal end and a deflectable or steerable distal end. In some embodiments, the steerable distal end will be laterally stabilized so that the distal end may be steered, i.e. bent or manipulated, within a plane but will resist deflection outside of the plane during use. The steering plane will generally be parallel to a central axis of the scope but may be rotated by rotation of the tool arm. hi this way, the arm(s) will maintain stable positioning within the field of view of the scope and will resist accidental deflection outside of the field. It may be appreciated that the tool arm may also be translated axially within the stabilized plane while maintaining viewing within the field.

[0013] A preferred structure for achieving lateral stability comprises a plurality of adjacent links. Usually, the links are pivotally attached by hinged structures. In some embodiments, the hinged structures comprise pivot pins which are disposed parallel to one another and generally transverse to the stabilized plane in which the ami may be steered. In other embodiments, the hinged structures comprise male and female bearing surfaces which define axes, wherein the axes are disposed in parallel to limit deflection of the distal section to within the plane. A variety of other structures are also available to provide lateral stability, such as deployment frames, various shaped linkages connected by reinforcements or pullwires, and slotted tubes, to name a few.

[0014] Typically, the distal end includes at least two steerable sections, wherein a distal-most steerable section includes a tip section which curves in a first direction and wherein an intermediate steerable section includes a base which curves in the opposite direction, where both curves are in the stabilized plane, hi some embodiments, the tip section curve has a radius which is greater than that of the curve of the base. To achieved such curvatures, the adjacent links may be shaped to allow substantially continuous deflection. Or, the adjacent links may be shaped so that the steerable distal end is deflectable to form a predetermined curvature wherein the arm is then restricted from further deflection.

[0015] Means for selectively deflecting the distal section of the tool arm(s) often comprise at least one pullwire or one pushwire. Such pull or pushwires may be present in any quantity and arrangement. The means for selectively deflecting the distal section can further include at least one spring which is configured to straighten the distal section in opposition to the pullwire or pushwire.

[0016] In some embodiments, the tool arm includes an end effector disposed at its distal end. A wide variety of end effectors may be used depending on the procedure or tissue manipulations which are desired. For example, end effectors may include but are not limited to knives, needles, sutures, staplers, fasteners, clippers, electrosurgical or hemostatic cutters and coagulators, laser welders, cryosurgery instraments, secondary scopes, forceps, lasers hooks, tongs, graspers, retractors, probes, clamps, scissors, tissue approximation devices and suction applicators. Alternatively, the tool arm may include a tool deployment lumen through which a tool having an end effector may be passed. In these embodiments, the tool arm may include a steering cuff arranged for passage of the tool therethrough so that manipulation of the tool within the steering cuff steers the distal end of the tool arm. Thus, in either case, manipulation of the end effector and the tool arm may be interconnected. [0017] In another aspect of the present invention, the elongated main body has a distal end, a proximal end, and an arm guide lumen extending through at least a distal section of the elongated main body. In preferred embodiments, the elongated main body has a viewing or scope lumen extending therethrough and terminating in the distal tip. It may be appreciated that the scope lumen may be used for passage of any viewing element or device or the scope lumen may comprise a viewing element or device fixed or integrated within the main body. Herein, it will be assumed that the term "scope lumen" will be used to refer to either of these embodiments. [0018] The arm guide lumens and the viewing scope lumen may be arranged in any suitable fashion within the main body. For example, when the elongated main body has a second arm guide lumen, the distal terminations of the two arm guide lumens and the one viewing scope lumen may be arranged in a generally triangular pattern on the distal tip of the main body. Alternatively, the lumens may be aligned, wherein the viewing scope lumen is disposed between the arm guide lumens.

[0019] Typically, at least the distal section of the elongated main body is steerable. In some embodiments, the elongated main body comprises a first section and a second section, the first section disposed proximally of the second section, and the first and second sections are independently lockable. Thus, the first section may be lockable while the second section remains steerable. Such steering may be achieved with means for selectively deflecting the second section within at least a single plane. This may include retro flexion wherein the distal end of the main body is directed toward the proximal end. In some embodiments, the distal section of the elongated main body comprises a plurality of adjacent links to allow for such steering.

[0020] Typically, at least the distal section of the elongated main body has a generally cylindrical exterior wherein the arm guide lumen does not extend out of the cylindrical exterior. And, the arm guide lumen terminates at a distal tip of the elongated main body so that the tool arm advances through the distal tip. Likewise, as mentioned previously, the elongated main body typically has a viewing scope lumen extending therethrough and terminating in the distal tip.

[0021] In yet another aspect of the present invention, the tool arms may have a distal end which is steerable by a variety of mechanisms. For example, the distal end may be comprised of a flexible tube having at least one pullwire attached thereto so that manipulation of the at least one pullwire deflects the steerable distal end. Or, the tool arm may have a steerable distal end which comprises a flexible tube having shape memory material so that emergence of the steerable distal end from the distal tip of the main body allows deflection of the steerable distal end to a shape memory position. Or, the tool arm may further comprise a deployment frame extending from the distal tip of the main body, the frame comprising at least two supports each attached to one of the at least two tool aπns so that manipulation of the deployment frame deflects the attached tool arms.

[0022] In an additional embodiment of the present invention, the endoluminal tool deployment system may be comprised of an elongated main body having a distal end, a proximal end, and at least two arm guide lumens extending over or through at least a distal section of the elongated main body, wherein said arm guide lumens extend fully to a distal tip of the main body, and at least two tool arms adapted to extend through the arm guide lumens of the elongated main body, said tool arms emerging from the distal tip of the main body. [0023] In still another aspect of the present invention, the endoluminal tool deployment system comprises an elongated main body having a distal end, a proximal end, and an arm guide lumen extending through at least a distal section of the elongated main body, wherein at least the distal section comprises a plurality of adjacent links. The system further includes a means for selectively deflecting the distal section within at least a single plane, and at least one tool arm adapted to extend through the arm guide lumen of the elongated main body.

[0024] hi a further aspect of the present invention, a method is provided for deploying one or more tools in an anatomical space. In a preferred embodiment, the method comprises introducing a distal end of a main body to said anatomical space, advancing a tool arm from a tool deployment lumen in said main body into said anatomical space, deflecting and positioning the tool arm to locate a distal tip thereof adjacent to a target location within the anatomical space, wherein a distal section of the arm is curved and laterally stabilized in a single plane, and advancing a tool through a lumen of the tool arm to the target location. [0025] In some embodiments, deflecting and positioning comprises tensioning a plurality of adjacent hinged links within the distal section of the tool arm. The adjacent hinged links may be joined by hinge pins which are disposed peφendicularly to the single plane such that the pins stabilize the distal section and inhibit deflection outside of the single plane. The method may further comprise viewing the target location through a viewing scope disposed in the main body, wherein the tool arm extends axially from a distal tip of the main body from a location adjacent to the viewing scope. [0026] hi some embodiments, an endoluminal system is provided comprising an elongated main body having a proximal end, a distal end sized for passage through a body lumen, and at least one lumen extending between the proximal and distal ends. The system further includes a torque transmitting feature which provides torque transmission between the proximal and distal ends while the main body is unlocked and able to form a desired configuration. In addition, the system includes a locking mechanism which locks the main body in the desired configuration. The at least one lumen may be used for passage of any desired device, including, for example, a viewing scope and optionally one or more tool arms. In addition, the system typically includes a steering mechanism which steers the main body to the desired configuration while the main body is unlocked. In most embodiments, the steering mechanism comprises at least one pullwire extending through the plurality of adjacent links.

[0027] In preferred embodiments, at least a portion of the elongated main body comprises a plurality of adjacent links. Torque may be transmitted through the adjacent links by a variety of torque transmitting features. For example, in some embodiments, when the plurality of adjacent links comprises at least a first link and an adjacent second link, the torque transmitting feature comprising at least one protrusion or tooth from the first link slidably engageable with at least one groove in the adjacent second link, the torque transmitting feature providing torque transmission through the portion of the main body while the links are rotateable. In some embodiments, the at least one protrasion comprises a pair of protrasions, each protrasion extending outwardly from an outer surface of the first link in a diametrically opposite position from the other protrasion. Correspondingly, the at least one groove may comprise a pair of grooves, each groove configured to accept one or the pair of protrusions passing therein. When the first link comprises a first domed ring having the outer surface and the adjacent second linlc comprises a second domed ring having an inner surface, the outer surface of the first domed ring is mateable with the inner surface of the second domed ring along a longitudinal axis, and the rings are rotateable away from the longitudinal axis. In some embodiments, each groove comprises a first groove end and a second groove end, the groove ends substantially aligned with the longitudinal axis to allow sliding of the protrusions along the grooves during rotation of the rings away from the longitudinal axis. It may be appreciated that such protrasions may extend inwardly from an inner surface and the grooves may be disposed on the outer surface of an adjacent link to accept such protrasions. Thus, the protrasions and associated grooves may function in a similar manner in an inverse arrangement. [0028] In other embodiments, the torque transmitting feature comprises a protrusion or a pin from the first link slidably engageable with a slot in the adjacent second link. This is an example of a torque transmitting feature which provides torque transmission by preventing disengagement of the adjacent links while the main body is unlocked and able to form a desired configuration. In some embodiments, the plurality of adjacent engageable links comprises at least a first link and an adjacent second linlc and the torque transmitting feature comprising at least one pin from the first link slidably engageable with at least one slot in the adjacent second link. Further, in some embodiments, the at least one pin comprises a pair of pins, each pin extending outwardly from an outer surface of the first linlc in a diametrically opposite position from the other pin. Similarly, the at least one slot comprises a pair of slots, each slot configured to accept one or the pair of pins passing therethrough. [0029] In preferred embodiments, the first linlc comprises a first domed ring having the outer surface and the adjacent second link comprises a second domed ring having an inner surface, the outer surface of the first domed ring being mateable with the inner surface of the second domed rings along a longitudinal axis, and the rings being rotateable away from the longitudinal axis. Typically, each slot comprises an elongate opening between a first slot end and a second slot end, the slot ends substantially aligned with the longitudinal axis to allow sliding of the pins through the slots during rotation of the rings away from the longitudinal axis. It may be appreciated that such pins may extend inwardly from an inner surface and extend through slots on adjacent links. Thus, the pins and associated slots may function in a similar manner in an inverse arrangement.

[0030] In yet other embodiments, the torque transmitting feature comprises a torque transmitting covering over the plurality of adjacent engageable links to prevent disengagement of the adjacent links. In some instances, the torque transmitting covering comprises a snuggly fit sheath including reinforcements, such as a braided material. The reinforcements may comprise nylon, polyurethane, polyethylene, Teflon, metal, or polymer, for example. Optionally, the reinforcements may be coated with a polymer or the reinforcements may be covered with a separate polymer component. Alternatively, the torque transmitting covering may comprise a polymer coating over the links themselves.

[0031] In still further embodiments, an endoluminal device is provided comprising an elongated main body having a proximal end, a distal end, and at least one lumen extending between the proximal and distal ends, at least a portion of the elongated main body comprising at least a first linlc and an adjacent second link which are rotateable relative to each other when unlocked, one of the at least one lumen extending through the links having at least one partition. An elongated shaft is present passing through one of the at least one lumen in a manner to transmit torque by contacting the least one partition. In addition, a locking mechanism is provided which locks the links upon actuation by preventing rotation of the links relative to each other. [0032] In some embodiments, the at least one partition comprises an inward protrusion. And, the at least one lumen extending through the links may have a fluted shape forming the inward protrusions. In other embodiments, the at least one partition comprises a divider spanning across the one of the at least one lumen. The shaft passes through the at least one lumen and is positioned between partitions in each of the links. Torqueing of the plurality of adjacent links is transmitted through the shaft and partitions. For example, by applying torque to a first link, the first link rotates about the longitudinal axis until the shaft contacts a partition. Since the partitions are generally aligned, the shaft will also contact partitions in a second link. Therefore, torque is transmitted from the first link to the second link. This transmission may be repeated through any number of links, transmitting torque through a plurality of adjacent links.

[0033] In additional embodiments, the torque transmitting feature comprises an oval shape of the plurality of adjacent links. And, in other embodiments, the torque transmitting feature comprises a plurality of wires or rods extending through the adjacent links, hi preferred embodiments, the plurality of rods comprises approximately 8 to 64 rods. Torque is transmitted from linlc to linlc through these torque transmitting features. [0034] Further, a method of accessing is provided comprising providing an elongated main body having a proximal end, a distal end, a visualizing element and a locking mechanism, wherein the main body is capable of forming a desired configuration in an unlocked state and holding the desired configuration in a locked state. The method further includes introducing the main body through a body passageway in the unlocked state forming the desired configuration so that the distal end reaches a target location, actuating the locking mechanism to hold the main body in the desired configuration, and viewing the target location with the use of the visualizing element. [0035] Introducing the main body may comprise allowing the main body to assume a shape of the body passageway in the unlocked state forming the desired configuration. Or, introducing the main body may comprise steering the main body through the body passageway in the unlocked state forming the desired configuration. In either situation, in some embodiments, the main body comprises a plurality of adjacent links so that actuating the locking mechanism comprises holding the links in a fixed relation to each other. In particular, the plurality of adjacent links sometimes comprises a plurality of nestable elements so that holding the links comprises wedging the links together to hold them by friction. [0036] When the main body includes at least one lumen extending between the proximal and distal ends, the method may further comprise introducing an instrument through the at least one lumen. In some embodiments, the instrument comprises a tool arm. When the elongated main body further includes a visualizing lumen and the visualizing element comprises an endoscope, the method may further comprise positioning the endoscope within the visualizing lumen. [0037] Other objects and advantages of the present invention will become apparent from the detailed description to follow, together with the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

[0038] Fig. 1 illustrates an embodiment of a system of the present invention. [0039] Fig. 2 illustrates the system of Fig. 1 in an assembled arrangement.

[0040] Fig. 2 A depicts the cross-section of the system of Fig. 2, and Fig. 2B depicts an alternative cross-section.

[0041] Figs. 3A-3D, 4-6 illustrate possible movements of the steerable distal ends of the tool arms. [0042] Figs. 7A-7B illustrate the use of an embodiment of the system to perform a mucosectomy.

[0043] Figs. 8 A-8C illustrate an embodiment of the main body in a variety of positions.

[0044] Fig. 9 A shows an embodiment of the shaft of the main body comprised of a multiplicity of nestable elements, and Fig. 9B provides an exploded view of these elements.

[0045] Figs. 9C-9E provide cross-sectional views of various nestable elements.

[0046] Fig. 10A provides an exploded view of nestable elements having a pullwire extending through their centers and Fig. 10B provides a cross-sectional view one of the nestable elements. [0047] Fig. 10C illustrates the nestable elements of Fig. 10A with the inclusion of liners and Fig. 10D provides a cross-sectional view of one of the nestable elements.

[0048] Figs. 10E-10O illustrate embodiments of the main body.

[0049] Fig. 11 illustrates an embodiment of a tool arm.

[0050] Figs. 12A- 12B, 13 A- 13B, 14 illustrate embodiments of adj acent links disposed at the distal end of a tool arm.

[0051] Fig. 15 illustrates examples of possible deflections or movements of an embodiment of the tool arm.

[0052] Figs. 16A-16B illustrate another embodiment of a tool arm comprising a plurality of adjacent links. [0053] Figs. 17, 17A-17C illustrate an embodiment of a tool arm which is steerable to a predetermined arrangement.

[0054] Figs. 18A-18B illustrate the creation of distinct curvatures achieved by separate pullwires. [0055] Fig. 19 illustrates two tool arms steered to a predetermined arrangement.

[0056] Fig. 20 illustrates an embodiment including both links which are steerable to a predetermined arrangement and links which are unrestrictedly steerable.

[0057] Figs. 21 A-21B illustrate an embodiment of a tool arm comprised of a slotted tube.

[0058] Figs. 21C-21D illustrate an embodiment of a tool arm comprised of a tube wherein a pullwire is positioned on the outside of the tube.

[0059] Figs. 21E-21F illustrate an embodiment of a tool arm comprised of a polymer wall co-extmded with shape memory material. [0060] Figs. 21G-21H illustrate a mechanism for steering the tool arms including a deployment frame.

[0061] Figs. 22A-22B, 23, 24 illustrate embodiments of the shaft of the main body.

[0062] Figs. 25A-25B provide a view of the proximal end of an embodiment of the main body wherein two tool arms are present, each including a steering cuff. [0063] Figs. 26, 27 A-27B, 28 A-28B illustrate embodiments of a steering cuff.

[0064] Figs. 29, 29A-29D illustrate embodiments of a tool having an end effector in the form of various types of scissors.

[0065] Fig. 30 illustrates an embodiment of the tool having an end effector in the form of gator toothed graspers. [0066] Fig. 31 illustrates an embodiment of the tool having an end effector in the form of an articulatable grasper.

[0067] Figs. 32-36 illustrate embodiments of the tool having end effectors in the form of various shaped retractors.

[0068] Figs. 37A-37B illustrate grasping hooks inserted through auxiliary lumens in the main body and Fig. 37C illustrates a fixation device which may be deployed by the tool amis when such grasping hooks are used in a plication procedure.

[0069] Figs. 38, 39, 40A-40B illustrate alternative tools passed through auxiliary lumens in the main body.

[0070] Fig. 41 illustrates a tool passed through an arm guide lumen for use in conjunction with a tool arm.

[0071] Fig. 42 illustrates an arm used to cleanse a portion of the main body, particularly the scope lens. [0072] Figs. 43 A-43F illustrate a torque transmitting feature utilizing a tooth and groove concept to maintain alignment of the plurality of adjacent links at locations along its length.

[0073] Figs. 44A-44D illustrate a torque transmitting feature utilizing a pin and slot concept to maintain alignment of the plurality of adjacent links at locations along its length. [0074] Figs. 45 A-45C illustrate the use of a torque transmitting covering over the plurality of adjacent links providing torque transmission therethrough while the links are rotateable. [0075] Figs. 46A-46D illustrate cross-sectional views of a link wherein one of the at least one lumen extending through the links has at least one partition.

[0076] Figs. 47A-47B illustrate a torque transmitting feature wherein the links have an oval cross-section.

[0077] Figs. 48A-48C illustrate a torque transmitting feature comprising a plurality of rods extending through the adjacent links.

DETAILED DESCRIPTION OF THE INVENTION J. Overview

[0078] An embodiment of a system 2 of the present invention is illustrated in Fig. 1.

The system 2 includes an elongated main body 10 having a proximal end 12 and a distal end 14 terminating in a distal tip 16. The main body 10 is used to access an internal target location within a patient's body. Typically, the distal end 14 is passed through a body orifice and one or more naturally occurring body lumens to the target location, such as in endoscopy, while the proximal end 12 remains outside of the body. Therefore, the main body 10 has a deflectable and/or steerable shaft 20, either due to choice of material or design of the shaft 20 to include links, hinges, coils or other similar stractures to allow deflection. Thus, Fig. 1 illustrates the main body 10 in a deflected position wherein the body 10 includes curvatures. Such deflection and/or steering may be useful in traversing body lumens to the target location and is achievable by manipulation of a handle 22 near the proximal end 12. It may be appreciated, however, that the system 2 may be used in laparoscopic procedures wherein such deflection and/or steering may be less utilized for placement of the main body 10. In either case, rigidization of some or all the shaft 20 maybe desired, for example to provide a stable visualization platform. Therefore, portions of the shaft 20 of the main body 10 are lockable to maintain a desired shape and provide rigidity, either due to choice of material or design of the shaft 20 to include locking mechanisms, as will be described in later sections. [0079] The main body 10 also includes at least one arm guide lumen 26 which extends over or through at least a distal section of the main body 10, typically along the majority of the length of the body 10 as shown. Here in Fig. 1, two arm guide lumens 26 are shown, each extending from a position along the shaft 20 near the proximal end 12 to the distal tip 16. hi addition, the main body 10 includes a scope lumen 24 which extends through the shaft 20 to the distal tip 16.

[0080] The system 2 also includes at least one tool arm 30, two are shown in Fig. 1, each arm 30 of which is insertable through a separate arm guide lumen 26 as indicated by dashed line. Each tool arm 30 has a proximal end 32, a distal end 34 and a shaft 36 therebetween. The distal end 34 is steerable, such as by manipulation of adjacent links as schematically indicated. Such steerability may be controlled by a steering cuff 35 which is part of the proximal end 32. The shaft 36 is typically flexible or deflectable to allow deflection of the surrounding main body shaft 20. Each tool arm 30 additionally includes a tool deployment lumen 38 therethrough. [0081] In this embodiment, the system 2 also includes at least one tool 40, two are shown in Fig. 1. Each tool 40 includes a distal end 42, a proximal end 44 and an elongate shaft 46 therebetween to allow passage through the tool deployment lumen 38 of the arm 30. Each tool 40 has an end effector 48 disposed at the distal end 42 and optionally a handle 50 at the proximal end 44 for manipulation of the end effector 48 from outside the body. The tool 40 is advanced so that the end effector 48 emerges from the distal end 34 of the arm 30. [0082] Fig. 2 illustrates the system 2 of Fig. 1 in an assembled arrangement. Here, the tool arms 30 are shown inserted through the arm guide lumens 26 of the main body shaft 20. The steerable distal ends 34 of the arms 30 protrude from the distal end 14 of the main body 10 and the proximal ends 32 of the arms 30 protrude from the proximal end 12 of the main body 10. As shown, the steering cuffs 35 are located at the proximal ends 32 of the arms 30. In addition, the tools 40 are shown inserted through the tool deployment lumens 38 so that the end effectors 48 extend beyond the steerable distal ends 34 of the arms 34. Likewise, the proximal ends 44 of the tools 40 with handles 50 are shown protruding from the steering cuffs 35. Movement of the tools 40 against the steering cuffs 35 will actuate steering of the distal ends 34 of the arms 30, as will be described in later sections.

[0083] Fig. 2A provides a cross-sectional view of system 2 of Fig. 2. Since the shaft

20 of the main body 10 has a generally cylindrical exterior in this embodiment, the cross- section of the shaft 20 has a circular shape. It may be appreciated that cylindrical shafts may alternatively have an elliptical, oval or oblong cross-section. The shaft 20 has an outer diameter in the range of about 5 to 25 mm, preferably approximately 14 mm. The shaft 20 has a wall 21 with a thickness in the range of about 0.5 to 5 mm, preferably about 2-3 mm, defining an inner central lumen 23. Within the wall 21 lies various pushwires or pullwires 96, hereinafter referred to as pullwires, for steering the main body 10 which may be present in a variety of quantities and arrangements. Alternatively, the pullwires 96 may be present within the central lumen 23. At least one arm guide lumen 26, two are shown, extend through the central lumen 23. Each arm guide lumen 26 has an inner diameter in the range of about 0.5 to 5 mm, preferably about 4 mm. Positioned within the lumens 26 are the shafts 36 of the tool aπns 30. And, likewise, positioned within the shafts 36 are the tools 40. Fig. 2A also illustrates the scope lumen 24 which has an inner diameter in the range of about 2 to 10 mm, preferably about 4 mm. In this embodiment, the two arm guide lumens 26 and the scope lumen 24 are arranged in a generally triangular pattern which is maintained to the distal tip 16, however any suitable arrangement may be used which allows viewing of the tool arms, particularly the end effectors, by the scope. For example, Fig. 2B illustrates a cross-section of an embodiment wherein the shaft 20 has an oval shape and the arm guide lumens 26 and the scope lumen 24 are generally aligned. Here, the scope lumen 24 is disposed between the arm guide lumens 26 to facilitate viewing of the tool arms 30. Also illustrated in Figs. 2A and 2B are additional lumens which may be used for various needs. For example, an irrigation suction lumen 60, an insufflation lumen 56 and an auxiliary lumen 58 may be present, each having an inner diameter in the range of about 0.5 to 5 mm, preferably about 2 mm. The auxiliary lumen 58 may be utilized for a variety of uses, such as insertion of additional tools, such as a macerator, a grasping tool, a cutting tool or a light source, to name a few, for use in conjunction with the end effectors present at the distal ends of the arms 30 or the distal ends of the tools 40 inserted through the arms 30. [0084] Figs. 3A-3D illustrate a series of movements of the steerable distal ends 34 of the tool arms 30. This series serves only as an example, as a multitude of movements may be achieved by the distal ends 34 independently or together. Fig. 3 A illustrates the distal tip 16 of the main body 10. The scope lumen 24 is shown along with two arm guide lumens 26 terminating at the distal tip 16 and forming a triangular pattern as illustrated in Fig. 2A. Fig. 3B illustrates the advancement of the distal ends 34 of the tool arms 30 through the arm guide lumens 26 so that the arms 30 extend beyond the distal tip 16. Figs. 3C-3D illustrate deflection of the arms 30 to a preferred arrangement. Fig. 3C illustrates deflection of the arms 30 laterally outward. This is achieved by curvature in the outward direction near the base 64 of the steerable distal end 34. Fig. 3D illustrates deflection of the tip section 66 of the distal end 34 laterally inward achieved by curvature in the inward direction so that each arm 30 forms a hook shape. By facing the tip sections 66 of the arms 30 toward each other as shown, the tip sections 66 are positioned directly in the path of the scope lumen 24. Therefore, when a scope 28 is positioned within the scope lumen 24, the tip sections 66 of the tool arms 30 and any tools 40 advanced therethrough, will be visible tiirough the scope 28. In Figs. 3C-3D, deflection of the arms 30 is achieved with the use of adjacent links 62 in the areas of desired curvature. Embodiments of such links 62 and other mechanisms of deflection will be discussed in later sections. Further, the deflection of Figs. 3A-3D are shown to be within a single plane. However, various embodiments include deflection in multiple planes. Likewise, the arms 30 are shown to be deflected simultaneously in Figs. 3A- 3D, however the arms 30 may be deflected selectively or independently. [0085] Figs. 4-6 illustrate additional possible movements of the tool arms 30. For example, Fig. 4 illustrates axial movement of the tool arms 30. Each tool arm 30 can independently move distally or proximally, such as by sliding within the tool deployment lumen 38, as indicated by arrows. Such movement maintains the arms 30 within the same plane yet allows more diversity of movement and therefore surgical manipulations. Fig. 5 illustrates rotational movement of the tool arms 30. Each tool arm 30 can independently rotate, such as by rotation of the ami 30 within the tool deployment lumen 38, as indicated by circular arrow. Such rotation moves the arm 30 through a variety of planes. By combining axial, lateral and rotational movement, the aπns 30, and therefore the tools 40 positioned therethrough, may be manipulated through a wide variety of positions in one or more planes. [0086] Fig. 6 illustrates further articulation of the tool arms 30. In some embodiments, the arms 30 are deflectable to form a predetermined arrangement, such as illustrated in Fig. 3D. Typically, when forming the predetermined arrangement, the arms 30 are steerable up until the formation of the predetermined arrangement wherein the arms 30 are then restricted from further deflection. In other embodiments, the arms are deflectable to a variety of positions and are not limited by a predetermined arrangement. Such an embodiment is illustrated in Fig. 6 wherein the amis 30 articulate so that the tip sections 66 curl inwardly toward the distal tip 16 of the main body 10. Again, the tip sections 66 are positioned in front of the scope lumen 24 and scope 28 for viewing. Typically, the tip sections 66a are positioned on opposite sides of a central axis 31 of the scope 28, wherein the field of view (indicated by arrow 29) spans up to approximately 140 degrees, approximately 70 degrees on each side of the central axis 31. In addition, the depth of field is typically in the range of approximately 1-10cm. [0087] As mentioned previously, the endoluminal tool deployment system 2 of the present invention may be used to access a various internal tissues or organs to perform a wide variety of surgical procedures. Figs. 7A-7B illustrate the use of an embodiment of the system 2 to perform a mucosectomy, or removal of a portion of the mucosa and/or submucosa of the stomach. Fig. 7A illustrates advancement of the main body 10 through the esophagus E to the stomach S. The main body 10 is then steered to a desired position within the stomach S and the stomach mucosa M is visualized through the scope 28 at the distal tip 16. Referring to Fig. 7B, the tool arms 30 are then advanced through the main body 10 and articulated. As mentioned, tools 40 may be advanced through the tool arms 30 or an end effector 48 may be disposed at the distal end of each arm 30. Here, a grasper 80 is disposed at the distal end of one aπxt 30 and a cutter 81 is disposed at the distal end of the other arm 30. The grasper 80 is used to grasp a portion of the mucosa M. The grasped portion of mucosa M can then be elevated by rotation or manipulation of the tool arm 30. This allows safe resection of the portion of mucosa M by cutting with the use of the cutter 82, as shown. Manipulation and resection of the tissue is visualized throughout the procedure through the scope 28 which is aligned with the tip sections 66, and therefore end effectors 48.

[0088] It may be appreciated that the systems, methods and devices of the present invention are applicable to diagnostic and surgical procedures in any location within a body, particularly any natural or artificially created body cavity. Such locations may be disposed within the gastrointestinal tract, urology tract, peritoneal cavity, cardiovascular system, respiratory system, trachea, sinus cavity, female reproductive system and spinal canal, to name a few. Access to these locations may be achieved through any body lumen or through solid tissue. For example, the stomach may be accessed through an esophageal approach, the heart tiirough a port access approach, the rectum through a rectal approach, the uterus through a vaginal approach, the spinal column through a port access approach and the abdomen through a port access approach.

[0089] A variety of procedures may be performed with the systems and devices of the present invention. The following procedures are intended to provide suggestions for use and are by no means considered to limit such usage: Laryngoscopy, Rhinoscopy, Pharyngoscopy, Bronchoscopy, Sigmoidoscopy (examination of the sigmoid colon, the sigmoid colon is the portion that connects the descending colon to the rectum; primarily for diagnostic pmposes, however a biopsy procedure and trans anal micro surgery may be performed for removing tumors), Colonoscopy (examination of colon; for the removal of polyps and tumors or for biopsy), and Esophagogastroduodenoscopy (EGD) which enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain.

[0090] In addition, endoscopic retrograde cholangiopancreatography (ERCP) may be achieved which enables the surgeon to diagnose disease in the liver, gallbladder, bile ducts, and pancreas. In combination with this process endoscopic sphincterotomy can be done for facilitating ductal stone removal. ERCP may be important for identification of abnormalities in the pancreatic and biliary ductal system. Other treatments include Cholecystectomy (removal of diseased gallbladder), CBD exploration (for common bile duct stones), appendicectomy. (removal of diseased appendix), hernia repair TAP, TEPP and other (all kinds of hernia), fundoplication and HISS procedures (for gastro esophageal reflux disease), repair of duodenal perforation, gastrostomy for palliative management of late stage upper G.I.T. carcinoma), selective vagotomy (for peptic ulcer disease), splenectomy (removal of diseased spleen), gastric restrictive and malabsorbtive procedures (for morbid obesity), upper and lower G.I. endoscopies (diagnostic as well as therapeutic endoscopies), pyloroplastic procedures (for children's congenital deformities), colostomy, colectomy, adrenalectomy (removal of adrenal gland for pheochromocytoma), liver biopsy, gastrojejunostomy, subtotal liver resection, gastrectomy, small intestine partial resections (for infarction or stenosis or obstruction), adhesions removal, treatment of rectum prolaps, Heller's Myotomy, devascularization in portal hypertension, attaching a device to a tissue wall and local drag delivery to name a few.

77. Main Body

[0091] As mentioned previously, the system 2 of the present invention includes an elongated main body 10 having a proximal end 12 and a distal end 14 terminating in a distal tip 16. The main body 10 may have a variety of features which are present in a variety of combinations. Generally, the features include deflectability, steerability, torqueability, lockability, lumens for the passage of visualization elements, tool arms, and/or instruments, and integral visualization elements, tool arms, and/or instruments, to name a few. In addition, the main body may have any of these features throughout any portion of the main body, including the entire length of the main body or individual subportions. [0092] One embodiment of the main body 10 is illustrated in Figs. 8A-8C, 9A-9D. i this embodiment, the main body 10 includes deflectability and/or steerability and lumens for the passage of visualization elements, tool arms, and/or instruments, such as scope lumen 24. Fig. 8 A illustrates the main body in a straight configuration. Since the main body 10 is used to access an internal target location within a patient's body, the main body 10 has a deflectable and/or steerable shaft 20. Thus, Fig. 8B illustrates the main body 10 having various curvatures in its deflected or steered state. In preferred embodiments, the main body 10 is steerable so that the main body 10 may be advanced through unsupported anatomy and directed to desired locations within hollow body cavities. In some embodiments, the main body 10 includes a first section 90 which is proximal to a second section 92, as indicated in Fig. 8B. Although both sections 90, 92 are steerable, the first section 90 may be locked in place while the second section 92 is further articulated. This is illustrated in Fig. 8C, wherein the first section 90 is shown in a locked position unchanged from Fig. 8B and the second section 92 is shown in various retroflexed positions. In retroflexion, the second section 92 is curved or curled laterally outwardly so that the distal tip 16 is directed toward the proximal end 12 of the main body 10. Optionally, the second section 92 may also be locked, either in retroflexion or in any other position. [0093] Steering and locking may be achieved by any suitable mechanisms. In some embodiments, the shaft 20 comprises a multiplicity of nestable elements 260, as illustrated in Fig. 9A. Fig. 9B provides an exploded view of the nestable elements 260 of Fig. 9A. Here it can be seen that the elements 260 are disposed so that a distal surface 262 of one element 260 coacts with a proximal surface 264 of an adjacent element. Each of the nestable elements 260 includes one or more pullwire lumens 98 through which pullwires 96 pass. The pullwires 96 are used to hold the elements 260 in nesting alignment and to provide steering and locking. The pullwires 98 preferably are made from a superelastic material, e.g. nickel titanium alloy, to provide flexibility, kink-resistance and smooth movement of the pullwires 96 through the pullwire lumens 98. Alternatively, the pullwires 96 may be made from braided stainless steel, a single stainless steel wire, poly-para-phenylene terephthalamide

(such as Kevlar®), a high tensile strength monofilament thread, combinations thereof or any suitable materials.

[0094] Generally, the adjacent surfaces 262, 264 are contoured to mate so that when the pullwires 96 are relaxed, surfaces 262, 264 can rotate relative to one another. This allows the shaft 20 to form curvatures throughout its length in any direction. Each pullwire 96 is fixed at its distal end to a specific element 260 along the shaft 20 or to the distal tip 16. When tension is applied to a specific pullwire 96, a curvature forms in the shaft 20 proximal to the fixation point, thus steering the shaft 20. The pullwires 96 may be arranged in various patterns to achieve steering in various directions. For example, Fig. 9C is a cross-sectional view of the shaft 20 in the first section 90 of Fig. 8B. Here, eight pullwires 96 (four pullwires 96a and four pullwires 96b) are shown passing through the wall 21. Four pullwires 96a terminate at the distal end of the first section 90 and are used to steer the first section 90. Since the pullwires 96a are equidistantly positioned, applying tension to the pullwires 96a, either individually or in combination, steers the first section 90 in any desired direction. The first section 90 may be locked in place by holding the tension in the pullwires 96a using any suitable mechanisms. For example, tension may be applied to the pullwires 96 simultaneously until the elements 260 are compressed to a state in which they are locked by friction wherein the tension is held. [0095] Fig. 9D is a cross-sectional view of the shaft 20 in the second section 92 of

Fig. 8B. Here, four pullwires 96b are shown passing tiirough the wall 21. These pullwires 96b extended through the first section 90, as indicated in Fig. 9C, and terminate near the distal tip 16. Since the pullwires 96b are equidistantly positioned, applying tension to the pullwires 96b, either individually or in combination, steers the second section 92 in any desired direction. Since the pullwires 96b also pass through the first section 90, such steering may also effect the curvature in the first section 90 when the first section is not locked. However, such effects are minimal, may be counteracted or compensated for by steering in the first section 90, and may be avoided by locking. The second section 92 may be also be locked in place by holding the tension in the pullwires 96b using any suitable mechanisms. [0096] hi this embodiment, the wall 21 extends continuously from the proximal end

12 to the distal end 14 with the first and second sections 90, 92 determined by the termination points of the pullwires 96 which extend therethrough. Alternatively, the first and second sections 90, 92 maybe comprised of separate shafts which are coaxially positioned adjacent to one another. [0097] In the embodiment illustrated in Fig. 9B, the nestable elements 260 have a central lumen 23 which passes through the length of the main body 10. Instraments or tools may be passed through this lumen 23, as indicated in Figs. 9C-9D, or tubes may be present within the lumen 23 through which instraments or tools may be passed. In preferred embodiments, the nestable elements 260 have holes formed therein so that lumens are formed by alignment of the holes when the elements 260 are stacked. For example, Fig. 9E provides a cross-sectional view of a nestable element 260 illustrating the holes formed therein which serve as lumens. As shown, a scope lumen 24, arm guide lumens 26, and auxiliary lumens 58 extend through the center of the element 260 while pullwire lumens 98 are located around the periphery. [0098] It may be appreciated that pullwire lumens 98 may also extend through the center of the element 260. For example, Fig. 10A illustrates an embodiment having a pullwire 96 which extends through the center of the stacked nestable elements 260. Fig. 10A provides an exploded view of the nestable elements 260 wherein the elements 260 are disposed so that a distal surface 262 of one element 260 coacts with a proximal surface 264 of an adjacent element. As shown, each of the nestable elements 260 includes a pullwire lumen 98 through its center. Fig. 10B provides a cross-sectional view of a nestable element 260 of Fig. 10A. As shown, the nestable element 260 includes a locking pullwire lumen 98c having a pullwire 96c therethrough in the center of the element 260 surrounded by various other lumens, such as a scope lumen 24, aπn guide lumens 26, auxiliary lumen 58 and various pullwire lumens 98 used for steering. Once the elements 260 are positioned in a desired arrangement, the shaft 20 may be locked in place by the central pullwire 96c. Applying tension to the pullwire 96c compresses the elements 260 to a state in which they are locked by friction wherein the tension is held. [0099] In addition, liners 266 may be passed through any of the lumens of the stacked nestable elements 260. Such liners 266 fomi create a continuous lumen connecting the lumen holes of the nestable elements 260. Fig. 10C illustrates the nestable elements 260 of Fig. 10A with the inclusion of liners 266 passing through, for example, the arm guide lumens 26. Likewise, Fig. 10D provides a cross-sectional view of a nestable element 260 of Fig. IOC. Here, liners 266 are shown positioned through the nestable element 260 forming lumens 24, 26, 58 therethrough. It may also be appreciated that liners 266 may extend through pullwire lumens 98 as well. The liners 266 may be coated on their luminal surface with a hydrophilic coating for reducing friction or the liners 266 may be comprised of a lubricious polymer such as Teflon®, fluoroethylene polymer (FEP) or the like. [0100] As mentioned previously, it may be appreciated that the shaft 20 of the main body 10 may have a variety of stractures to provide features such as deflectability, steerability, torqueability, lockability, visualization and various tools, etc. Exemplary embodiments of structures which provide deflectability, steerability and or lockability are described above and provided in co-pending U.S. Patent Application No.10/281,462 filed October 25, 2002, which is a continuation in part of U.S. Patent Application Nos. 10/173,203, 10/173,227, 10/173,238 and 10/173,220, all of which were filed on June 13, 2002 and herein incoφorated by reference for all pvuposes. Also of interest and incoφorated by reference for all puφoses are co-pending U.S. Patent Application Nos.10/281,461 and 10/281,426 each filed on October 25, 2002. It is understood that lockablility includes locking the main body in a desired configuration to maintain one or more curvatures along its length. Thus, in these instances the main body is shape lockable. Stractures which provide torqueability will be described in later sections, however it is understood that these features are applicable to any of the embodiments described herein. [0101] In addition, it may be appreciated that the main body 10 may be comprised of a traditional endoscope or laparoscope. Exemplary embodiments of traditional endoscopes are provided in U.S. Patent Nos. 3,948,251; 4,036,218; 4,201,198; 4,224,929; 4,988,171; 5,020,539; 5,035,231; 5,068,719; 5,170,775; 5,172,225; 5,187,572; and 5,196,928, all of which are herein incoφorated by reference for all puφoses. Fig. 10E illustrates the shaft 20 of the main body 10 comprising a traditional endoscope 650, or other endoscope, which includes a visualizing element 652 and at least one light source 654. In this embodiment, the endoscope 650 includes two arm guide lumens 26 for the passage of tool arms 30. The tool arms 30 each have end effectors 48, as shown, or tools 40 which have end effectors 48 may be advanced through a tool deployment lumen 38 in each arm 30. Fig. 10F provides a cross- sectional view of the shaft 20 of Fig. 10E. Fig. 10G illustrates the shaft 20 of the main body 10 comprising a plurality of steerable and/or lockable nestable elements 260 and a traditional endoscope 650, or other endoscope, passing therethrough which includes a visualizing element 652 and at least one light source 654. The endoscope 650 may be advanceable and/or retractable through an endoscope lumen 656 in the shaft 20 of the main body 10 or may be fixed within the shaft 20. The endoscope 650 may be positioned so that a distal end 658 of the endoscope 650 is flush with the distal tip 16 of the shaft 20 or is disposed at any position along the shaft 20 including extending beyond the distal tip 16, as shown. Fig. 10H provides a cross-sectional view of Fig. 10G. Here, the wall 21 of the shaft 20 is more clearly visible including pullwires 96 for steering and/or locking. Further, the shaft 20 of the main body 10 may include one or more arm guide lumens 26 for the passage of tool arms 30, as shown in Fig. 101. The tool arms 30 each have end effectors 48, as shown, or tools 40 which have end effectors 48 may be advanced through a tool deployment lumen 38 in each arm 30. Fig. 10J provides a cross-sectional view of Fig. 101. [0102] Fig. 10K illustrates the shaft 20 of the main body 10 having an integral or integrated visualizing element 652 and at least one light source 654. Again, the shaft 20 comprising a plurality of nestable elements 260 for steering and/or locking. Optionally, the shaft 10 may also include a lumen 660, illustrated in Figs. 10M-10N, for passage of a variety of tools, instraments or devices therethrough, including tool arms 30. Or, as shown in Fig. 10O, the shaft 20 having an integral visualizing element and at least one light source 654 may have individual arm guide lumens 26 for the passage of tool aπns 30. It may also be appreciated that the tool arms 30 of Fig. 10O may alternatively be fixed or integral with the shaft 20.

[0103] The visualizing elements 652 of any of the embodiments include elements which transmit and/or detect a visual image. For example, such visualizing elements 652 may include a coherent fiber optic bundle, an ultrasound device, and/or charge coupled devices (CCD) for operation in the visible spectrum of electromagnetic radiation, the infrared spectrum of electromagnetic radiation, the ultraviolet spectrum of electromagnetic radiation, and/or the x-ray spectmm of electromagnetic radiation.

III. Tool arms

[0104] As mentioned previously, system 2 also includes at least one tool arm 30, each arm 30 of which is insertable through a separate arm guide lumen 26 in the main body 10. As shown in Fig. 11, each tool arm 30 has a proximal end 32, a distal end 34 and a shaft 36 therebetween. The distal end 34 is steerable, such as by manipulation of adjacent links 62 as schematically indicated. Such steerability may optionally be controlled by a steering cuff 35, disposed within the proximal end 32. Each tool arm 30 additionally includes a tool deployment lumen 38 therethrough.

A. Distal end [0105] Figs. 12A-12B illustrate an embodiment of adjacent links 62 disposed at the distal end 34 to allow steerability of the arm 30. Here, links 62 are pivotally connected by hinge stractures 100. As shown in Fig. 12A, the links 62 are shaped so that connection by the hinge stractures 100 creates gaps 102 between the links 62 directly opposite to the hinge structures 100. A pullwire 96 is shown extending through the links 62 and terminating at a fixation point 104. Refeπing now to Fig. 12B, retraction of the pullwire 96 draws the links 62 together, minimizing the gaps 102 between the links 62. Due to the shape and aπangement of the links 62, this movement creates a curve in the arm 30 as shown. The distal end 34 may be steered to have any curvature between substantially straight and a maximum curvature wherein the gaps 102 are completely closed or another limiting feature is established. In some embodiments, up to 360 degree curvature of the distal end 34 is possible. The distal end 34 may be returned to a straightened position by advancement of the pullwire 96 or by the presence of a spring which will straighten the distal end 34 by recoil force. [0106] Figs. 13A-13B illustrate a similar embodiment of adjacent links 62 disposed at the distal end 34 to allow steerability of the arm 30. Again, links 62 are pivotally connected by hinge stractures 100. However, as shown in Fig. 13 A, the links 62 are shaped so that connection by the hinge stractures 100 creates gaps 102 between the links 62 on both sides of the hinge structures 100. A pullwire 96 is shown extending through the links 62 and terminating at a fixation point 104. Referring now to Fig. 13B, retraction of the pullwire 96 draws the links 62 together, minimizing the gaps 102 between the links 62 along the pullwire 96 and maximizing the gaps 102 on the opposite side of the hinge stractures 100. Due to this shape and aπangement of the links 62, this movement creates a curve in the arm 30 as shown. The distal end 34 may also be returned to a straightened position by advancement of the pullwire 96 or by the presence of a spring which will straighten the distal end 34 by recoil force. However, in this embodiment, the distal end 34 may be deflected or curved in the opposite direction by continued advancement of the pullwire 96. Advancement of the pullwire 96 minimizes the gaps 102 on the opposite side of the hinge stractures 100 causing a curvature in the opposite direction. Likewise, a spring may be present to straighten the distal end 34 from a curvature in this opposite direction.

[0107] Fig. 14 illustrates an embodiment similar to the embodiment illustrated in Fig.

13A-13B. The links 62 are shown pivotally connected by hinge structures 100. Here the hinge structures 100 comprise pivot pins 106 which are arranged in parallel to limit deflection to a single plane. In some embodiments, the hinge structures comprise male and female bearing surfaces which define axes, wherein the axes are disposed in parallel to limit deflection of the distal section to within the single plane. The links 62 are shaped so that connection by the pivot pins 106 creates gaps 102 between the links 62. Closure of the gaps 102 on one side of the pivot pins 106 simultaneously opens gaps on the other side of the pins 106. Fig. 14 also illustrates an end effector 48 of a tool 40 which has been advanced through the tool deployment lumen 38 of the arm 30.

[0108] Fig. 15 illustrates examples of possible deflections or movements of the tool arms 30. Here, two arms 30 are shown emerging from the distal tip 16 of the elongated main body 10. The distal end 34 of each arm 30 is steerable and comprised of a plurality of adjacent links 62. The arm 30 on the left is shown steered to a position wherein the tip section 66 is curled inwardly forming an almost complete circular shape. In contrast, the arm 30 on the right is shown steered to a position wherein the tip section 66 is deflected slightly inwardly forming an arc shape. Thus, the arms 30 may be independently steerable to varying degrees of curvature. Preferably, the arms 30 are steerable inwardly to perform surgical procedures in cooperation and to maintain visibility through the centrally located scope. [0109] Figs. 16A-16B illustrate another embodiment of a tool arm 30 comprising a plurality of adjacent links 62. Here, the links 62 are comprised of disks 110 having faces which are angled to form gaps 102 between the disks 110 when the disks 110 are stacked. The disks 110 are connected by one or more wires or ribbons 112. In this embodiment, illustrated in Fig. 16B, two ribbons 112 are present, each at diametrically opposite positions within the wall of each of the stacked disks 110 so that the angled faces are aligned between the ribbons 112. The ribbons 112 may be embedded in the wall, co-molded with the stacked disks or simply advanced tiirough a lumen in the wall. The ribbons 112 maintain relative position of the disks 110 and stabilize the steerable distal end 34 to be deflectable in only a single plane. Also shown in Fig. 16B, lumens 114 are present between the ribbons 112 for positioning pullwires 96 therethrough. The pullwires 96 pass through the angled portions of the disks 110 so that application of tension to a pullwire 96 draws the angled faces of the disks 110 together to close the gaps 102 therebetween. This in turn widens the diametrically opposite gaps 102 creating curvature in the stack.

[0110] As mentioned previously, in some embodiments, the arms 30 are deflectable to form a predetermined arrangement, such as previously illustrated in Fig. 3D. Typically, when foπning the predeteπnined arrangement, the arms 30 are steerable up until the formation of the predetermined arrangement wherein the arms 30 are then restricted from further deflection. Fig. 17 illustrates an embodiment of such an arm 30 comprising a plurality of adjacent links 62 wherein the arm 30 is steerable to a predeteπnined arrangement. As shown, the distal end 34 comprises a base 64 which deflects the distal end 34 outwardly and a tip section 66 which deflects inwardly. Between the base 64 and tip section 66 lies a spacer 68 which is rigid. The spacer 68 may be considered a larger elongate link or simply a straight section. Usage of such spacers 68 is optional and may be used to create specific predetermined arrangements. Fig. 17A is an enlarged view of the tip section 66 which illustrates the shapes of the links 62 which are pivotally connected by hinge stractures 100 formed into the links 62. Gaps 102 are present on opposite sides of the structures 100 to allow curvature of the distal end 34. The size of the gaps 102 will vary due to varying sizes and shapes of the links 64 so that closure of the gaps 102 forms a specific curvature. This is most easily seen in Figs. 17B-17C. Fig. 17B illustrates links 62 of the base 64 having varying shapes to create gaps 102 of varying size. As shown, a pullwire 96 extends through the links 62 along the gaps 102. Applying tension to the pullwire 96 draws the links 62 together to close the gaps 102 and to form a predetermined curve as in Fig. 17C. [0111] The predetermined arrangement of Fig. 17 includes curvatures in opposite directions, the base 64 curving laterally outwardly and the tip section 66 curving laterally inwardly. These distinct curvatures may be achieved by separate pullwires 96. For example, as shown in Fig. 18A, a first pullwire 97a may be positioned along one side of the tool arm 30 terminating at a fixation point 104a located midway along the distal end 34. The links 62 which lie proximally of this fixation point 104a form the base 64. A second pullwire 97b may be positioned along the opposite side of the arm 30 terminating at a fixation point 104b located at the tip of the distal end 34. Generally, the links 62 which lie between the fixation point 104a and the fixation point 104b form the tip section 66. Referring now to Fig. 18B, by applying tension to the first pullwire 97a, the base curves laterally outwardly, and by applying tension to the second pullwire 97b, the tip section curves laterally inwardly. [0112] Fig. 19 illustrates two tool arms 30 which are steered to a predetermined arrangement. Such steering is achieved with the use of pullwires 96 as illustrated in Figs. 18A-18B. Fixation points 104b are visible while fixation points 104a are hidden within the arms 30. As shown, the links 62 are varied in size and shape to form this arrangement when tension is applied to the pullwires 96. For example, the links 62 are generally larger thought the bases 64 and smaller through the tip sections 66. Further, this embodiment includes stabilizers 120 which pass through the arms 30 for stability.

[0113] In some embodiments, the steerable distal end 34 includes both types of links, links which are steerable to a predetermined arrangement and links which are unrestrictedly steerable. For example, Fig. 20 illustrates an embodiment wherein the base 64 is comprised of links 62 which are appropriately shaped and sized to deflect laterally outwardly to fomi a predetermined arrangement. Such deflection is achieved with a pullwire which is hidden from view and terminates midway along the distal end 34. In this embodiment, the tip section 66 is comprised of links 62 which are appropriately sized and shape to deflect laterally inwardly in an unrestricted fashion. The links 62 of the tip section 66 are hinged together by pivot pins 106 to provide support throughout the unrestricted movement. In addition, a tool 40 having an end effector 48 is shown passed through the tool deployment lumen 38 in the arm 30. Also shown in Fig. 20, the arms 30 are rotated to lie in different planes, a feature which has been described in previous sections.

[0114] It may be appreciated that the embodiments which include links may have any number of links. For example, the steerable distal end 34 may have two links 62 which are hinged together by a hinge structure 100. In this example, the shaft 36 would direct the first linlc 62 in a first direction and the hinge structure 100 would turn the distal tip 16 towards a second direction. The addition of more linkages 62 would create a smoother curve and/or allow multiple curves throughout the steerable distal end 34. [0115] Although the previous embodiments of the tool arms 30 have been comprised of a plurality of adjacent links, it may be appreciated that the arms 30 may be comprised of material in any suitable form. For example, each arm 30 may be comprised of a polymeric tube which has been pre-shaped, such as by heat setting, to form a desired curvature. The polymeric tube is comprised of a material which is sufficiently flexible to allow straightening of the curve for delivery through the arm guide lumen 26 and adequately flexible to allow recoiling of the arm 30 to form the desired curvature upon emergence from the lumen 30. [0116] In another embodiment, each arm 30 is comprised of a slotted tube, as illustrated in Figs. 21A-21B. Referring to Fig. 21 A, a tube 130 has a series of slots 132 along its length. In this embodiment, the slots 132 are present along one side of the tube 130 however, it may be appreciated that the slots 132 may be present on both sides of the tube or along any portion of the tube which is desired to deflect. Referring back to Fig. 21 A, the pullwire 96 is positioned within the tube along the slots 132 and fixed to the tube 130 at a fixation point 104. By applying tension to the pullwire 96, the tube 130 is deflected toward the pullwire 96 as shown in Fig. 21B. The presence of the slots 132 allows the tube 130 to be comprised of a relatively rigid or thick material while deflecting and curving with minimal buckling or impedance by the tube 130. It may be appreciated that the tube 130 of Figs. 21 A- 2 IB may alternatively be a solid-walled tube without slots comprised of a thinner or more flexible material which itself allows deflection and curvature with minimal buckling or impedance. Further, each of the following embodiments illustrating various tool arms 30 may be comprised of solid-walled or slotted tubes, or any other suitable tube construction. [0117] Figs. 21C-21D illustrate an embodiment of the arm 30 comprised of a tube

130 wherein a pullwire 96 is positioned on the outside of the tube 130 and fixed to the tube 130 at a fixation point 104. By applying tension to the pullwire 96, the tube 130 is deflected toward the pullwire 96 as shown in Fig. 2 ID. Since the pullwire 96 is disposed outside of the tube 130, the pullwire 96 forms a tether to the fixation point 104 and does not follow along the surface of the tube 130.

[0118] Figs. 21E-21F illustrate an embodiment of the arm 30 comprised of a polymer wall co-extruded with shape memory material, such as nitinol wire. Fig. 2 IE illustrates the arm 30 in a straightened position, wherein the arm 30 is passed through the arm guide lumen 26, and a curved position, wherein the arm 30 recoils to a shape-memory curve. Fig. 21F provides a cross-sectional view of the aπn 30 of Fig. 21E illustrating shape-memory material 280 distributed within the wall of the arm 30.

[0119] Figs. 21G-21H illustrate an alternative mechanism for steering the tool arms 30. Referring to Fig. 21G, the shaft 20 of the main body 10 is illustrated having a pair of tool arms 30 extending therefrom. Surrounding the arms 30 lies a deployment frame 290. The frame 290 is comprised of a semi-rigid or rigid material, such as stainless steel wire, which provides sufficient strength to apply force to the arms 30. The frame 290 comprises at least two supports 292, each extending from the distal tip 16 of the shaft 20 and connecting at a peak 294. Each support 292 attaches to a tool arm 30 at an attacliment point 296. The frame 290 also includes an actuation support 298 extending from the distal tip 16 to the peak 294. The arms 30 and supports 292, 298 advance from the distal tip 16 of the main body 10 to a desired location in the body in a straight configuration as illustrated in Fig. 21 G. Referring to Fig. 21H, application of tension to the actuation support 298 draws the peak 294 toward the distal tip 16 causing the supports 292 to bow or bend outward drawing the attached arms 30 outward. Likewise, the supports 292 may include hinges wherein the supports 292 would bend at the hinge. Although Fig. 21H illustrates the arms 30 bending at the attachment points 296, it may be appreciated that the arms 30 may bend at any location. Such bending directs the tool deployment lumens 38 toward each other to facilitate coordination of tools passed therethrough. Movement of the peak 294 proximally and distally varies the curvature of the arms 30 and provides steering. The frame 290 also serves to create a working space, restricting suπounding tissue from encroaching on the arms 30 and tools 40. [0120] In most embodiments, the distal ends of the tool arms are lockable to maintain a deflected position. Such locking may be achieved by any suitable mechanisms. When the tool arm is steerable by manipulation of pullwires or pushwires, the wires may be held in place to lock the distal end in a desired position. In embodiments comprising a multiplicity of nestable elements through which pullwires pass, the pullwires are typically used to hold the elements in nesting alignment and to provide steering and locking. By applying tension to the pullwires simultaneously, the elements may be compressed to a state in which they are locked by friction wherein the tension is held. Other locking mechanism may also be used. Further, the tool arms may be locked rotationally and axially within the main body to maintain positioning of the tool arm in relation to the main body.

B. Shaft [0121] As described previously, the shaft 36 of the tool arm 30 passes though the main body 10. In embodiments wherein the main body 10 is deflectable, the shaft 36 is also deflectable. However, although it is desired that the shaft 36 be laterally deflectable, it is also desired that the shaft 36 maintain axial rigidity. Any suitable construction may be used, including a braid reinforced torqueable tube. Additional embodiments are described below. [0122] Figs. 22A-22B illustrate embodiments of the shaft 36 comprising a coil 140.

Here, illustrated in Fig. 22 A, the turns of the coil 140 lie adjacent to each other to prevent axial movement and maintain axial rigidity. However, the coil configuration allows deflection of the shaft 36 as shown in Fig. 22B. [0123] In another embodiment, illustrated in Fig. 23, the shaft 36 comprises a plurality of adjacent linkages 150. Here, each linkage 150 includes a pair of protruding structures 152 on its face and a pair of notches 154 on its base. The protmding stractures 152 and notches 154 are both arc shaped so that the protruding stractures 152 of one linkage 150 rotateably interfϊt with the notches 154 of an adjacently stacked linkage 150. By alternating the position of the pairs of protmding stractures 152 and notches 154 as shown in Fig. 23, the shaft 36 is flexible in both lateral bending directions while maintaining stiffness axially and in torsion. Also shown are flared lumens 158 which pass through the protruding stractures 152 and the wall of the shaft 36. Flaring allows for a rod or wire passed therethrough to move within the lumen 158 as a linkage 150 rotates over the protruding structure 152. Round pullwire lumens 156 pass through the notches 154 and the wall of the shaft 36 as shown. The rod or wire holds the linkages 150 in a stacked configuration and optionally may be used to steer the shaft 36.

[0124] In another embodiment, illustrated in Fig. 24, the shaft 36 comprises a plurality of adjacent linkages 160 which are also stacked to provide lateral deflection while maintaining axial rigidity. Here, each linkage 160 includes a pair of protruding stractures 162 on its face and a pair of notches 164 on its base. The protruding stractures 162 and notches 164 are both arc shaped so that the protruding stractures 162 of one linkage 160 rotateably interfit with the notches 164 of an adjacently stacked linkage 160. By alternating the position of the pairs of protruding stractures 162 and notches 164 as shown in Fig. 24, the shaft 36 is flexible in both lateral bending directions while maintaining stiffness axially and in torsion, hi this embodiment, the linkages 150 include a central lumen 166 through which a rod or wire is passed. The rod or wire is used to hold the linkages 60 in the stacked configuration. C. Proximal End

[0125] The proximal end 32 of the tool arm 30 may simply terminate in an endpiece or connector for passage of a tool 40 through its tool deployment lumen 38. However, the proximal end 32 may optionally include a steering cuff 35 for steering the tool arm 30, particularly for steering its distal end 34.

[0126] Fig. 25A illustrates an embodiment of the proximal end 12 of the main body

10 wherein two tool arms 30 are present, each inserted through an arm guide lumen 26 in the shaft 20 of the main body 10. As shown, each tool arm 30 includes a steering cuff 35 which remains outside of the main body 10 and the tool deployment lumen 38 is accessible through the steering cuff 35. Fig. 25B illustrates an alternative embodiment of the proximal end 12 wherein two tool arms 30 are present, each inserted through an arm guide lumen 26 through the handle 22 of the main body 10. Again, each tool ami 30 includes a steering cuff 35 which remains outside of the main body 10 and the tool deployment lumen 38 is accessible through the steering cuff 35. This embodiment also includes a locking mechanism 170 on each arm 30. The locking mechanism 170 can be manipulated, such as by turning a lever 172 shown in Fig. 25B, to lock the distal end 34 or the tool arm 30 in a steered or deflected position. [0127] Fig. 26 illustrates an embodiment of a steering cuff 35 disposed at the proximal end 32 of a tool arm 30 wherein a tool 40 is passed therethrough. In this embodiment, the tool arm 30 includes four pullwires 96 (three are visible in Fig. 26) which are equidistantly positioned around the perimeter of the shaft 36. The pullwires 96 are used to steer the distal end 34 of the arm 30 as previously described. As shown, the tool 40 has a distal end 42 with an end effector 48 which emerges from the distal end 34 of the arm 30. Likewise, the tool 40 has a proximal end 44 which emerges from the steering cuff 35. In this embodiment, the steering cuff 35 has a funnel shape wherein one end is attached to at least the pullwires 96 and typically additionally to the arm 30 itself. Deflection of the proximal end 44 of the tool 40, indicated by angular arrow 180, presses the proximal end 44 against the steering cuff 35 which rotates the steering cuff 35 to a deflected position, indicated by dashed line. Such rotation applies tension to pullwires 96 diametrically opposite to the deflected position as indicated by anrows 182. Such tension steers the distal end 34 of the arm 30. Thus, manipulation of the tool 40 within the steering cuff 35 can be used to steer the distal end 34 of the arm 30.

[0128] Figs. 27A-27B and Figs. 28 A-28B illustrate another embodiment of a steering cuff 35. Here, the steering cuff 35 has a sphere shape and is disposed at the proximal end 32 of the tool arm 30. The tool 40 is passed through a lumen 184 in the sphere shaped cuff 35 so that the distal end 42 of the tool emerges from the distal end 34 of the arm 30 and the proximal end 44 remains outside of the cuff 35 as shown. In this embodiment, the tool arm 30 includes four pullwires 96 (three are visible) which are equidistantly positioned around the perimeter of the shaft 36. The pullwires 96 are used to steer the distal end 34 of the arm 30 as previously described. Fig. 27A illustrates the pullwires 96 emerging from the shaft 36 of the arm 30 and attached to the surface of the sphere shaped cuff 35. Likewise, Fig. 27B provides a similar view, however in this case the arm 30 is cutaway to reveal the pullwires 96 extending through lumens in the shaft 36 and the tool 40 extending through the tool deployment lumen 38. Fig. 28A illustrates the embodiment in the straight position. Deflection of the proximal end 44 of the tool 40, indicated by angular arrow 180, presses the proximal end 44 against the steering cuff 35 which rotates the steering cuff 35 to a deflected position, as shown in Fig. 28B. Such rotation applies tension to pullwires 96 diametrically opposite to the deflected position as indicated by arrow 182. Such tension steers the distal end 34 of the arm 30. Thus, manipulation of the tool 40 within the steering cuff 35 can be used to steer the distal end 34 of the arm 30.

[0129] It may be appreciated that the embodiments of the steering cuff 35 depicted in

Fig. 26 and Figs. 27A-27B, 28A-28B may include any number of pullwires 96 for any desired level of steerability. For example, in each embodiment, two pullwires 96 maybe present disposed on opposite sides of the steering cuff 35 for movement of the steerable distal end 34 of an arm 30 in a single plane. This would be the case for laterally stabilized arms 30.

IV. Tool

[0130] As mentioned previously, the system 2 also includes at least one tool 40. In some embodiments, the tool 40 may simply comprises an end effector 48 positioned at the distal end of the tool ami 30 wherein the end effector 48 is operated by manipulation of mechanisms which extend through the arm 30. In other embodiments, each tool 40 includes a distal end 42, a proximal end 44 and an elongate shaft 46 therebetween to allow passage through the tool deployment lumen 38 of the arm 30. The shaft 46 is typically desired to be a torque-stable tube comprised of any suitable material, such as a braid or coil-reinforced extrusion. In these embodiments, each tool 40 has an end effector 48 disposed at the distal end 42 and optionally a handle 50 at the proximal end 44 for manipulation of the end effector 48 from outside the body. Thus, the tool 40 is advanced so that the end effector 48 emerges from the distal end 34 of the arm 30. [0131] A wide variety of end effectors 48 may be used depending on the procedure or tissue manipulations which are desired. For example, end effectors 48 may include but are not limited to knives, needles, sutures, staplers, fasteners, clippers, electrosurgical or hemostatic cutters and coagulators, laser welders, cryosurgery instraments, secondary scopes, forceps, lasers hooks, tongs, graspers, retractors, probes, clamps, scissors, tissue approximation devices and suction applicators.

[0132] Fig. 29 illustrates an embodiment of a tool 40 having an end effector 48 in the form of scissors 200. Scissors are one of the oldest surgical instruments used by surgeons. Scissors are used to perform many tasks in open surgical procedure but its use in minimal access surgery requires greater skill. As shown, the scissors 200 includes two blades 202, a fulcrum 204 and force applicators 206. The cutting force of the scissors 200 works on the law of lever. The force applied on the blade 202 can be calculated by length of the force applicators 206 and force applied on the applicators 206. The scissors 200 of the tool 40 do not apply the exact law of lever because of the cylinder action of the long shaft 46, but the design of applicators 206 helps in the amplification of force by lever action. When the blades 202 of the scissors 200 close, its shaφ edges grind against each other and any tissue which comes between the blades of scissors will be cut.

[0133] The scissors 200 of Fig. 29 provide an example of straight scissors wherein the blades are straight. This is a widely used instrument for mechanical dissection in laparoscopic surgery. Other types of scissors include curved scissors 214, illustrated in Fig. 29 A, wherein the blade 202 of the scissors 214 is slightly curved. In some cases curved scissors 214 are prefeπed because the curvature of the blade 202 of this scissors creates additional angles of manipulation and may provide a better view through the scope. Other types of scissors include seπated scissors 216 wherein seπated edges 218 prevent the tissue from slipping out of the blades 202. This may be useful in cutting a slippery tissue or ligature. Still other types of scissors include hook scissors 220 which encircle a tissue structure before cutting. Since the tissue is held between its hooked blades, there is minimal chance of slipping. The hook scissor 220 is especially^'useful for cutting secured ducts or arteries. Likewise, the cutting of nerve bundles in neurectomy becomes may benefit from the use of hook scissors 220. Hook scissors 220 are also helpful in partial cutting of cystic ducts for infra-operative cholangiography. Further, additional types of scissors include microtip scissors 222. One of the main advantages of microtip scissors 222 is to cut ducts partially for facilitating cannulation. Likewise, this scissor 222 may be used for cutting the cystic duct for performing infra-operative cholangiogram. Exploration of small ducts like common bile duct is very helpful with microtip scissors 222 due to its fine small blades. Fine microtip scissors

222 are also available in curved form.

[0134] Fig. 30 illustrates an embodiment of a tool 40 having an end effector 48 in the form of gator toothed graspers 230. These graspers 230 have reverse angled teeth 232 which are capable of providing an aggressive grip on tissue. In addition, the graspers 230 are cupped to allow tissue to hemiated when the tissue is compressed. Thus, the graspers 230 may be useful for pelviscopy and handling fibrous ovaries and uterine tissue.

[0135] Fig. 31 illustrates an embodiment of a tool 40 having an end effector 48 in the form of an articulatable grasper 236. The grasper 236 includes an articulation section 238 between grasper jaws 240 and the shaft 46. This allows the grasper 236 to articulate in an additional degree of freedom relative to tool arm 30.

[0136] Embodiments of the tool 40 having an end effector 48 may be in the form of various shaped retractors. Examples of such retractors include an angled retractor 242, (Fig.

32), hooked retractors 244 (Fig. 33-34), a triangular retractor 246 (Fig. 35), and a circular retractor (Fig. 36), to name a few. Each retractor is flexible and allows for manipulation of organs and tissue stractures.

V. Auxiliary Lumens

[0137] As mentioned previously, lumens in addition to the scope lumen 24 and arm guide lumens 26 may be present within the main body 10 and may be considered auxiliary lumens 58. Such lumens 58 may be used for any puφose, such as irrigation, suction, insufflation, macerating, illuminating, grasping, or cutting to name a few, and are typically used in conjunction with the arms 30 and/or tools 40 inserted through the arms 30 or positioned at the ends of the arms 30. [0138] In one embodiment, illustrated in Fig. 37A, grasping hooks 310 are inserted through a single auxiliary lumen or through separate auxiliary lumens 58 (shown) in the shaft 20. The grasping hooks 310 may be comprised of any suitable material, such as shape- memory wire or shapeable polymer, that allows a hook shape to be formed once the hooks 310 have emerged from the distal tip 16. In addition, the hooks 310 may have a pointed or shaφ tip to assist in grasping or piercing tissue. Refeπing to Fig. 37B, the grasping hooks 310 may be used to grasp a portion of tissue T to create a plication or fold. The tool arms 30 may then be extended on opposite sides of the folded tissue T to deploy a fixation device 312 which will hold the plication in place. Fig. 37C illustrates such a fixation device 312 comprising a tie 314 passing through the tissue T with anchors 316 positioned on either side of the plication. The tie 314 may be comprised of a suture, wire or rod, for example, and the anchors 316 may be comprised of knots, disks or expandable umbrellas, to name a few. Such plication procedures may be used for treating gastroesophageal reflux disease (GERD). [0139] Alternatively, other tools may be passed through auxiliary lumens 58 for similar or other puφoses. For example, a corkscrew device 320 (Fig. 38) or a grasper claw 322 (Fig. 39) may be passed through an auxiliary lumen 58 for grasping tissue T. Or, tissue T may be grasped with a suction device. Fig. 40A illustrates a suction device 324 in an undeployed configuration. The suction device 324 comprises a deployment sleeve 328 which houses an expandable funnel 326. Withdrawal of the deployment sleeve 328 releases the funnel 326 allowing the funnel 326 to self-expand, as shown in Fig. 40B. The increased surface area of the funnel 326 allows for adequate suction for grasping tissue T and holding the tissue T within the funnel 326.

[0140] It may be appreciated that tools 40 may alternatively be passed through an arm guide lumen 26 for use in conjunction with a tool arm 30 passed tiirough another arm guide lumen 26. For example, as illustrated in Fig. 41, a macerator 336 may be passed through an arm guide lumen 26 for maceration of tissue T or a blood clot while a tool aπn 30 is used for iπigation and aspiration. The macerator 336 macerates the tissue T to form small particles which may be more readily aspirated. Further, irrigation tiirough the arm 30 may be used to cleanse portions of the device. For example, as illustrated in Fig. 42, the arm 30 may be steered to face the scope 28 allowing irrigation to cleanse the scope 28 thus improving viewing.

VI. Torque Transmission

[0141] As mentioned previously, the system 2 of the present invention includes an elongated main body 10 having a proximal end 12 and a distal end 14 terminating in a distal tip 16. An embodiment of the main body 10 was illustrated in various configurations in Figs. 8A-8C utilizing steering and/or locking. Steering and locking may be achieved by any suitable mechanisms. In some embodiments, the shaft 20 comprises a plurality of adjacent links, such as nestable elements 260 illustrated in Fig. 9A. Fig. 9B provided an exploded view of the nestable elements 260 of Fig. 9A, illustrating that the elements 260 are disposed so that a distal surface 262 of one element 260 coacts with a proximal surface 264 of an adjacent element. And, each of the nestable elements 260 includes one or more pullwire lumens 98 through which pullwires 96 pass. The pullwires 96 are used to hold the elements 260 in nesting alignment and to provide steering and locking. Generally, the adjacent surfaces 262, 264 are contoured to mate so that when the pullwires 96 are relaxed, surfaces 262, 264 can rotate relative to one another. This allows the shaft 20 to form curvatures throughout its length in any direction.

[0142] In addition to steering with the use of pullwires 96, the main body 10 can be manipulated by torqueing. Typically, the distal end 14 of the main body 10 is positioned within the body while the proximal end 12 remains outside of the body. It is often desired to rotate the distal end 14 within the body by manually rotating the proximal end 12. To achieve this effectively, the main body 10 should be capable of effectively transmitting torque. To achieve this, particularly through portions of the main body 10 which include adjacent links, such as nestable elements 260, a torque transmitting feature may be included. [0143] One such torque transmitting feature is illustrated in Figs. 43A-43F. Figs.

43A-43F illustrate the use of a tooth and groove concept to maintain alignment of the plurality of adjacent links at locations along its length. By maintaining alignment in particular locations, torque may be more easily transmitted while still allowing freedom of rotation of the links for steering.

[0144] Fig. 43 A is a perspective view of one of the plurality of adjacent links, a first link 500. The first link 500 has a top edge 502, a bottom edge 504, an outer surface 506 and an inner surface 508 foπning a domed ring-like structure having a lumen 505 therethrough. Pullwire lumens 98 are shown passing through the imier surface 508 and out through the top edge 502. It may be appreciated that the pullwire lumens 98 may be used for other elements, such as support wires or rigidizing wires, however at least some of the pullwire lumens 98 are used for passing pullwires 96 for steering. The first link 500 also includes a torque transmitting feature comprising at least one protrasion, such as a tooth 510, which protrudes inward from the inner surface 508 in this embodiment. The tooth 510 may have any suitable shape or size and may extend beyond the edges 502, 504. In this embodiment, the tooth 510 has a first tooth end 512 and a second tooth end 514 wherein the first tooth end 512 is flush with the inner surface 508 and the second tooth end 514 protrudes outwardly toward the bottom edge 504 of the linlc 500 forming a wedge shape. The torque transmitting feature also includes at least one groove 516 in the outer surface 506. The groove 516 is sized, shaped and positioned so that when the first link 500 is engaged with an adjacent link, the groove 516 in the first link 500 accepts a tooth 510 on the adjacent link.

[0145] hi some embodiments, a pair of teeth 510, 510' are present wherein one tooth

510 is located in a diametrically opposite position from the other tooth 510'. Likewise, a pair of grooves 516, 516' are also present wherein one groove 516 is located in a diametrically opposite position from the other groove 516', or 180 degrees apart. Typically, the pair of teeth 510, 510' and pair of grooves 516, 516' are located so that each are separated by approximately 90 degrees, as shown in Fig. 43 A. Fig. 43B provides a side view and Fig. 43 C provides a partial perspective view of the link of Fig. 43 A. [0146] The first link 500 is engageable with a series or plurality of additional links, each having the same or similar features as the first link 500. Such a plurality of adjacent links is shown in Fig. 43D. Here, the first link 500 is shown mated with a second link 520, a third linlc 522, a fourth linlc 524 and a fifth link 526. The links 500, 520, 522, 524, 526 are each individually rotateable by steering, such as with the use of pullwires 96 as described in related earlier sections. Fig. 43E, illustrates four of these links 500, 520, 522, 524 wherein the outer surface 506 of each link is mated with the inner surface 508 of an adjacent linlc along a longitudinal axis 530. The first link 500 is shown to have a pair of teeth 510, 510', one tooth 510 disposed in a position along the inner surface 508 which is diametrically opposite to the other tooth 510'. The one tooth 510 is slidably engageable with a groove 516 in the outer surface 506 of the adjacent second link 520 and the other tooth 510' is slidably engageable with a groove 516' in a diametrically opposite position in the outer surface 506. In this embodiment, groove 516 has a first groove end 518 and a second groove end 519. The groove ends 518, 519 are substantially aligned with the longitudinal axis 530 to allow sliding of the tooth 510 along the groove 516 during rotation of the link away from the longitudinal axis 530. Likewise, groove 516' has a first groove end 518' and a second groove end 519' in a similar arrangement.

[0147] The second link 520 also includes a pair of teeth 510, 510' which are each disposed 90 degrees from the grooves 516, 516'. Therefore, only one tooth 510 is visible in the second link 520 since the teeth 510, 510' aligned in the view of Fig. 43E, however it may be appreciated that each of the pair of teeth 510, 510' in the second link 520 are slidably engaged with one of a pair of grooves 516, 516'in the third link 522. Likewise, the third link 522 is shown to have a pair of teeth 510, 510', one tooth 510 disposed in a position along the inner surface 508 which is diametrically opposite to the other tooth 510'. The one tooth 510 is slidably engageable with a groove 516 in the outer surface 506 of the adjacent fourth link 524 and the other tooth 510' is slidably engageable with a groove 516' in a diametrically opposite position in the outer surface 506.

[0148] Steering rotates at least some of the links away from the longitudinal axis 530, such as illustrated in Fig. 43F. Here, the first linlc 500 is shown rotated along another axis 532 which forms an angle with the longitudinal axis 530. Such rotation slides the one tooth 510 on the first link 500 downward along the groove 516 in the second link 520 while the other tooth 510' slides upward along the groove 516' in the second link 520. Thus, the first link 500 is free to rotate in this plane. It may be appreciated that each link is free to rotate in at least a plane defined by the alignment of teeth and grooves. When the position of such aligned teeth and grooves are varied along the length of the plurality of adjacent links, the links are able to rotate in various directions.

[0149] hi addition, torqueing of the plurality of adjacent links is transmitted through the aligned teeth and grooves. For example, by applying torque to the fourth link 524, as indicated by arrow 534 in Fig. 43F, the fourth linlc 524 will rotate about the longitudinal axis 530 until one of the grooves 516' contacts the slidably engaged tooth 510' which transmits the torque to the third linlc 522. This transmission is repeated through each of the links, transmitting torque to the first link 500.

[0150] Another embodiment of a torque transmitting feature is illustrated in Figs.

44A-44D. Figs. 44A-44D illustrate the use of a pin and slot concept to maintain alignment of the plurality of adjacent links at locations along its length. By maintaining alignment in particular locations, torque may be more easily transmitted while still allowing freedom of rotation of the links for steering. In addition, the pin and slot concept prevents disengagement of the adjacent links while the main body is unlocked. This further enhances torque transmission. [0151] Fig. 44A is a perspective view of one of the plurality of adj acent links, a first link 500. The first link 500 has a top edge 502, a bottom edge 504, an outer surface 506 and an inner surface 508 forming a domed ring-like structure having a lumen 505 therethrough. Although pullwire lumens are not shown, it may be appreciated that pullwire lumens may be present, for example passing through the inner surface and out tiirough the top edge. It may also be appreciated that the pullwire lumens may be used for other elements, such as support wires or rigidizing wires, however at least some of the pullwire lumens are used for passing pullwires for steering. The first linlc 500 also includes a torque transmitting feature comprising at least one protrasion, such as a pin 550, which protrudes outward from the outer surface 506. The torque transmitting feature also includes at least one slot 552, providing an opening between the inner surface 508 and the outer surface 506.

[0152] In some embodiments, a pair of pins 550, 550' are present wherein one pin 550 is located in a diametrically opposite position from the other pin 550'. Likewise, a pair of slots 552, 552' are also present wherein one slot 552 is located in a diametrically opposite position from the other slot 552', or approximately 180 degrees apart. Typically, the pair of pins 550, 550' and pair of slots 552, 552' are located so that each is separated by approximately 90 degrees as illuatrated.

[0153] Fig. 44B provides a side view of the first link 500 of Fig. 44A. Dimensions provided are related to an exemplary embodiment are not intended to be limiting. It may be appreciated that the pin 550 may have any suitable shape or size and may be positioned anywhere along the outer surface 506. In this embodiment, the pins 550, 550' each have a cylindrical shape with a cross-sectional diameter of approximately 0.0325 in. and each is positioned near the top edge 502. Each slot 552 is sized, shaped and positioned so that when the first link 500 is engaged with an adjacent linlc, a slot 552 in the first link 500 accepts a pin 550 on the adjacent link. Typically, each slot 552 is positioned near the bottom edge 504, preferably 0.010 in. from the bottom edge 504 as illustrated in Fig. 44B. Also illustrated in Fig. 44B, each slot 552 has a first slot end 554 and a second slot end 556, typically approximately 0.090 in. apart. The slot ends 554, 556 are substantially aligned with the longitudinal axis 530 to allow sliding of the pin 550 through the slot during rotation of the linlc away from the longitudinal axis 530, as will be illustrated in Figs. 44C-44D.

[0154] Fig. 44C illustrates the first link 500 engaged with a second linlc 520 having the same or similar features as the first linlc 500. The links 500, 520 are each individually rotateable by steering, such as with the use of pullwires 96 (not shown) as described in related earlier sections. As shown, the outer surface 506 of each link is mated with the inner surface 508 of an adjacent link along a longitudinal axis 530. The first link 500 is shown to have a pair of slots 552, 552', one slot 552 which is visible in this view. Extending through the one slot 552 is a pin 550 which protrudes from the outer surface 506 of the adjacent second link 520. It may be appreciated that the second link 520 also has an additional pin 550' which passes through slot 552'. [0155] Steering rotates at least some of the links away from the longitudinal axis 530, such as illustrated in Fig. 44D. Here, the first link 500 is shown rotated along another axis 532 which forms an angle with the longitudinal axis 530. Such rotation slides one pin 550 on the second linlc 520 upward along the slot 552 in the first link 500 while another pin 510' slides downward along the slot 552' in the first link 500. Thus, the second link 520 is free to rotate in this plane. It may be appreciated that each link is free to rotate in at least a plane defined by the alignment of pins and slots. When the position of such aligned pins and slots are varied along the length of the plurality of adjacent links, the links are able to rotate in various directions. [0156] In addition, torqueing of the plurality of adjacent linlcs is transmitted tiirough the aligned pins and slots. For example, by applying torque to the second link 520, the second link 520 will rotate about the longitudinal axis 530 until one of the slots contacts the slidably engaged pin which transmits the torque to the first link 500. This transmission may be repeated through any number of linlcs, transmitting torque through a plurality of adjacent links.

[0157] Another torque transmitting feature is illustrated in Figs. 45A-45C. Figs. 45A-

45 C illustrate the use of a torque transmitting covering over the plurality of adjacent links providing torque transmission therethrough while the linlcs are rotateable. Fig. 45 A illustrates an embodiment of the torque transmitting covering, i this embodiment, the covering 570 comprises a sheath 576 having reinforcements 578 throughout. Such reinforcements 578 are comprised of nylon, polyurethane, polyethylene, Teflon, metal, polymer or any suitable material and are typically braided or woven, however any arrangement of the reinforcements 578 may be used. The reinforcements 578 may be dipped in a polymer dispersion in a suitable solvent to coat the reinforcements 578. Such coating holds the reinforcements 578 together in a desired arrangement suitable for torque transmission. Alternatively or in addition, the reinforcements 578 may be sprayed, painted or otherwise coated with a polymer. Likewise, other methods of foπning the covering 570 may be used. It may also be appreciated that the covering 570 may be formed without reinforcements 578. The coating may also be an independent component that is draped over the reinforcements 578.

[0158] The covering 570 may have any suitable size or shape, but is typically an elongate tube sized to fit snuggly around the plurality of adjacent links which are rotateable relative to each other when unlocked. Typically the covering 570 has a wall thickness in the range of approximately 0.005 to 0.015 in., typically in the range of approximately 0.010 to 0.015 in. Snug fit of the covering around the adjacent linlcs prevents the linlcs from disengaging while allowing the linlcs to rotate during steering. Thus, the covering 570 may also be formed by dipping the adjacent links in a polymer dispersion to form a coating on the linlcs.

[0159] Fig. 45B illustrates the covering 570 fit over a series or plurality of adjacent linlcs (a first linlc 500, second linlc 520, third linlc 522, fourth link 524 and fifth link 526) wherein the outer surface of each link is mated with the inner surface of the adjacent link along a longitudinal axis 530. The linlcs 500, 520, 522, 524, 526 are each individually rotateable by steering, such as with the use of pullwires 96 as described in related earlier sections. [0160] Torqueing of the plurality of adjacent links is transmitted with the use of the covering 570. For example, by applying torque to the fifth link 526 and surrounding covering 570, as indicated by arrow 572 in Fig. 45C, the fifth linlc 526 will rotate about the longitudinal axis 530 along with the surrounding covering 570. The torqueing force applied to the covering 570 will be transmitted along the length of the covering 570 from the fifth link 526 toward the first link 500. Since the covering 570 is snuggly fit around the links, the linlcs will maintain engagement, assisting in the transmission of torque. Thus, the first link 500 will then rotate about the longitudinal axis 530, as indicated by arrow 574, in response to the rotation of the fifth linlc 526. [0161] Another torque transmitting feature is illustrated in Figs. 46A-46E. As mentioned, embodiments of the main body typically include a proximal end, a distal end and at least one lumen extending between the proximal and distal ends, at least a portion of the elongated main body comprising at least a first linlc and an adjacent second link which are rotateable relative to each other when unlocked. Figs. 46A-46D illustrate cross-sectional views of a linlc wherein one of the at least one lumen extending through the linlcs has at least one partition. For example, referring to Fig. 46A, a first link 500 is shown having lumen 505 extending therethrough. The lumen 505 has two partitions 590, each partition 590 having the form of an inward protrusion. Any number of partitions 590 may be present, such as two, three, four, five, six, seven, eight or more. For example, Fig. 46B illustrates a first link 500 having a lumen 505 with five partitions 590. In this example, the partitions 590 provide the lumen 505 with a fluted shape. The partitions 590 may have any shape, for example, blunt, pointed, rounded, or square, and may extend inwardly any distance. For example, Fig. 46C illustrates a first link 500 having a lumen 505 with partitions 590 which extend further into the lumen 505 than in the embodiments of Figs. 46A-46B. Further, as illustrated in Fig. 46D, the partitions 590 may comprise at least one divider 592 spanning across the lumen 505 of the link 500 foπning sub-lumens 594. In addition, also illustrated in Figs. 46A-46D, the links 500 may also include other lumens, such as steering or pullwire lumens 98 for the passage of pullwires used in steering. [0162] The partitions 590 are used as a torque transmitting feature with the use of an elongated shaft 600 passing through the lumen 505, as illustrated in Fig. 46E. As shown, the first link 500 is engageable with a plurality of adjacent links, such as a second link 520 and third linlc 522, each having the same or similar features as the first link 500. In addition, the linlcs 500, 520, 522 are aπanged so that the partitions 590 within each link are generally aligned. The shaft 600 passes through the lumen 505 and is positioned between partitions 590 in each of the links. Torqueing of the plurality of adjacent links is transmitted through the shaft 600 and partitions 590. For example, by applying torque to the first link 500, the link 500 rotates about the longitudinal axis 530 until the shaft 600 contacts a partition 590. Since the partitions 590 are generally aligned, the shaft 600 will also contact partitions 590 in the second link 520 and third link 522. Therefore, torque is transmitted from the first link 500 to the third link 522. This transmission may be repeated through any number of links, transmitting torque through a plurality of adjacent links.

[0163] ^' Another torque transmitting feature is illustrated in Figs. 47A-47B. As mentioned, embodiments of the main body typically include a proximal end, a distal end and at least one lumen extending between the proximal and distal ends, wherein at least a portion of the elongated main body comprises a plurality of adjacent links. Fig. 47A illustrates a section of adjacent linlcs, including a first link 500, a second link 520 and a third link 522, wherein the linlcs have an oval cross-section. As mentioned previously, and illustrated in Fig. 2B, the linlcs may have an oval shape for a variety of puφoses, including providing for a desired arrangement of, for example, a scope 28 and optionally tool anns 30 passing through lumen 505. The oval shape may also function as a torque transmitting feature. As shown in Fig. 47B, torqueing of the first link 500 rotates the first link 500 about the longitudinal axis 530, as indicated by arrows 602. The first link 500 will contact the second linlc 522 due to the oval shape, as shown. This will cause the second link 522 to rotate, as indicated by aπows 604. Thus, torque is transmitted to the second linlc 522. This transmission may be repeated through any number of links, transmitting torque through a plurality of adjacent linlcs.

[0164] Another torque transmitting feature is illustrated in Figs. 48A-48C. As mentioned previously, embodiments of the main body typically include a proximal end, a distal end and at least one lumen extending between the proximal and distal ends, wherein at least a portion of the elongated main body comprises a plurality of adjacent links. A cross- sectional view of one of these adjacent linlcs, such as the first link 500, is shown in Figs. 48 A- 48C, wherein each of the linlcs have the same or similar cross-section. The torque transmitting feature comprises a plurality of wires or rods 620 extending through the adjacent linlcs. Fig. 48A shows eight rods 620, symmetrically arranged around lumen 505. It may be appreciated, however, that the rods 620 may be present in any arrangement. When torque is applied to a linlc which is adjacent to the first link 500, the rods 620 passing through the first link 500 transmit the torque (indicated by arrows 622) to the first linlc 500 thereby rotating the first link 500. This transmission may be repeated through any number of links, transmitting torque through a plurality of adjacent links. Similarly, Fig. 48B shows sixteen rods 620, symmetrically arrangement around lumen 505. Again, when torque is applied to a link which is adjacent to the first link 500, the rods 620 passing through the first link 500 transmit the torque (indicated by arrows 622) to the first link 500 thereby rotating the first link 500. Thus, the more rods 620 present the higher the torque transmission. Fig. 48C shows thirty-two rods 620, symmetrically aπangement around lumen 505. Any number of rods 620 may be present, typically ranging from eight to sixty- four. It may also be appreciated that the rod 620 may be comprised of any suitable material, such as metal, metal wire, polymer, nitinol, filament or fiber, to name a few. Also, some or all of the rods 620 may be pushwires or pullwires 96.

[0165] Although the foregoing invention has been described in some detail by way of illustration and example, for puφoses of clarity of understanding, it will be obvious that various alternatives, modifications and equivalents may be used and the above description should not be taken as limiting in scope of the invention which is defined by the appended claims.

Claims

WHAT IS CLAIMED IS: 1. An endoluminal system comprising: an elongated main body having a proximal end, a distal end sized for passage through a body lumen, and at least one lumen extending between the proximal and distal ends; a torque transmitting feature which provides torque transmission between the proximal and distal ends while the main body is unlocked and able to form a desired configuration; and a locking mechanism which locks the main body in the desired configuration.

2. The endoluminal system of claim 1, further comprising a visualizing element.

3. The endoluminal system of claim 2, wherein the visualizing element is integral with the main body.

4. The endoluminal system of claim 2, wherein the at least one lumen comprises a visualizing lumen and the visualizing element is configured for passage through the visualizing lumen.

5. The endoluminal system of claim 4, wherein the visualizing element comprises an endoscope.

6. The endoluminal system of claim 1, wherein the at least one lumen comprises an arm guide lumen.

7. The endoluminal system of claim 6, further comprising at least one tool arm being adapted to extend through the arm guide lumen.

8. The endoluminal system of claim 1, further comprising a steering mechanism which steers the main body to the desired configuration while the main body is unlocked.

9. The endoluminal system of claim 1 , wherein at least a portion of the elongated main body comprises a plurality of adj acent links.

10. The endoluminal system of claim 9, wherein the plurality of adjacent links comprises at least a first link and an adjacent second link, the torque transmitting feature comprising a tooth from the first link slidably engageable with a groove in the adjacent second link.

11. The endoluminal system of claim 9, wherein the plurality of adjacent linlcs comprises at least a first link and an adjacent second link, the torque transmitting feature comprising a pin from the first link slidably engageable with a slot in the adjacent second linlc.

12. The endoluminal system of claim 9, wherein the torque transmitting feature comprises a fluted shape of the at least one lumen.

13. The endoluminal system of claim 9, wherein the torque transmitting feature comprises an oval shape of the plurality of adjacent linlcs.

14. The endoluminal system of claim 13, wherein the torque transmitting feature comprises a plurality of rods extending through the adjacent linlcs.

15. The endoluminal system of claim 14, wherein the plurality of rods comprises approximately 8 to 64 rods.

16. The endoluminal system of claim 9, wherein the steering mechanism comprises at least one pullwire extending tiirough the plurality of adjacent linlcs.

17. The endoluminal system of claim 1, wherein the torque transmitting feature comprises a torque transmitting covering over the main body extending between the proximal and distal ends.

18. The endoluminal system of claim 17, wherein the torque transmitting covering comprises a sheath having reinforcements.

19. An endoluminal device comprising: an elongated main body having a proximal end, a distal end, and at least one lumen extending between the proximal and distal ends, at least a portion of the elongated main body comprising a plurality of adjacent engageable links; and a torque transmitting feature which provides torque transmission by preventing disengagement of the adjacent links while the main body is unlocked and able to fonn a desired configuration.

20. The endoluminal device of claim 19, wherein the plurality of adjacent engageable linlcs comprises at least a first link and an adjacent second link, the torque transmitting feature comprising at least one pin from the first link slidably engageable with at least one slot in the adjacent second linlc.

21. The endoluminal device of claim 20, wherein the at least one pin comprises a pair of pins, each pin extending outwardly from an outer surface of the first link in a diametrically opposite position from the other pin.

22. The endoluminal device of claim 21 , wherein the at least one slot comprises a pair of slots, each slot configured to accept one or the pair of pins passing therethrough.

23. The endoluminal device of claim 22, wherein the first link comprises a first domed ring having the outer surface and the adjacent second link comprises a second domed ring having an inner surface, the outer surface of the first domed ring mateable with the inner surface of the second domed ring along a longitudinal axis, and the rings rotateable away from the longitudinal axis.

24. The endoluminal device of claim 22, wherein each slot comprises an elongate opening between a first slot end and a second slot end, the slot ends substantially aligned with the longitudinal axis to allow sliding of the pins through the slots during rotation of the rings away from the longitudinal axis.

25. The endoluminal device of claim 19, wherein the torque fransmitting feature comprises a torque transmitting covering over the plurality of adjacent engageable linlcs to prevent disengagement of the adjacent linlcs.

26. The endoluminal device of claim 19, further comprising a locking mechanism which locks the linlcs in the desired configuration.

27. An endoluminal device comprising: an elongated main body having a proximal end, a distal end, and at least one lumen extending between the proximal and distal ends, at least a portion of the elongated main body comprising a at least a first link and an adjacent second linlc which are rotateable relative to each other when unlocked; a torque transmitting feature comprising at least one protrasion from the first link slidably engageable with at least one groove in the adjacent second link, the torque transmitting feature providing torque transmission through the portion of the main body while the links are rotateable; and a locking mechanism which locks the linlcs upon actuation by preventing rotation of the linlcs relative to each other.

28. The endoluminal device of claim 27, wherein the at least one protrasion comprises a pair of protrasions, each protrusion extending outwardly from an outer surface of the first link in a diametrically opposite position from the other protrasion.

29. The endoluminal device of claim 28, wherein the at least one groove comprises a pair of grooves, each groove configured to accept one or the pair of protrasions passing therein.

30. The endoluminal device of claim 29, wherein the first link comprises a first domed ring having the outer surface and the adjacent second link comprises a second domed ring having an inner surface, the outer surface of the first domed ring mateable with the inner surface of the second domed ring along a longitudinal axis, and the rings rotateable away from the longitudinal axis.

31. The endoluminal device of claim 30, wherein each groove comprises a first groove end and a second groove end, the groove ends substantially aligned with the longitudinal axis to allow sliding of the protrasions along the grooves during rotation of the rings away from the longitudinal axis.

32. An endoluminal device comprising: an elongated main body having a proximal end, a distal end, and at least one lumen extending between the proximal and distal ends, at least a portion of the elongated main body comprising a plurality of adj acent linlcs which are rotateable relative to each other when unlocked; a torque transmitting covering over the plurality of adjacent linlcs providing torque transmission therethrough while the links are rotateable; and a locking mechanism which locks the linlcs upon actuation by preventing rotation of the links relative to each other.

33. The endoluminal device of claim 32, wherein the torque transmitting covering comprises a snuggly fit sheath.

34. The endoluminal device of claim 33, wherein the sheath includes reinforcements.

35. The endoluminal device of claim 34, wherein the reinforcements comprises nylon, polyurethane, polyethylene, Teflon, metal, or polymer.

36. The endoluminal device of claim 34, wherein the reinforcements have a braided or woven aπangement.

37. The endoluminal device of claim 34, wherein the reinforcements has been coated with a polymer.

38. The endoluminal device of claim 32, wherein the torque transmitting covering comprises a polymer coating.

39. An endoluminal device comprising: an elongated main body having a proximal end, a distal end, and at least one lumen extending between the proximal and distal ends, at least a portion of the elongated main body comprising at least a first link and an adjacent second link which are rotateable relative to each other when unlocked, one of the at least one lumen extending through the linlcs having at least one partition; an elongated shaft passing through one of the at least one lumen in a manner to transmit torque by contacting the least one partition; and a locking mechanism which locks the linlcs upon actuation by preventing rotation of the links relative to each other.

40. The endoluminal device of claim 39, wherein the at least one partition comprises an inward protrusion.

41. The endoluminal device of claim 40, wherein the at least one lumen extending through the linlcs has a fluted shape forming the inward protrasions.

42. The endoluminal device of claim 40, wherein the at least one partition comprises at least one divider spanning across the one of the at least one lumen.

43. The endoluminal device of claim 39, wherein the at least one lumen includes at least one steering lumen through which a pullwire passes for use in steering the elongated main body.

44. The endoluminal device of claim 43, wherein the at least one steering lumen comprises a plurality of steering lumens around the one of the at least one lumens.

45. A method of accessing comprising: providing an elongated main body having a proximal end, a distal end, a visualizing element and a locking mechanism, wherein the main body is capable of forming a desired configuration in an unlocked state and holding the desired configuration in a locked state; introducing the main body tiirough a body passageway in the unlocked state forming the desired configuration so that the distal end reaches a target location; actuating the locking mechanism to hold the main body in the desired configuration; and viewing the target location with the use of the visualizing element.

46. A method as in claim 45, wherein introducing the main body comprises allowing the main body to assume a shape of the body passageway in the unlocked state forming the desired configuration.

47. A method as in claim 46, wherein the main body comprises a plurality of adjacent links and wherein actuating the locking mechanism comprises holding the links in a fixed relation to each other.

48. A method as in claim 47, wherein the plurality of adjacent links comprises a plurality of nestable elements and wherein holding the linlcs comprises wedging the linlcs together to hold them by friction.

49. A method as in claim 45, wherein introducing the main body comprises steering the main body through the body passageway in the unlocked state forming the desired configuration.

50. A method as in claim 49, wherein the main body comprises a plurality of adjacent linlcs and wherein actuating the locking mechanism comprises holding the links in a fixed relation to each other.

51. A method as in claim 50, wherein the plurality of adjacent links comprises a plurality of nestable elements and wherein holding the linlcs comprises wedging the links together to hold them by friction.

52. A method as in claim 45, wherein the main body includes at least one lumen extending between the proximal and distal ends, and further comprising introducing an instmment through the at least one lumen.

53. A method as in claim 52, wherein the instrument comprises a tool arm.

54. A method as in claim 45, wherein the elongated main body further includes a visualizing liunen and the visualizing element comprises an endoscope, the method further comprising positioning the endoscope within the visualizing lumen.