Modulating surgical device settings based on tissue whitening

Abstract

To provide systems, devices and methods for automatic control of a surgical site temperature during an endoscopic procedure.SOLUTION: An exemplary endoscopic surgical system comprises an endoscopic surgical device controllably coupled to a medical instrument to deliver energy to a surgical site during a procedure, an imaging sensor to generate images or video frames of at least a portion of the surgical site during the procedure, and a controller circuit to analyze the generated images or video frames to determine whether a degree of heat built up in a first target at the surgical site exceeds a predetermined threshold. On the basis of such determination, the controller circuit can determine whether to adjust at least one operating parameter associated with the endoscopic surgical system to achieve or maintain a treatment effect of a different second target at the surgical site while avoid damaging the first target during the procedure.SELECTED DRAWING: Figure 2

Description

[Technical Field]

[0001] Priority claims This application claims the benefit of priority to U.S. Provisional Patent Application No. 63 / 369,099, filed July 22, 2022, the contents of which are incorporated herein by reference.

[0002] The present invention relates generally to endoscopic surgical systems, and more particularly to techniques for adjusting one or more settings of an endoscopic surgical system based on tissue whitening detected from images or video frames of at least a portion of a surgical site. [Background technology]

[0003] Endoscopes are typically used to provide access to internal locations of a patient, providing visual access to physicians. Some endoscopes are used in minimally invasive surgery to remove unwanted tissue or foreign bodies from a patient's body. For example, a nephroscope is used by clinicians to examine the renal system and perform various procedures under direct visual control. In a percutaneous nephrolithotomy (PCNL) procedure, a nephroscope is placed through the patient's flank into the renal pelvis. For example, stones or masses from various areas of the body can be visualized and extracted, including the urinary system, gallbladder, nasal passages, digestive tract, stomach, or tonsils.

[0004] Various medical devices, such as laser or plasma systems, have been used to deliver surgical laser energy to various target treatment areas, such as soft or hard tissue. Examples of laser treatments include ablation, coagulation, vaporization, and fragmentation. In lithotripsy applications, lasers have been used to destroy stone structures in the kidney, gallbladder, and ureter, among other stone-forming areas, or to ablate large stones into smaller fragments. The stone fragments can be removed through the working channel of an endoscope (e.g., a ureteroscope) or can be naturally passed by the patient after the procedure.

[0005] Heat accumulation is a potentially dangerous consequence of laser treatment of anatomical or stone targets, especially when relatively high intensity laser power is used in the treatment, such as in laser lithotripsy to ablate or fragment stone targets of a particular size, shape, hardness, or composition. Excessive heat accumulation at or near the surgical site can result in thermal damage to non-target tissues or organs. Summary of the Invention [Problem to be solved by the invention]

[0006] Effective surgical site temperature control can help prevent tissue thermal damage caused by heat accumulation during medical procedures, such as laser lithotripsy or ultrasonic lithotripsy procedures. Traditionally, temperature is sensed from the surgical site and displayed to a user (e.g., a physician) during the procedure. The user can manually change medical device settings (such as laser output intensity) or temporarily turn off the laser if the surgical site temperature reaches or exceeds a safe limit. Such manual temperature adjustment techniques may not provide precise temperature control at the surgical site. Adjusting medical device settings (such as laser output intensity) may also fail to achieve adequate, rapid temperature removal at the surgical site. For example, in some cases, reducing laser output intensity or shutting off laser output may impair treatment efficiency and / or prolong procedure time. While the medical device herein refers to a laser system, it should also be noted that any suitable medical device, such as an ultrasound system that can be coupled to or implemented with an endoscope to provide targeted treatment or diagnosis, is within the scope of the present invention. [Means for solving the problem]

[0007] The present invention describes systems, devices, and methods for improving surgical site temperature control by automatically adjusting one or more device settings based on tissue whitening (also referred to as tissue bleaching) that can be detected from images or video frames of at least a portion of the surgical site. Tissue whitening can be an early indication of the risk of laser-induced thermal tissue damage. According to one embodiment, an exemplary endoscopic surgical system includes an endoscopic surgical device controllably coupled to a medical instrument (e.g., a laser system) and configured to deliver energy (e.g., laser energy) to the surgical site during a procedure; an imaging sensor configured to generate images or video frames of at least a portion of the surgical site during the procedure; and control circuitry configured to analyze the generated images or video frames to determine whether the degree of heat accumulation at a first target at the surgical site exceeds a predetermined threshold. The predetermined threshold, which can be different for different types of tissue, can be represented by a threshold temperature (e.g., 42°C) that begins to cause undesirable clinical effects in the tissue. Because there is a positive correlation between the degree of tissue whitening and the degree of heat accumulation, the degree of heat accumulation can be estimated by assessing the degree of tissue whitening at a first target, and a predetermined threshold for heat accumulation can be represented by the threshold degree of tissue whitening. Based on such a determination, the control circuitry can determine whether to adjust at least one operating parameter associated with the endoscopic surgical system to achieve or maintain a therapeutic effect on a second target at the surgical site that is different from the first target during the procedure while avoiding damage to the first target. The surgical site temperature control techniques described herein can advantageously prevent or reduce the severity of thermal tissue damage induced by energy (e.g., laser energy) delivered to the tissue site. Various temperature control measures allow for more versatile control of the surgical site temperature depending on the condition of the surgical site. Alternative temperature control measures (e.g., irrigation or aspiration flow, and irrigation fluid therapy) can help avoid cessation or substantial reduction of energy output during endoscopic procedures (e.g., laser or ultrasonic lithotripsy procedures).Thereby, more precise and faster temperature control and improved laser treatment efficacy and tissue safety can be achieved.

[0008] Example 1 is an endoscopic surgical system comprising: an endoscopic surgical device controllably coupled to a medical instrument for delivering energy to a surgical site during a procedure; an imaging sensor configured to generate images or video frames of at least a portion of the surgical site during the procedure; and control circuitry configured to: analyze the generated images or video frames to determine whether a degree of heat accumulation at a first target at the surgical site exceeds a predetermined threshold; and, based on the determination, determine whether to adjust at least one operating parameter associated with the endoscopic surgical system to achieve or maintain a therapeutic effect at a second target at the surgical site that is different from the first target while avoiding damaging the first target during the procedure.

[0009] In Example 2, the subject matter of Example 1 optionally includes, wherein the first target includes tissue in the urinary system, the second target includes a stone target, and the medical device includes at least one laser system for delivering laser energy to treat the stone target at the surgical site.

[0010] In Example 3, the subject matter of any one or more of Examples 1-2 optionally includes wherein the control circuitry is further configured to detect, in the image or video frame, a change over time in the intensity of one or more color components associated with the first target in the image or video frame, and determine whether tissue whitening has occurred in the first target based on the detected change in the intensity of the one or more color components.

[0011] In Example 4, the subject matter of any one or more of Examples 1-3 optionally includes: the endoscopic surgical device is configured to direct an aiming beam from a light source toward a surgical site, the aiming beam having a characteristic color component; and the control circuitry is configured to identify a footprint of the aiming beam in a generated image or video frame; and determine a degree of heat accumulation in the first target based on an increase in intensity of the characteristic color component in the vicinity of the footprint of the aiming beam.

[0012] In Example 5, the subject matter of any one or more of Examples 1-4 optionally includes that the control circuitry is further configured to determine a rate of heat accumulation in the first target based on a comparison of images or video frames taken at different times during the procedure, and adjust at least one operating parameter associated with the endoscopic surgical system according to the determined degree or rate of tissue whitening.

[0013] In Example 6, the subject matter of Example 2 optionally includes, wherein the at least one operating parameter adjusted includes a laser power setting of the at least one laser system.

[0014] In Example 7, the subject matter of Example 6 optionally includes, wherein the laser power settings include at least one of a pulse width of the laser pulse, a pulse shape of the laser pulse, a peak power of the laser pulse, or a pulse frequency representing a number of laser pulses per unit time.

[0015] In Example 8, the subject matter of Example 7 optionally includes, wherein the control circuitry is further configured to automatically perform an adjustment of the laser output setting upon determining that a degree of heat accumulation at the first target exceeds a predetermined threshold.

[0016] In Example 9, the subject matter of any one or more of Examples 6-8 optionally includes, wherein the control circuitry is further configured to adjust laser power settings to produce a non-equilibrium irrigation flow or to promote bubble collapse due to laser energy-induced evaporation.

[0017] In Example 10, the subject matter of Example 9 optionally includes, wherein the adjusted laser output settings include a pulse sequencing representing a temporal distribution of laser pulses within a specific time interval, and the laser pulses are delivered to a second target according to the adjusted pulse sequencing.

[0018] In Example 11, the subject matter of Example 10 optionally includes, to adjust the pulse sequencing, the control circuitry is further configured to randomize the timing of each of the laser pulses within a particular time interval.

[0019] In Example 12, the subject matter of any one or more of Examples 6-11 optionally includes, wherein, for adjusting the laser power setting, the control circuit is further configured to prioritize adjusting the pulse shape or adjusting the pulse sequencing over adjusting the average power of the laser pulses.

[0020] In Example 13, the subject matter of any one or more of Examples 1-12 optionally includes an irrigation and / or aspiration system configured to provide irrigation fluid to the surgical site and to provide aspiration of fluid from the surgical site.

[0021] In Example 14, the subject matter of Example 13 optionally includes, wherein the at least one operating parameter associated with the endoscopic surgical system includes at least one of irrigation flow or aspiration flow associated with the irrigation system and aspiration system, respectively.

[0022] In Example 15, the subject matter of Example 14 optionally includes a pressure sensor configured to sense pressure at the surgical site during a procedure, wherein the control circuitry is further configured to selectively increase irrigation flow or aspiration flow through the irrigation and / or aspiration system, including increasing aspiration flow but not increasing irrigation flow when the sensed pressure exceeds an upper pressure limit, increasing one or both of the irrigation flow or aspiration flow when the sensed pressure is within a range defined by an upper pressure limit and a lower pressure limit, and increasing irrigation flow but not increasing aspiration flow when the sensed pressure falls below the lower pressure limit.

[0023] In Example 16, the subject matter of any one or more of Examples 13-15 optionally includes an irrigation fluid treatment unit configured to alter the temperature of the irrigation fluid, wherein the control circuit is further configured to generate a control signal to the irrigation fluid treatment unit to adjust the temperature of the irrigation fluid before it reaches the surgical site when it determines that the degree of heat accumulation in the first target exceeds a predetermined threshold.

[0024] In Example 17, the subject matter of any one or more of Examples 2 and 6-12 optionally includes: the endoscopic surgical device includes an optical pathway with an adjustable distal portion, the optical pathway configured to direct laser energy toward the surgical site, and the control circuitry is further configured, upon determining that a degree of heat accumulation at the first target exceeds a predetermined threshold, to generate a control signal to an actuator coupled to the optical pathway to adjust a position or orientation of the distal portion of the optical pathway relative to the surgical site.

[0025] In Example 18, the subject matter of any one or more of Examples 1-17 optionally includes that at least one operating parameter associated with the endoscopic surgical system includes at least one of a temperature of the irrigation fluid before application to the surgical site, an irrigation flow rate, an aspiration flow rate, or a laser power setting of the laser system.

[0026] In Example 19, the subject matter of Example 18 optionally includes, wherein the control circuitry is further configured to perform an adjustment by biasing one of the operating parameters based at least in part on at least one of a degree of heat accumulation at the first target or pressure at the surgical site.

[0027] In Example 20, the subject matter of Example 19 optionally includes, wherein the control circuit is further configured to adjust at least one of an irrigation flow rate or an aspiration flow rate before adjusting the laser power setting when the control circuit determines that the pressure at the surgical site is substantially less than the maximum allowable pressure.

[0028] In Example 21, the subject matter of any one or more of Examples 19-20 optionally includes, wherein the control circuit is further configured to adjust the laser output setting before adjusting the irrigation flow rate or the aspiration flow rate when the control circuit determines that the pressure at the surgical site is substantially close to the maximum allowable pressure.

[0029] In Example 22, the subject matter of any one or more of Examples 1-21 optionally includes a user interface device configured to generate a warning upon determining that the degree of heat accumulation in the first target exceeds a predetermined threshold.

[0030] In Example 23, the subject matter of any one or more of Examples 1-22 optionally includes a user interface device further configured to generate a recommended adjustment of at least one operating parameter and to accept user input to confirm, reject, or modify the recommended adjustment.

[0031] Example 24 is a method for controlling temperature at a surgical site of a patient during an endoscopic procedure using an endoscopic surgical system, the method including: directing energy generated by a medical device toward the surgical site; generating images or video frames of at least a portion of the surgical site using an imaging sensor; analyzing the generated images or video frames to determine whether a degree of heat accumulation at a first target at the surgical site exceeds a predetermined threshold; and, based on the determination, determining whether to adjust at least one operating parameter associated with the endoscopic surgical system to achieve or maintain a therapeutic effect at a second target at the surgical site, different from the first target, while avoiding damage to the first target during the procedure.

[0032] In Example 25, the subject matter of Example 24 optionally includes, wherein the first target includes tissue in the urinary system, the second target includes a stone target, and the energy produced by the medical device includes laser energy produced by at least one laser system to treat the stone target at the surgical site.

[0033] In Example 26, the subject matter of Example 25 optionally includes wherein the at least one operating parameter adjusted includes a laser power setting of the at least one laser system, the laser power setting including at least one of a pulse width of a laser pulse, a pulse shape of a laser pulse, a peak power of a laser pulse, or a pulse frequency representing the number of laser pulses per unit time.

[0034] In Example 27, the subject matter of Example 26 optionally includes that the adjusted laser output settings include a pulse sequence representing a temporal distribution of laser pulses within a specific time interval, and the laser pulses are delivered to the surgical site according to the adjusted pulse sequence that creates a non-equilibrium irrigation flow and promotes bubble collapse due to evaporation induced by the laser pulses.

[0035] In Example 28, the subject matter of Example 27 optionally includes, wherein adjusting the pulse sequencing includes randomizing the timing of each of the laser pulses within a particular time interval.

[0036] In Example 29, the subject matter of any one or more of Examples 24-28 optionally includes detecting, in an image or video frame, a change over time in the intensity of one or more color components associated with a first target in the image or video frame, and determining whether tissue whitening has occurred in the first target based at least in part on the detected change in the intensity of the one or more color components.

[0037] In Example 30, the subject matter of any one or more of Examples 24-29 optionally includes the steps of directing an aiming beam from a light source toward a surgical site, the aiming beam having a characteristic color component; identifying a footprint of the aiming beam in a generated image or video frame; and determining a degree of heat accumulation in the first target based at least in part on an increase in intensity of the characteristic color component in the vicinity of the footprint of the aiming beam.

[0038] In Example 31, the subject matter of any one or more of Examples 24-30 optionally includes the steps of determining a rate of heat accumulation in the first target based on a comparison of images or video frames taken at different times during the procedure, and adjusting at least one operating parameter associated with the endoscopic surgical system depending on the determined degree or rate of tissue whitening.

[0039] In Example 32, the subject matter of any one or more of Examples 24-31 optionally includes that adjusting at least one operating parameter associated with the endoscopic surgical system includes adjusting at least one of an irrigation flow of irrigation fluid to the surgical site or an aspiration flow of fluid out of the surgical site.

[0040] In Example 33, the subject matter of Example 32 optionally includes the step of using a pressure sensor to sense pressure at the surgical site during the procedure, and adjusting at least one of the irrigation flow or the aspiration flow includes increasing the aspiration flow but not increasing the irrigation flow when the sensed pressure exceeds an upper pressure limit, increasing one or both of the irrigation flow or the aspiration flow when the sensed pressure is within a range defined by the upper and lower pressure limits, and increasing the irrigation flow but not increasing the aspiration flow when the sensed pressure falls below the lower pressure limit.

[0041] In Example 34, the subject matter of any one or more of Examples 24-33 optionally includes adjusting at least one operating parameter includes adjusting the temperature of the irrigation fluid before it reaches the surgical site via an irrigation fluid treatment unit coupled to the irrigation and / or aspiration system upon determining that the degree of heat accumulation in the first target exceeds a predetermined threshold.

[0042] In Example 35, the subject matter of any one or more of Examples 24-34 optionally includes adjusting at least one operating parameter includes, upon determining that the degree of heat accumulation at the first target exceeds a predetermined threshold, adjusting a position or orientation of a distal portion of the optical path relative to the surgical site and directing energy via the optical path to the surgical site.

[0043] In Example 36, the subject matter of any one or more of Examples 24-35 optionally includes a step of prioritizing adjustment of two or more operating parameters of the endoscopic surgical system, including the temperature of the irrigation fluid before application to the surgical site, the irrigation flow rate, the aspiration flow rate, and the laser power setting of the laser system.

[0044] In Example 37, the subject matter of any one or more of Examples 24-36 optionally includes, upon determining that the degree of heat accumulation in the first target exceeds a predetermined threshold, generating an alert or generating a recommended adjustment of at least one operating parameter and accepting user input to confirm, reject, or modify the recommended adjustment.

[0045] This summary is an overview of some of the teachings of the present application and is not intended to be an exclusive or exhaustive discussion of the present subject matter. Further details about the present subject matter are found in the detailed description and the appended claims. Other aspects of the present disclosure will become apparent to those skilled in the art upon reading and understanding the following detailed description and viewing the drawings that form a part of the detailed description, each of which is not to be taken in a limiting sense. The scope of the present disclosure is defined by the appended claims and their legal equivalents.

[0046] Various embodiments are illustrated by way of example in the accompanying drawing figures. Such embodiments are illustrative and are not intended to be exhaustive or exclusive embodiments of the present subject matter. [Brief explanation of the drawings]

[0047] [Figure 1] FIG. 1 is a block diagram illustrating an example of a laser energy delivery system configured to provide laser treatment to an anatomical target at or near a surgical site. [Figure 2] 1 is a block diagram illustrating an endoscopic surgery system with automatic surgical site state control and at least a portion of the environment in which the system may operate. [Figure 3] FIG. 1 is a diagram of an example endoscopic laser lithotripsy system with automatic surgical site condition control. [Figure 4] FIG. 1 is a diagram of an endoscopic image of an illuminated target site including the footprint of the aiming beam. [Figure 5A] 10A-10C are diagrams of examples of varying laser pulse sequencing and resulting irrigation flow and foam conditions. [Figure 5B] 10A-10C are diagrams of examples of varying laser pulse sequencing and resulting irrigation flow and foam conditions. [Figure 5C] 10A-10C are diagrams of examples of varying laser pulse sequencing and resulting irrigation flow and foam conditions. [Figure 5D] 10A-10C are diagrams of examples of varying laser pulse sequencing and resulting irrigation flow and foam conditions. [Figure 6] 1 is a flow diagram of an example method for controlling the temperature of a surgical site during a laser procedure to treat an anatomical target. [Figure 7A] 10 is a flow chart illustrating an example method for generating a temperature management plan based on a surgical site condition, such as tissue whitening and / or pressure at the surgical site. [Figure 7B] 1 is a flow chart illustrating an example of a temperature management plan with a prioritization means for controlling the temperature of a surgical site. [Figure 8] FIG. 1 is a block diagram illustrating an example machine in which any one or more of the techniques (e.g., methodologies) discussed herein may be implemented. DETAILED DESCRIPTION OF THE INVENTION

[0048] Endoscopic procedures are medical procedures that view and operate on internal organs and / or deliver energy (e.g., laser energy or ultrasound energy) to targeted body regions to achieve a specific diagnostic or therapeutic effect. For example, laser endoscopes have been used for the treatment of soft and hard tissues (e.g., to damage or destroy cancer cells) or in lithotripsy applications. During a procedure, a practitioner can insert a scope into a patient's kidney through an incision in the patient's ureter. Through the scope, the practitioner can locate a specific stone in the kidney or upper ureter and shatter it into smaller fragments by shining a relatively high-power infrared laser beam through the scope. The laser beam can ablate the stone into smaller fragments, which can then be extracted from the kidney. The scope can be an endoscope, a nephroscope, and / or a cystoscope.

[0049] Laser energy delivered to at least a portion of the surgical site and the environment for laser treatment of anatomical targets (e.g., ablation and fragmentation of stone targets) can cause heat accumulation at or near the surgical site, particularly when relatively high laser power intensities are used, such as for ablating or fragmenting stone targets of a particular size, hardness, or composition. To prevent dangerous consequences such as thermal tissue damage, the temperature within the body or at the surgical site can be monitored during the procedure to ensure it remains within a safe temperature range. Conventional surgical site temperature control involves monitoring the temperature in real time. If a temperature reading reaches or exceeds a safety limit (e.g., a preset threshold), a user (e.g., a physician) can reduce or temporarily disable the laser power intensity. Such manual temperature adjustment has several limitations. First, the temperature at the surgical site can rise rapidly, especially when high laser power is used during the procedure, and reducing or shutting off the laser power when the temperature reading reaches or exceeds a safety limit may be too late to prevent laser-induced thermal tissue damage. Second, the timing of laser power adjustments is important to prevent tissue damage without compromising the efficiency of ablation or fragmentation. Manual adjustment of laser power not only places a burden on the operating physician, but can also lack precision and predictability, especially for inexperienced physicians. Third, reducing or shutting off laser power may not produce adequate, rapid temperature removal at a particular surgical site or tissue anatomy. In some cases, it is not feasible to shut off or significantly reduce laser power without compromising the efficiency of ablation. For at least the above reasons, the present inventors have recognized an unmet need for devices and methods for automatic, more efficient temperature control to prevent heat accumulation at a surgical site during procedures such as laser lithotripsy procedures.

[0050] The present invention describes systems, devices, and methods for automatic control of surgical device settings based on tissue whitening that can be detected from images or video frames of at least a portion of a surgical site. An exemplary endoscopic surgical system includes an endoscopic surgical device controllably coupled to a medical instrument (e.g., a laser system) and configured to deliver energy (e.g., laser energy) to the surgical site during a procedure, an imaging sensor configured to generate images or video frames of at least a portion of the surgical site during the procedure, and control circuitry configured to analyze the generated images or video frames to determine whether a degree of heat accumulation in a first target (e.g., tissue) at the surgical site exceeds a predetermined threshold. Because there is a positive correlation between the degree of tissue whitening and the degree of heat accumulation, determining the degree of heat accumulation can be based on whether tissue whitening has occurred and the degree of heat accumulation in the first target. Based on such a determination, the control circuitry can determine whether to adjust at least one operating parameter associated with the endoscopic surgical system to achieve or maintain a therapeutic effect on a second target (e.g., a stone target) different from the first target at the surgical site while avoiding damaging the first target during the procedure.

[0051] Systems, devices, and methods according to various embodiments discussed herein improve real-time surgical site temperature control during laser endoscopic procedures. The features described herein may further be used in connection with endoscopy, laser surgery, laser or ultrasonic lithotripsy, irradiation parameter settings, and / or spectroscopy. Example targets and applications may include laser or ultrasonic lithotripsy of kidney stones and laser ablation or vaporization of soft tissue. In an example endoscopic system incorporating features as described herein, a surgical site condition, such as excessive heat accumulation, can be detected by analyzing images or video frames of at least a portion of the surgical site taken during the procedure and identifying tissue whitening from the images or video frames as an early sign of thermal tissue damage. Compared to traditional displays of temperature measurement, image-based surgical site temperature control as described herein allows tissue whitening to be detected at an earlier stage of thermal accumulation at the surgical site. Identifying tissue whitening can allow for earlier and more effective preventative measures to be taken before temperatures rise to critical levels, thereby preventing thermal tissue damage and improving patient safety.

[0052] This document describes various temperature control measures to regulate the temperature at the surgical site, such as keeping the temperature below critical levels or within a desired safety range. In some examples, the laser output intensity or one or more laser delivery parameters (e.g., one or more laser pulse parameters such as power, duration, frequency, or pulse shape, exposure time, or firing angle) can be adjusted. In some examples, pulse sequencing (representing the temporal distribution of laser pulses within a specific time period) can be adjusted or randomized to create a non-equilibrium state of irrigation flow. Such flow can help prevent or reduce the possibility of evaporative bubbles (induced by laser pulses) due to successive applications to the same area of ​​tissue, which can exacerbate localized heat accumulation. For example, adjusting laser settings can result in a non-equilibrium flow that applies bubbles created by laser energy to a wide area of ​​tissue rather than a single tissue area where tissue whitening is observed. In one embodiment, the non-equilibrium irrigation flow can promote evaporative bubble collapse at or near the surgical site. In addition to or instead of adjusting laser power settings, regulating the inflow of irrigation to the surgical site and / or the outflow (aspiration) from the surgical site can also keep the temperature at the surgical site under control. In some embodiments, the irrigation fluid may be treated (e.g., cooled) before flowing to the surgical site to more quickly and effectively reduce the temperature at the surgical site. One or more of these temperature control measures may be optimized based on the conditions at the surgical site. For example, based on tissue pressure at or near the surgical site, the irrigation or aspiration flow may be adjusted to achieve or maintain a desired environmental pressure at or near the surgical site while still producing a temperature control effect. In some examples, multiple temperature control measures (e.g., adjusting laser power or irradiation parameters, adjusting irrigation or aspiration flow, or providing irrigation fluid therapy) may be combined or arranged to form a tiered temperature control strategy based on the conditions at the surgical site.Compared with conventional approaches that focus on controlling laser power, the various temperature control means and tiered temperature control strategies discussed herein advantageously allow for more versatile control of the temperature at the surgical site depending on the condition of the surgical site. The use of alternative temperature control means, such as irrigation or suction flow and irrigation fluid therapy, can help avoid discontinuing or substantially reducing laser energy output during a laser lithotripsy procedure, so that the effectiveness of the laser treatment is not significantly compromised. As a result, more precise and faster temperature control, and improved laser treatment efficacy and tissue safety can be achieved.

[0053] 1 is a block diagram illustrating an example of a laser energy delivery system 100 configured to provide laser treatment to an anatomical target at or near a surgical site 122 in a subject's body, such as an anatomical structure (e.g., soft tissue, hard tissue, or an abnormality such as cancerous tissue) or a stone structure (e.g., a kidney stone, a pancreatic bile duct stone, or a gallbladder stone). In some examples, the laser energy delivery system 100 can deliver a precisely controlled therapeutic treatment of tissue or other anatomical structure (e.g., tissue ablation, coagulation, or vaporization, etc.), or treatment of a non-anatomical structure (e.g., ablation or dedusting of a stone structure).

[0054] The laser energy delivery system 100 may comprise a feedback control system 101 and at least one laser system 102 in operative communication with the feedback control system 101. By way of example, and not limitation, FIG. 1 illustrates a laser feedback system connected to a first laser system 102 and, optionally, a second laser system 104 (shown in dotted lines). Additional laser systems are contemplated within the scope of this disclosure. The first laser system 102 may comprise a first laser source 106 and associated components, such as a power supply, display, and cooling system. The first laser system 102 may also comprise a first optical pathway 108 operatively coupled to the first laser source 106. In an example, the first optical pathway 108 comprises an optical fiber. The first optical pathway 108 may be configured to transmit a laser beam from the first laser source 106 to a target structure at or near the surgical site 122.

[0055] The feedback control system 101 can receive feedback signals 130 from the target. Various feedback signals can be used to control laser delivery, laser energy output, and / or other system parameters to achieve or maintain desired conditions, such as a desired temperature at or near the surgical site, to improve the effectiveness of treatment and to prevent or reduce the severity of laser-induced thermal tissue damage. In an example, the feedback signal 130 can include a signal indicative of a condition at the surgical site, such as the temperature or pressure at or near the surgical site during a procedure. In an example, the feedback signal 130 can include an acoustic signal produced by a laser pulse propagating through a medium (e.g., liquid and vapor) and projecting onto the target, causing the target to vibrate. In another example, the feedback signal 130 can include a reflected electromagnetic signal (e.g., illumination light emitted from a light source and reflected). In yet another example, the feedback signal 130 can include a reflected laser signal. The feedback control system 101 can analyze the feedback signal 130, generate signal characteristics from the feedback signal 130, and control the laser output (e.g., energy intensity; other laser irradiation parameters such as power, duration, frequency, or pulse shape; exposure time; or firing angle). In an example, the feedback signal 130 can comprise images or video frames of at least a portion of a surgical site, such as those generated by an imaging sensor during a procedure. The feedback control system 101 can analyze the images or video frames to determine whether the degree of heat accumulation in a first target (e.g., tissue) at the surgical site exceeds a predetermined threshold. The predetermined threshold, which can be different for different types of tissue, can be represented by a threshold temperature (e.g., 42°C) that begins to cause undesirable clinical effects in the tissue. Because there is a positive correlation between the degree of tissue whitening and the degree of heat accumulation, the degree of heat accumulation can be inferred by assessing the degree of tissue whitening in the first target, and the predetermined threshold for heat accumulation can be represented by a threshold degree of tissue whitening.Based on the determination of the degree of heat accumulation (e.g., tissue whitening at the first target), the feedback control system 101 can adjust laser power or delivery, and / or other system parameters, to achieve or maintain a therapeutic effect at a second target (e.g., a stone target) at a different surgical site than the first target, while avoiding damaging the first target during the procedure. In an example, the first target may be tissue in the urinary system, and the second target may be a kidney stone target. The feedback control system 101 can adjust laser power or delivery, and / or other system parameters, to achieve or maintain desired surgical site conditions, such as a desired surgical site temperature, during the lithotripsy procedure to prevent laser-induced tissue thermal damage or reduce the severity of thermal damage, while maintaining the therapeutic effect of ablating or fragmenting the kidney stone target.

[0056] 1, based on analysis of the feedback signal 130, the feedback control system 101 can control the first laser system 102 and / or the second laser system 104 to generate an appropriate laser power to achieve a desired therapeutic effect, and to achieve or maintain a desired condition, such as a desired temperature at or near the surgical site, to prevent laser-induced thermal tissue damage or reduce the severity of thermal damage. For example, the feedback control system 101 can monitor the characteristics of a target structure during a therapeutic procedure (e.g., ablation of a stone, such as a kidney stone, into smaller fragments) to determine if the tissue has been adequately ablated before another therapeutic procedure (e.g., coagulation of a blood vessel).

[0057] In an example, the first laser source 106 can be configured to provide a first output 110. The first output 110 can extend over a first wavelength range, such as one that corresponds to a portion of the absorption spectrum of the target structure. Because the first output 110 spans a wavelength range that corresponds to the absorption spectrum of tissue, it can provide effective ablation and / or carbonization of the target structure.

[0058] In an example, the first laser source 106 may be configured such that the first output 110 emitted in a first wavelength range is irradiated with light having a high absorption of the incident first output 110 by tissue (e.g., approximately 250 cm -1 In an example embodiment, the first laser source 106 can emit a first output 110 between about 1900 nanometers (nm) and about 3000 nm (e.g., corresponding to high absorption by water) and / or between about 400 nm and about 520 nm (e.g., corresponding to high absorption by oxyhemoglobin and / or deoxyhemoglobin). Clearly, there are two primary mechanisms of light interaction with tissue: absorption and scattering. When tissue absorption is high (below 250 cm), -1 absorption coefficients above 250 cm), the first absorption mechanism dominates and is more pronounced in the low absorption cases (e.g., lasers in the wavelength range 800–1100 nm). -1 absorption coefficient less than 1000 Å), scattering mechanisms dominate.

[0059] Various commercially available medical-grade laser systems may be suitable for the first laser source 106. For example, a semiconductor laser such as an InXGa1-XN semiconductor laser may be used that provides a first output 110 in a first wavelength range between about 515 nm and about 520 nm, or about 370 nm to about 493 nm. Alternatively, an infrared (IR) laser may be used, such as those summarized in Table 1 below.

[0060] [Table 1]

[0061] The optional second laser system 104 may comprise a second laser source 116 for providing the second output 120 and associated components, such as a power supply, display, and cooling system. The second laser system 104 may be either operably separate from or operably coupled to the first laser source 106. In some embodiments, the second laser system 104 may include a second optical path 118 (separate from the first optical path 108) operably coupled to the second laser source 116 for transmitting the second output 120. Alternatively, the first optical path 108 may be configured to transmit both the first output 110 and the second output 120.

[0062] In certain aspects, the second output 120 can extend over a second wavelength range that is separate from the first wavelength range. Thus, there may be no overlap between the first wavelength range and the second wavelength range. Alternatively, the first wavelength range and the second wavelength range may have at least partial overlap with each other. In advantageous aspects of the present disclosure, the second wavelength range may not correspond to a portion of the absorption spectrum of the target structure where the incident radiation is strongly absorbed by previously ablated or carbonized tissue. In some such aspects, the second output 120 may advantageously not ablate uncarbonized tissue. In another embodiment, the second output 120 may ablate previously ablated and carbonized tissue. In additional embodiments, the second output 120 may provide an additional therapeutic effect. For example, the second output 120 may be better suited to coagulating tissue or blood vessels.

[0063] 2 is a block diagram illustrating an endoscopic surgery system 200 with automatic surgical site condition control and at least a portion of an environment in which the system 200 may operate. The system 200 may be an embodiment of the laser energy delivery system 100 or an embodiment of a lithotripsy system that may be used to destroy hardened masses such as kidney stones, gastroliths, and gallstones, among other stone structures. The system 200 may monitor and control conditions at or around the surgical site 122 during a laser procedure to maintain the temperature of the surgical site at a substantially desired level during the procedure to prevent laser-induced tissue thermal damage or reduce the severity of thermal damage. As used herein, the term "substantially" means ±10%, and in some embodiments, ±5%.

[0064] The endoscopic surgery system 200 may include a feedback control system 210, one or more sensors 220, a laser system 230, an irrigation and / or aspiration system 240, and a user interface device 250. The feedback control system 210, which is an embodiment of the feedback control system 101 of the laser energy delivery system 100, may include a feedback analyzer 212 and a control circuit 218. According to an example embodiment, the feedback control system 210 may include a processing device such as a microprocessor, a digital signal processor (DSP), an application specific integrated circuit (ASIC), a field programmable gate array (FPGA), or any other equivalent integrated or discrete logic circuit, as well as any combination of such components for performing one or more of the functions attributed to the feedback control system 210. The feedback analyzer 212 may be communicatively coupled to one or more sensors 220, may receive feedback signals from the sensors 220, and may analyze the feedback signals to generate one or more signal characteristics that may be used to control a condition at the surgical site. In an example such as that shown in FIG. 2 , the one or more sensors 220 may include an imaging sensor 222 configured to generate images or video frames of at least a portion of the surgical site 122 during a procedure. The imaging sensor 222 may be included in an imaging system that further includes a lens system. An example of the image sensor 222 may be a CCD or CMOS camera sensitive to ultraviolet (UV), visible light (VIS), or infrared (IR) wavelengths. The imaging sensor 222 may position a distal portion of an endoscope for use during a procedure, an example of which is shown in FIG. 3 . The imaging sensor 222 may generate images or video frames at different times. The one or more sensors 220 may additionally include a pressure sensor 224 to sense pressure at the surgical site during a procedure.

[0065] Images or video frames of the surgical site can be transmitted to a feedback analyzer 212. The feedback analyzer 212 can include an image analysis circuit 214 and a tissue whitening detection circuit 216. The image analysis circuit 214 can process the images or video frames to detect image features from the images or video frames that indicate changes in tissue color over time. The tissue whitening detection circuit 216 can use the detected image features to detect indications of tissue whitening. The tissue whitening can indicate the degree of heat accumulation in a first target (e.g., tissue) at the surgical site. In an example, the image analysis circuit 214 can compare images or video frames taken at different times during a procedure and identify changes in the intensity of one or more characteristic color components (e.g., CMOS or CCD color components) at registered locations in the images or video frames. The registered locations corresponding to specific tissue sites can be identified by a user. In an example, an aiming beam can be used to assist in identifying registered locations corresponding to specific tissue sites, as discussed later. The tissue whitening detection circuit 216 compares the intensity of one or more characteristic color components (e.g., RGB values) of the registered location with respective threshold values ​​(e.g., threshold RGB values, RGB) for a "white" color (RGB(255, 255, 255)) or a predetermined "whitened" color (e.g., RGB(240, 240, 240)). TH) can be compared. If the intensity values ​​(e.g., from 0 to 255) of one or more color components are sufficiently close to the color "white" within a certain margin (e.g., RGB values ​​within the range of (240-255, 240-255, 240-255)), tissue whitening is considered to be detected. In some examples, the image analysis circuit 214 can compare successively captured images or perform a frame-by-frame comparison of video frames to determine the color intensity change rate toward the color "white" or a predetermined "whitened" color at the registered location. The tissue whitening detection circuit 216 can compare the color intensity change rate with a rate threshold and determine the presence of tissue whitening if the color intensity change rate exceeds the rate threshold. Tissue whitening thus detected indicates that the degree of heat accumulation in the tissue at the surgical site is indicative of a change in the RGB TH Or it indicates exceeding a predetermined threshold corresponding to a threshold color intensity change rate.

[0066] The control circuitry 218 may be coupled by a wired or wireless connection to the feedback analyzer 212. In response to the identified tissue whitening, the control circuitry 218 may generate control signals to adjust operating parameters associated with the system 200 to substantially achieve or maintain a desired temperature (e.g., ±10%, or in some cases ±5%) at the surgical site. In an example, the tissue whitening detection circuitry 216 detects a time t(RGB t ) and a threshold value RGB for a "white" color (RGB(255, 255, 255)) or a predetermined "whitened" color (RGB(240, 240, 240)). TH The degree of tissue whitening ΔRGB based on the difference between and, i.e., ΔRGB = RGB t -RGB THA smaller ΔRGB value indicates a higher degree of tissue whitening (i.e., closer to "white" or a predetermined "whitened" color) and therefore a higher temperature at the surgical site and a higher risk of tissue thermal damage. In another example, the tissue whitening detection circuit 216 can determine the rate of tissue whitening ΔRGB / Δt (i.e., the amount of color intensity change toward "white" or a predetermined "whitened" color per unit time). A higher rate of tissue whitening ΔRGB / Δt indicates a faster heat accumulation at the surgical site and, in turn, a higher risk of tissue thermal damage. The control circuit 218 can determine the aggressiveness of parameter adjustments (e.g., by adjusting laser power settings, irrigation and / or aspiration flow rates, irrigation fluid temperature controls, etc.) based on the degree of tissue whitening ΔRGB or the rate of tissue whitening ΔRGB / Δt. For example, if a higher degree of tissue whitening or a faster rate of tissue whitening (i.e., faster tissue whitening) is detected, the control circuit 218 may provide a more aggressive adjustment of one or more system parameters (e.g., a greater reduction in laser power, a higher irrigation flow rate and / or a higher aspiration flow rate, or greater cooling of the irrigation fluid before it flows to the surgical site) to bring the temperature at the surgical site under control.

[0067] Laser system 230, which is an example of laser system 102 or laser system 104 as shown in FIG. 1, may include a laser source (e.g., first laser source 106) and an optical path (e.g., first optical path 108) for directing laser energy to a surgical site. The laser source can generate laser energy according to laser output intensity or one or more laser irradiation parameters (e.g., one or more laser pulse parameters such as power, duration, frequency, or pulse shape, exposure time, or launch angle). At least some of these laser parameters are programmable or adjustable, either automatically, such as by control circuitry 218, or manually by a user via user interface device 250. In response to an indication of tissue whitening (as detected by tissue whitening detection circuitry 216), control circuitry 218 can automatically adjust laser output settings according to one or more of the degree of tissue whitening ΔRGB or the rate of tissue whitening ΔRGB / Δt. For example, the control circuit 218 can automatically reduce the average power of the laser pulses delivered to the surgical site, such as by reducing one or more of the pulse width of the laser pulses, the peak power of the laser pulses, or the pulse frequency, which represents the number of laser pulses per unit time. Reducing the average power of the laser pulses can reduce laser-induced heating effects at or near the surgical site, thereby preventing thermal damage to tissue and improving patient safety during the procedure.

[0068] In addition to or instead of adjusting one or more laser output parameters, the control circuit 218 can automatically select one of a plurality of predetermined laser output settings or pulse profiles with different energy output levels depending on the degree of tissue whitening ΔRGB or the rate of tissue whitening ΔRGB / Δt. In an example, the control circuit 218 can automatically switch between a first "high power" setting and a second "low power" setting with the values ​​of the respective predetermined parameters. The "low power" setting has a lower average power than the "high power" setting. When the degree of tissue whitening ΔRGB or the rate of tissue whitening ΔRGB / Δt exceeds the respective threshold value, the "low power" setting will be automatically selected.

[0069] In some examples, the laser system 230 may include a first laser source 232 and a different second laser source 234. The first laser source 232 may generate therapeutic laser energy directed to a target at a surgical site through an optical path, such as the first optical path 108. Examples of the first laser source 232 may include a thulium laser, Ho:YAG, Nd:YAG, and CO2, among others. The second laser source 234 may be optically coupled to the same or a different optical path, such as the second optical path 118. The second laser source 234 may generate an aiming beam directed to a target through the same or a different optical path. For example, the wavelength of the aiming beam may be in the range of 500-550 nm. In some examples, the second laser source 234 may emit at least two different aiming beams with different characteristics, such as one or more of wavelength, power level, or emission pattern. For example, the first aiming beam can have a wavelength in the range of 500 nm to 550 nm, and the second aiming beam can have a wavelength in the range of 635 nm to 690 nm. The characteristics of the different aiming beams can be selected based on the visibility of the aiming beams in an image or video frame of the surgical site.

[0070] The aiming beam may be emitted when the target is illuminated by an illuminated light (such as the illumination light source 324 shown in FIG. 3). In some examples, the aiming beam may be generated using a light source different from the second laser source 234. The light source may generate the aiming beam with a distinct color to distinguish it from the illuminated background of the surgical site. By way of example, and not limitation, the aiming beam may be green light in the range of approximately 520 nm, or in another example, red in the range of approximately 620 nm.

[0071] The aiming beam incident on tissue at the surgical site may be captured by the imaging sensor 222 and shown as an aiming beam footprint in an image or video frame. FIG. 4 shows an endoscopic image 410 including a graphical depiction of the illuminated target site within the field of view of the imaging sensor 222 and a circular aiming beam footprint 412. Also shown in image 410 are an image of the distal tip 413 of the optical path (e.g., the distal end 336 of the optical path 334 as shown in FIG. 3) and an image of the distal portion 414 of the endoscope (such as endoscope 301 as shown in FIG. 3). When a colored (e.g., green) aiming beam is used, the aiming beam footprint 412 may also appear green in the endoscopic image 410. The tissue whitening detection circuit 216 may identify the aiming beam footprint 412 from each of a series of images or video frames of the surgical site and may detect tissue whitening from portions of the images or video frames at or near the aiming beam footprint. In one embodiment, when tissue becomes "white," a colored (e.g., green or red) aiming beam incident on the "whitened" tissue can appear brighter in an image or video frame than on "unwhitened" tissue. For example, for a green aiming beam, a brighter green footprint can indicate a higher degree of tissue whitening than a dull green footprint. The color brightness of the footprint can be measured as color intensity or saturation (e.g., RGB values). In an example, the tissue whitening detection circuit 216 can detect tissue whitening based on an increase in color intensity at or near the aiming beam footprint (and can further determine the degree of tissue whitening ΔRGB and / or the tissue whitening rate ΔRGB / Δt). Based on the tissue whitening indicated by the aiming beam, the control circuit 218 can adjust one or more system parameters to bring the temperature of the surgical site under control.

[0072] As previously described, in response to detecting tissue whitening (by the tissue whitening detection circuit 216), the control circuit 218 can automatically adjust laser output settings, including one or more laser illumination parameters, depending on the degree of tissue whitening ΔRGB or the rate of tissue whitening ΔRGB / Δt to reduce the temperature of the surgical site. Maintaining a desired surgical site condition (e.g., temperature) can help achieve or maintain a desired therapeutic effect (e.g., ablation or fragmentation of a stone target) at a treatment target at the surgical site while avoiding damaging tissue near the treatment target during the procedure. One example of a laser illumination parameter adjusted to control the temperature of the surgical site is pulse sequencing (also referred to as pulse profile). Pulse sequencing describes the timing or temporal distribution of laser pulses over a specific period of time. Adjusting pulse sequencing can alter the heat distribution within the surgical space, such as by altering the formation, flow, and volume of vapor bubbles produced by the pulsed laser beam. Such vapor bubbles can form as the laser pulse propagates through the surgical space into contact with the tissue wall. Tissue areas in contact with evaporative bubbles tend to be heated by the bubbles. For example, in some cases, a temperature increase of 25°C to 30°C can occur in tissue areas contacted by the bubbles. The temperature increase in tissue at or near the surgical site can also be affected by the size of the bubbles and the location of the optical path (e.g., fiber-to-tissue distance). Therefore, reducing the size and number of evaporative bubbles and / or redistributing the bubbles over a wider range of tissue areas (to prevent bubbles from constantly contacting the same tissue area) can help reduce the temperature at the surgical site and prevent or reduce the severity of thermal tissue damage.

[0073] A constant pulse sequence of the laser may facilitate the bubbles' progression in equilibrium toward a consistent point of contact with the tissue wall. Under such equilibrium, a predictable turbulent flow of bubbles toward the same tissue region may consistently strike the tissue region, causing heat accumulation. To mitigate the distracting effects of a single point of tissue constantly absorbing laser-induced heat via the flow of bubbles, the control circuit 218 responds to the identification of tissue whitening in an image or video frame by generating control signals to the first laser source 232 to adjust the laser power settings, including the laser pulse sequencing, to prevent the bubbles from progressing in equilibrium and continuously striking the same tissue region. Specifically, varying the pulse sequencing (i.e., changing the temporal distribution of the laser pulses within a particular time period) can create a non-equilibrium irrigation flow, in which bubbles strike a wider range of tissue regions than the single tissue region where tissue whitening may be observed, or a more chaotic and unpredictable irrigation flow. The pulse sequencing may be changed periodically or at user-specified times. 5A-5D illustrate an example of changing pulse sequencing from a first pulse profile 510 (in FIG. 5A) to a different second pulse profile 520 (in FIG. 5B) within a given time period T, and the resulting irrigation flow and foam conditions. The second pulse profile 520 is characterized by a chaotic distribution of laser pulses 522 that differs from the distribution of pulses 512 of the first pulse profile 510. In an example, a random number generator may be used to determine the timing for the laser pulses 522 within the given time period T. FIG. 5C illustrates an equilibrium state created by laser pulses emitted from the distal tip 501 into the surgical space of tissue 502 according to the first pulse profile 510. The equilibrium state is characterized by a predictable, steady turbulence 530 in which evaporation bubbles 532 flow toward location "A" of the tissue 502, always impinging on the same tissue location "A," causing heat accumulation there. In contrast, FIG. 5D illustrates the non-equilibrium condition created by a laser pulse delivered according to a second pulse profile 520.The non-equilibrium state is characterized by a more unpredictable irrigation flow 540 with less evaporative bubbles 542 due to a higher probability of bubble collapse. Bubbles 542 in the non-equilibrium state can impinge on a broader range of areas of tissue 502 rather than a single tissue area "A," thereby preventing or reducing the severity of thermal tissue damage at the surgical site.

[0074] In some examples, in response to an indication of tissue whitening (as detected by tissue whitening detection circuit 216), control circuit 218 can generate control signals to an actuator coupled to the optical path (e.g., laser fiber) of laser system 230 to adjust the position or orientation of an adjustable distal portion of the optical path (laser emission portion) relative to an anatomical target at or near the surgical site. Adjusting the position or orientation of the adjustable distal portion of the optical path can include adjusting the distance between the distal portion and the anatomical target (the “fiber-to-target” distance) or the aiming angle of the distal portion relative to the anatomical target, depending on one or more of the degree of tissue whitening ΔRGB or the rate of tissue whitening ΔRGB / Δt provided by tissue whitening detection circuit 216. For example, control circuit 218 can, via the actuator, automatically move the distal portion of the optical path farther away from the surgical site (i.e., increase the fiber-to-target distance) and / or rotate the distal portion of the optical path to aim the laser away from the surgical site (to increase the aiming angle). Increasing the fiber-to-target distance and / or increasing the aiming angle can reduce the density of laser energy incident on the surgical site and the laser-induced heat transferred to the surgical site.

[0075] In certain procedures (e.g., lithotripsy) where the target intended to be treated is not an anatomical tissue or organ, but a mass such as a stone structure at the surgical site, identification of tissue whitening can be an indication of insufficient aiming of the laser fiber. Adjusting the position or orientation of the distal portion of the optical pathway (to change the aiming angle or "fiber-to-target" distance), such as via an actuator that represents tissue whitening, can redirect the laser energy to the intended stone target to improve the effectiveness of the treatment while preventing thermal tissue damage.

[0076] The irrigation and / or aspiration system 240 may include one or more irrigation and / or aspiration sources that can provide a flow of irrigation fluid (also referred to as irrigation fluid, e.g., saline solution) to the surgical site through at least one irrigation passageway, such as that included in an endoscope during a procedure. The irrigation fluid can facilitate the removal of tissue debris, stone fragments, and other unwanted material through the aspiration passageway. The irrigation flow may have a cooling effect on tissue at or near the surgical site and surgical tools (e.g., an endoscopic tissue removal device) and can help dissipate heat generated during stone ablation. An example of the irrigation and / or aspiration system 240 is discussed below with reference to FIG. 3.

[0077] In some examples, in response to an indication of tissue whitening (as detected by tissue whitening detection circuit 216), control circuit 218 can automatically adjust one or more irrigation parameters, such as irrigation flow or aspiration flow, depending on the degree of tissue whitening ΔRGB or the rate of tissue whitening ΔRGB / Δt provided by tissue whitening detection circuit 216. For example, control circuit 218 can automatically increase irrigation flow from the irrigation source to the surgical site to increase convective heat transfer. Additionally or alternatively, control circuit 218 can automatically increase aspiration flow (or aspiration pressure) to more effectively draw fluid away from the surgical site to improve heat dissipation and reduce the temperature at the surgical site.

[0078] The application of irrigation or aspiration flow to control the temperature of the surgical site can fluctuate the pressure at or near the surgical site. For example, irrigation flow to the surgical site generally increases the surgical site pressure (a positive pressure change), while aspiration pressure (i.e., outflow) generally decreases the surgical site pressure (a negative pressure change). Such irrigation- and / or aspiration-induced positive or negative pressure changes can be harmful to tissue or organs at or near the surgical site if not properly regulated. To keep the anatomical environment pressure under control during the procedure and to avoid or reduce pressure-related tissue damage, the system 200 can include a pressure sensor 224 to sense the pressure at the surgical site during the procedure. When the degree of tissue whitening ΔRGB or the tissue whitening rate ΔRGB / Δt meets the respective conditions (e.g., ΔRGB is less than a threshold value or ΔRGB / Δt exceeds a threshold value), the control circuit 218 can selectively activate or adjust the irrigation flow or aspiration flow based on the measured surgical site pressure (P). For example, an increase in irrigation flow to a surgical site can introduce a positive pressure change at or near the surgical site, causing the measured surgical site pressure to exceed a predetermined or user-specified pressure limit (also referred to as the maximum allowable pressure) P max When it exceeds (P>P max ), the control circuit 218 can increase aspiration flow to reduce the surgical site temperature but avoid increasing irrigation flow to prevent a further increase in surgical site pressure. For example, the irrigation flow can be maintained at its flow rate, set to a reduced rate, or temporarily deactivated. The increased aspiration flow can also help reduce the surgical site pressure to a level within the desired pressure range. When the measured surgical site pressure is below the upper pressure limit P max and the pressure lower limit P min If the pressure is within the desired range between min <P<P max), the control circuit 218 can increase one or both of the irrigation flow and the aspiration flow to reduce the temperature at the surgical site. The increase in aspiration flow can introduce a negative pressure change at or near the surgical site, causing the measured surgical site pressure to exceed the lower pressure limit P min If it is less than (P <P min ), the control circuit 218 can increase irrigation flow to the surgical site to reduce the temperature at the surgical site, but avoid increasing the aspiration flow to prevent a further drop in surgical site pressure. For example, the aspiration flow can be maintained at its flow rate, set to a reduced rate, or temporarily deactivated. The increased irrigation flow can also help increase the surgical site pressure to a level within the desired pressure range.

[0079] In some examples, the irrigation and / or aspiration system 240 can include an irrigation fluid treatment unit that can adjust the temperature of the irrigation fluid (irrigation fluid) before application to the surgical site. In some examples, in response to an indication of tissue whitening (as detected by the tissue whitening detection circuit 216), the control circuit 218 can generate a control signal to the irrigation fluid treatment unit to modify the temperature of the irrigation fluid in response to one or more of the degree of tissue whitening ΔRGB or the rate of tissue whitening ΔRGB / Δt provided by the tissue whitening detection circuit 216. In examples, the irrigation fluid treatment unit can include a cooling system (e.g., a heat sink or an in-line chiller) that can cool the irrigation fluid before it reaches the surgical site under the control of the control circuit 218. In another example, the irrigation fluid treatment unit includes a fluid mixer that can mix at least two irrigation fluids of different temperatures before it reaches the surgical site under the control of the control circuit 218. Cooled irrigation via a cooling system or mixed irrigation fluid via a fluid mixer can enhance convective heat transfer when applied to a surgical site, effectively and efficiently reducing the temperature at the surgical site.

[0080] In some examples, the control circuitry 218 can maintain the temperature of the surgical site substantially at a desired level or range according to a temperature management plan. The temperature management plan may include a prioritized sequence of two or more temperature control measures described above, including, for example, altering the laser power setting or one or more laser delivery parameters, adjusting the position or orientation of a distal portion of the optical path (e.g., the laser fiber), activating or adjusting irrigation flow to and / or aspiration flow away from the surgical site, or modifying the temperature of irrigation fluid before application to the surgical site, among other things. The temperature management plan can be programmed or refined by the user, such as via the user interface device 250. The sequence of temperature control measures can be determined based on availability (e.g., an irrigation fluid cooling system), efficiency of temperature control, or potential adverse effects at the surgical site. In an example, a temperature management plan may be programmed with a bias toward maintaining an optimal or user-selected laser power setting while adjusting other device settings (e.g., the position or orientation of the distal portion of the optical pathway, irrigation and / or aspiration flow, irrigation fluid temperature) appropriate to maintain the temperature of the surgical site. Maintaining the laser power setting may be desirable during a laser lithotripsy procedure to reduce procedure time and ensure treatment effectiveness and efficiency. Adjusting the laser power setting (e.g., reducing the average laser power) may also have a gradual effect on the temperature of the surgical site. In another example, a temperature management plan may be programmed such that irrigation fluid temperature control (e.g., cooling the irrigation fluid before application to the surgical site) may be used before attempting to adjust the irrigation or aspiration flow to prevent irrigation- and / or aspiration-induced pressure fluctuations at or near the surgical site. For example, in response to an indication of tissue whitening (as detected by tissue whitening detection circuit 216), control circuit 218 may initially generate a control signal to an irrigation fluid processing unit of irrigation and / or aspiration system 240 to cool the irrigation fluid before it is applied to the surgical site.The feedback control system 210 can then re-evaluate the image or video frame to determine whether tissue whitening still persists or worsens, and in such case, the control circuit 218 can generate a control signal to the irrigation and / or aspiration system 240 to increase irrigation and / or aspiration flow to reduce the temperature at the surgical site. The selection between irrigation and aspiration flow, or the order in which irrigation and aspiration flows are applied, can be based on the surgical site pressure, as discussed above. For example, to maintain the surgical site temperature at a substantially desired level or range during the procedure, the system may adjust the current surgical site pressure P to a predetermined or user-specified pressure limit P. max The current surgical site pressure P can be compared to max If it is less than (for example, P and P max If the difference between P and P exceeds a threshold, the irrigation inflow rate may be increased to increase convective heat transfer through the irrigation. Additionally or alternatively, the aspiration flow may be increased to efficiently move heat away from the surgical site. In contrast, if the current surgical site pressure P is substantially P max If the current surgical site pressure P is close to (e.g., within a user-specified or predetermined margin, such as ±10%), the laser power setting may be reduced rather than increasing the irrigation inflow rate. In embodiments where the aspiration flow is actively controlled (e.g., via a pump), the current surgical site pressure P may be increased to substantially P max If the pressure is close to 0.05, the aspiration flow rate can be increased to reduce the pressure at the surgical site, either as an alternative or in addition to reducing the laser power setting. While bodily tissues can generally limit some positive pressure changes, many organs are relatively vulnerable to negative pressure changes. Therefore, in some instances, increasing the irrigation flow can be attempted before activating or increasing the aspiration flow.

[0081] The feedback control system 210 can then reevaluate the image or video frame to determine whether tissue whitening still persists or worsens; in such a case, the control circuit 218 can generate control signals to the laser system 230 to adjust the position or orientation of the distal portion of the optical path or to change the laser power setting or one or more laser delivery parameters. The laser delivery parameters may be adjusted in a predetermined order or priority. For example, adjusting the pulse shape or pulse sequencing (the temporal distribution of laser pulses within a specific time period) may be prioritized over adjusting the average power of the laser pulses. The stacked sequential activation or adjustment of different temperature control means can help maintain desired surgical site conditions (e.g., temperature, pressure) during a procedure without compromising the effectiveness and efficiency of the treatment or imposing additional risk of tissue damage at or near the surgical site.

[0082] The user interface device 250 may be in operative communication with a feedback control system. The user interface device 250 may include an output / display unit 252 for displaying information, including, for example, image, pressure, or other information sensed by the sensor 220; feedback signals generated by the feedback analyzer 212, including detected indications of tissue whitening; the degree of tissue whitening ΔRGB; the tissue whitening rate ΔRGB / Δt; or the status of the surgical site, including current device settings such as laser power settings, irrigation flow rate, or suction flow rate. The output / display unit 252 may display UI elements, including visual elements, alerts, tactile feedback, or any combination thereof. The output / display unit 252 may generate warnings about potentially dangerous conditions at or near the surgical site, such as elevated temperature indicated by tissue whitening or elevated surgical site pressure. The warnings may be provided in an audible, visual, tactile, or other human-perceivable form.

[0083] The user interface device 250 may include one or more input units 254 for accepting user programming of the device, such as parameter values ​​used to detect tissue whitening (e.g., including predetermined RGB values ​​for the color "whitened" and threshold values ​​for the degree of tissue whitening ΔRGB and / or the rate of tissue whitening ΔRGB / Δt). User input may include parameter adjustments for laser power settings, irrigation flow, or aspiration flow, among other device parameters, for controlling the temperature of the surgical site. In some examples, a user may provide, via one or more input units 254, a temperature management plan that defines a prioritized sequence of two or more temperature control measures, such as those described above. For example, a user may initially direct the control circuit 218 to reduce irrigation fluid temperature (if available) without adjusting the laser power of the irrigation flow rate. Then, if tissue whitening at the surgical site persists or worsens, the flow rate may be increased and / or the irrigation fluid temperature may be decreased. Examples of prioritization measures for controlling the surgical site are discussed below with reference to FIGS. 7A-7B.

[0084] In some examples, the output / display unit 252 may generate recommendations for taking preventative actions to prevent tissue damage, such as recommended adjustments to laser power or other system parameters. A user may provide input via one or more input units 254 to confirm, reject, or modify the recommended adjustments.

[0085] FIG. 3 illustrates an example of an endoscopic laser lithotripsy system 300 with automatic surgical site state control, which may be an example of the endoscopic surgical system 200. The endoscopic laser lithotripsy system 300 may include an endoscope 301, a feedback control system 310, an actuator 338, an irrigation and / or aspiration system 340, and an irrigation fluid treatment unit 342. The endoscope 301 has a proximal portion and an elongated distal portion configured to be inserted into a patient's surgical site during an endoscopic laser lithotripsy procedure. The endoscope 301 can provide visual inspection or treatment of soft tissue (e.g., non-calcified tissue) or hard tissue (e.g., calcified tissue), as well as visualization, destruction, or other treatment of kidney stones, other stones, or other targets. As shown in FIG. 3 , the endoscope 301 can include or provide visualization and illumination optics, such as a visualization optical path 360 and an illumination optical path 350, each of which may extend longitudinally along the elongated body of the endoscope 301. An eyepiece, camera, or imaging display device may be provided in or coupled to the visualization optical path 360 to enable user or machine viewing of a target area at or near the distal end of the endoscope 301. The target area may be illuminated by light 370, such as provided by an illumination light source 324 at the proximal end of the illumination optical path 350 and emitted from the distal end of the illumination optical path 350. The light source 324 may comprise, for example, a xenon lamp, a light-emitting diode (LED), a laser diode (LD), or any combination thereof. In an example, the light source 324 may comprise two or more light sources that emit light having different illumination characteristics, referred to as illumination modes. In an example, the illumination modes may include a white light illumination mode or a special light illumination mode, such as a narrowband imaging mode, an autofluorescence imaging mode, or an infrared imaging mode. The special light illumination may concentrate and enhance light of specific wavelengths, resulting in, for example, better visualization of tissue or other structures at the surgical site.

[0086] Lithotripsy system 300 may include or be coupled to at least one laser source 332, which may be an example of first laser source 106, second laser source 116, or a laser source included in laser system 230. Laser source 332 may be mechanically and optically connected to optical pathway 334, which may comprise a single optical fiber or a bundle of optical fibers. Optical pathway 334, which is an embodiment of first optical pathway 108 or second optical pathway 118, or an optical pathway included in laser system 230, may be introduced through a proximal access port to extend within a working channel, other longitudinal passageway, or lumen of endoscope 301 or a similar instrument.

[0087] In some examples, laser source 332 may comprise a first laser source (such as first laser source 232) for generating the treatment beam and a second, different laser source for generating the aiming beam (such as second laser source 234). The treatment beam and the aiming beam may be directed at the target through the same or different optical paths. In some examples, the aiming beam may be generated using a different light source than the second laser source. As described above with reference to FIG. 2, the aiming beam may have a distinct color (e.g., green or red) to distinguish it from the illuminated background of the surgical site.

[0088] The lithotripsy system 300 may include a camera or imaging device 325. The camera or imaging device 325 may include an imaging sensor (such as imaging sensor 222) capable of generating an imaging signal of a target in response to electromagnetic radiation (e.g., illumination light 370) of the target at or near the surgical site. The imaging signal may be transmitted to a feedback control system 310 (an embodiment of the feedback control system 210) via optical path 360, or alternatively, via optical path 334. The feedback control system 310 may include a feedback analyzer 312 and a control circuit 318. In an example, the imaging signal may pass through an optical splitter before reaching the feedback analyzer 312. The feedback analyzer 312 may include a spectrometer capable of generating one or more spectral signatures from the imaging data. The feedback analyzer 312 may use the one or more spectral signatures to recognize the target as a stone target or anatomical target at or near the surgical site, or to classify the target as a type of tissue or a type of stone having a distinct composition. In some examples, the feedback analyzer 312 can use the spectroscopic characteristics to calculate or estimate the fiber-to-target distance. The control circuit 318 can generate control signals to the laser source 332 to adjust the laser power setting, to the actuator 338 to adjust the position or orientation of the distal end 346 of the irrigation and / or aspiration passage 344 (e.g., fiber-to-tissue distance, or aiming angle), or to the irrigation and / or aspiration system 340 to adjust the irrigation or aspiration flow based on the structure, composition, or type of target.

[0089] In some examples, the camera or imaging device 325 may include an imaging sensor (such as imaging sensor 222) capable of generating an image or video frame of a target. The image or video frame of the surgical site may be transmitted to the feedback analyzer 312. Similar to the feedback analyzer 212, the feedback analyzer 312 (an embodiment of the feedback analyzer 212) may detect an indication of tissue whitening from the image or video frame of the surgical site. In examples, the tissue whitening may be detected based on a threshold value for a predetermined "white" color (RGB TH ) of the image or video frame taken at time t. In another example, the feedback analyzer 312 can perform a frame-by-frame comparison of video frames to determine the rate of color intensity change toward a "white" color (RGB(255, 255, 255)) or a predetermined "whitened" color. The feedback analyzer 312 can compare the intensity values ​​(RGB values) of the image or video frame taken at time t (RGB(255, 255, 255)) as discussed above with reference to FIG. 2. t ) and threshold value RGB TH The degree of tissue whitening ΔRGB or the speed of tissue whitening ΔRGB / Δt can be determined based on the difference between the

[0090] In some examples, the feedback analyzer 312 can detect tissue whitening (and determine a tissue whitening degree ΔRGB or a tissue whitening rate ΔRGB / Δt) from a portion of an image or video frame at or near the footprint of the aiming beam incident on tissue at the surgical site, as described with reference to Figure 4. Tissue whitening (including the degree and rate of tissue whitening) can be detected based on an increase in color intensity at or near the aiming beam footprint.

[0091] Detection of tissue whitening, including the degree and / or rate of tissue whitening, may be used by the control circuit 318 to regulate the temperature at the surgical site, such as by adjusting the operating parameters of one or more devices, such as the laser source 332, the irrigation and / or aspiration system 340, or the irrigation fluid treatment unit 342.

[0092] Irrigation and / or aspiration system 340 (an embodiment of irrigation and / or aspiration system 240) may include an irrigation source and a suction source, each fluidly coupled to a working channel of endoscope 301, such as irrigation and / or aspiration passageway 344. Irrigation and / or aspiration passageway 344 may be a common, unified passageway for providing irrigation inflow and suction outflow at different times. Alternatively, in some examples, irrigation and / or aspiration passageway 344 may comprise two separate passageways, such as an irrigation passageway and a suction passageway. The separate irrigation and aspiration passageways may be parallel to each other or may be coaxially arranged on a common axis, such as in a nested configuration. An irrigation source may function to provide irrigation fluid (irrigation liquid) to irrigation and / or aspiration passageway 344. The irrigation fluid may be gravity-fed or pressurized. In examples, a pump may generate pressurized irrigation flow to the surgical site through irrigation and / or aspiration passageway 344. The suction source may function to pull, suck, draw, aspirate, or otherwise move or remove fluids and unwanted materials from the surgical site to a container. The suction source may perform the foregoing functions by generating and applying a vacuum, suction, or negative pressure to the irrigation and / or aspiration passages 344.

[0093] The feedback analyzer 312 of the feedback control system 310 can receive feedback information produced by one or more sensors, including, for example, an imaging sensor in a camera or imaging device 325 and a pressure sensor 224 configured to sense pressure at the surgical site during a procedure. The pressure sensor 224 can be positioned at the distal end 336 of the optical path 334. Alternatively, the pressure sensor 224 can be positioned elsewhere, such as at the distal end 346 of the irrigation and / or aspiration passageway 344. As previously described, the feedback analyzer 312 can detect indications of tissue whitening from images or video frames of the surgical site and can determine a tissue whitening degree ΔRGB or a tissue whitening rate ΔRGB / Δt. Depending on the degree and / or rate of tissue whitening determined, control circuit 318 (an embodiment of control circuit 218) can automatically adjust, or prompt the user to manually adjust, one or more system parameters to regulate the temperature at the surgical site to prevent laser-induced tissue thermal damage or reduce the severity of thermal damage.

[0094] Various temperature control means can be used to regulate the temperature of the surgical site during a procedure. In an example, the control circuit 318 can generate control signals to the laser source 332 to automatically adjust laser power settings, including one or more laser firing parameters, in response to the degree of tissue whitening, ΔRGB, or the rate of tissue whitening, ΔRGB / Δt. In an example, the laser power settings can be adjusted by altering the pulse sequencing (i.e., changing the temporal distribution of laser pulses within a particular time period) to create an unbalanced irrigation flow where bubbles impinge on a wider range of tissue regions than a single tissue region where tissue whitening may be observed, or a more chaotic and unpredictable irrigation flow, as described above with reference to FIGS. 5B and 5D.

[0095] In addition to or instead of adjusting the laser power setting, in some examples, the control circuitry 318 can generate a control signal to an actuator 338 to adjust the position of the laser emitting tip relative to a target at the surgical site. The actuator 338 can be coupled to a portion of the optical pathway 334 and can be in electrical communication with the control circuitry 318. In examples, the actuator 338 can be positioned at or near the distal end of the endoscope 301. The actuator 338 can comprise one or more electromagnetic, electrostatic, piezoelectric, or other actuating elements to actuate the distal end 336 of the optical pathway 334 or to otherwise enable longitudinal or rotational positioning of the distal end 336 relative to the working channel or other longitudinal passageway of the endoscope 301 or relative to another reference location that the endoscope 301 can serve as a coordinate system. In response to the identified tissue whitening, the control circuitry 318 can operate the actuator 338 to adjust the position or orientation of the distal end 336 of the optical pathway 334, such as adjusting the longitudinal position by moving the distal end 336 further away from the surgical site (to increase the fiber-to-target distance) and / or adjusting the rotational position by steering the distal end 336 away from the surgical site (to increase the aiming angle).

[0096] In yet another example, the control circuit 318 can generate control signals to the irrigation and / or aspiration system 340 to automatically adjust one or more irrigation parameters, such as irrigation flow or aspiration flow. The irrigation or aspiration flow can help dissipate heat generated during a procedure (e.g., laser treatment of tissue or stone fragmentation). The irrigation or aspiration flow can also assist in the removal of fluid and undesirable material (e.g., tissue debris or stone fragments) and can control and maintain pressure at the surgical site, such as to substantially maintain pressure at a user-specified pressure level (e.g., a user-specified pressure with a tolerance of ±5-10%). In response to identified tissue whitening, the control circuit 318 can control the irrigation and / or aspiration system 340 to automatically increase irrigation flow to the surgical site to increase convective heat transfer and / or increase aspiration flow (or aspiration pressure) to draw fluid away from the surgical site to improve heat dissipation and reduce the temperature at the surgical site. In some examples, irrigation flow or aspiration flow may be selectively activated or adjusted based on surgical site pressure being monitored via pressure sensor 224, as described above with reference to FIG. 2.

[0097] In another example, the control circuit 318 can generate a control signal to the irrigation fluid treatment unit 342 to automatically adjust the temperature of the irrigation fluid before application to the surgical site. The irrigation fluid treatment unit 342 can include a cooling system (e.g., a heat sink or an in-line cooler) for cooling the irrigation fluid or a fluid mixer to mix at least two irrigation fluids of different temperatures. In response to the identified tissue whitening, the control circuit 318 can control the irrigation and / or aspiration system 340 to automatically cool the irrigation fluid via the cooling system or the fluid mixer. As such, the irrigation / aspiration system 340 can apply cooled irrigation to the surgical site via the irrigation and / or aspiration passages 344 to improve convective heat transfer at the surgical site and effectively and efficiently reduce the temperature at the surgical site.

[0098] The control circuit 318 can generate or accept from a user a temperature management plan that defines a prioritized sequence of two or more of the temperature control measures described above, including, among other things, changing the laser power setting or one or more laser delivery parameters, adjusting the position or orientation of a distal portion of the optical path (e.g., the laser fiber), activating or adjusting irrigation flow to and / or aspiration flow away from the surgical site, or modifying the temperature of irrigation fluid before it is applied to the surgical site.

[0099] 6 is a flow chart illustrating a method 600 for controlling conditions at a surgical site (such as the temperature at the surgical site) during an endoscopic procedure to treat an anatomical target (e.g., soft tissue, hard tissue, cancerous tissue, or a stone structure such as a kidney stone, pancreatic bile duct stone, or gallbladder stone). Method 600 may be implemented in or executed by endoscopic surgery system 200 or endoscopic laser lithotripsy system 300. The steps of method 600, although depicted in a flow chart, need not be performed in any particular order. In various examples, some of the steps may be performed in a different order than illustrated herein.

[0100] At 610, laser energy (e.g., a laser beam or a series of laser pulses) is delivered to an anatomical target. The laser energy may be generated by a laser source (first laser source 106, second laser source 116, or laser source 332) and transmitted through an optical path (first optical path 108, second optical path 118, or optical path 334). At 620, images or video frames of the surgical site taken at different times may be generated using an imaging sensor, such as imaging sensor 222. At 630, the images or video frames may be analyzed, such as using image analysis circuitry 214, and used to determine whether the degree of heat accumulation in the first target (e.g., tissue) at the surgical site exceeds a predetermined threshold. In an example, the degree of heat accumulation may be determined by detecting tissue whitening (a lightening of the color of the tissue) in the images or video frames and the degree of tissue whitening detected. In an example, images or video frames taken at different times can be compared to one another to identify changes in the intensity of one or more color components (e.g., RGB values) at registered locations in the images or video frames. The registered locations corresponding to tissue sites can be identified by a user. In an example, the intensity of one or more color components can be compared to respective threshold values ​​(RGB) for a "white" color (RGB(255, 255, 255)) or a predetermined "whitened" color (e.g., RGB(240, 240, 240)). TH ) and compared to the color intensity threshold. If the intensity values ​​(e.g., from 0 to 255) of one or more color components are sufficiently close to the color "white" within a certain margin (e.g., RGB values ​​within the range of (240-255, 240-255, 240-255)), tissue whitening is deemed to have been detected at 630. In some examples, a frame-by-frame comparison of video frames, or a comparison of consecutively captured images, may be used to determine the color intensity change rate toward the color "white" (RGB (255, 255, 255)) or a predetermined "whitened" color at a registered location in the image or video frame. If the color intensity change rate exceeds a rate threshold, tissue whitening is deemed to have occurred. Tissue whitening thus detected may indicate that the degree of heat accumulation in the tissue at the surgical site is increasing with increasing RGBTH Or, it indicates exceeding a threshold value corresponding to a threshold color intensity change rate.

[0101] In some examples, in addition to detecting an indication of tissue whitening, the degree of tissue whitening and / or the rate of tissue whitening may be determined at 630. The degree of tissue whitening is determined over time t(RGB t ) and threshold values ​​RGB for the color components that represent a "white" color or a predetermined "whitened" color. TH That is, ΔRGB = RGB t -RGB TH The tissue whitening rate ΔRGB / Δt can be determined based on the following: A smaller ΔRGB value indicates a higher degree of tissue whitening, and therefore a higher temperature at the surgical site and a higher risk of tissue thermal damage. The tissue whitening rate ΔRGB / Δt represents the amount of color intensity change toward "white" or a predetermined "whitened" color per unit time. A higher tissue whitening rate ΔRGB / Δt indicates a faster heat accumulation at the surgical site and, therefore, a higher risk of tissue thermal damage.

[0102] In an example, an aiming beam may be used to assist in identifying tissue whitening at a registered location in an image or video frame. The aiming beam, such as one generated by the second laser source 234 or other light source, may be emitted when the target is illuminated. The aiming beam may have a distinct color (green light in the approximate 520 nm range or red in the approximate 620 nm range) to distinguish it from the illuminated background of the surgical site, as shown in FIG. 4. The aiming beam incident on tissue at the surgical site may be captured by the imaging sensor when it is within the field of view of the imaging sensor. A footprint of the aiming beam may be identified from the image or video frame of the surgical site. When a colored (e.g., green) aiming beam is used, the aiming beam footprint may also be shown in green in the image or video frame. As described above with reference to FIG. 4, when tissue becomes "whitened," a colored (e.g., green or red) aiming beam incident on the "whitened" tissue can appear brighter in an image or video frame than in "unwhitened" tissue. Tissue whitening can be detected from a portion of the image or video frame at or near the aiming beam footprint. The degree of tissue whitening, ΔRGB, or the tissue whitening rate, ΔRGB / Δt, can also be determined based on the increase in color intensity at or near the aiming beam footprint.

[0103] At 640, at least one operating parameter associated with the endoscopic surgical system may be adjusted using control circuit 218 or control circuit 318 based at least in part on the degree of heat accumulation at a first target at the surgical site, such as tissue whitening detected from the image or video frame. By adjusting the at least one operating parameter, a desired surgical site condition, such as a desired temperature at the surgical site, may be maintained during the procedure. Maintaining the desired surgical site condition (e.g., temperature) may help achieve or maintain a therapeutic effect at the surgical site (e.g., targeted ablation or fragmentation of a stone) while avoiding potential tissue thermal damage due to laser-induced overheating at the surgical site. The adjustment of the at least one operating parameter may be performed automatically, such as by control circuit 218 or control circuit 318, electrically coupled to various devices of the endoscopic surgical system. Alternatively, the identified tissue whitening may be presented to a user via user interface device 250 or the like. The user may be warned of the elevated temperature at the surgical site and recommended to take appropriate preventative action, such as adjusting laser power or other system parameters.

[0104] Various temperature control measures may be attempted, including, among others, changing the laser power setting or one or more laser delivery parameters, adjusting the position or orientation of a distal portion of the optical path (e.g., the laser fiber), activating or adjusting irrigation flow to and / or aspiration flow away from the surgical site, or modifying the temperature of the irrigation fluid before application to the surgical site, as described above with reference to FIGS. 2 and 3 . In some examples, the temperature of the surgical site may be controlled according to a temperature management plan. The temperature management plan may include a prioritized order of two or more temperature controls described above. The temperature management plan may be programmed or refined by the user, such as via the user interface device 250. The order of the temperature control measures may be determined based on availability (e.g., an irrigation fluid cooling system), efficiency of the temperature control, or potential adverse effects at the surgical site. In some examples, the aggressiveness of parameter adjustments (e.g., by adjusting laser power settings, irrigation and / or aspiration flow rates, irrigation fluid temperature control, etc.) may be determined based on the degree of tissue whitening ΔRGB or the rate of tissue whitening ΔRGB / Δt. For example, if a higher degree of tissue whitening or a higher rate of tissue whitening (i.e., faster tissue whitening) is detected, control circuitry 218 may provide a more aggressive adjustment of one or more system parameters (e.g., a greater reduction in laser power, a higher irrigation and / or aspiration flow rate, or greater cooling of the irrigation fluid before it flows to the surgical site) to bring the temperature at the surgical site under control.

[0105] 7A is a flow chart illustrating an example method for generating such a temperature management plan based on surgical site conditions, including, for example, surgical site whitening and pressure. The temperature management plan may include a prioritized sequence of two or more temperature controls as previously described. At 701, the tissue whitening identified at 630 may be evaluated against a tissue whitening criterion, such as a tissue whitening threshold above a rate threshold or a degree of tissue whitening ΔRGB falling below a rate threshold. At 702, pressure may be sensed at the surgical site, such as using pressure sensor 224. At 703, the measured surgical site pressure P may be compared to a predetermined pressure upper limit P, also referred to as the maximum allowable pressure. max , or the user-specified pressure limit P max and the temperature of the surgical site may be compared. A temperature management plan may be determined at 704 based on the temperature check at 701 and the pressure check at 703. The availability and efficiency of a temperature control measure (e.g., an irrigation cooling system) or potential adverse effects to the surgical site may also be considered to determine an individualized temperature management plan for the patient. The temperature management plan may include, among other things, a prioritized ordering of two or more temperature control measures as described above, including, for example, altering the laser power setting or one or more laser delivery parameters, adjusting the position or orientation of a distal portion of the optical path (e.g., the laser fiber), activating or adjusting irrigation flow to the surgical site and / or aspiration flow away from the surgical site, or modifying the temperature of the irrigation fluid before application to the surgical site. In the example shown in FIG. 7A, when the temperature trend or prediction of future surgical site temperature meets the temperature adjustment criteria at 701, the prioritized ordering between adjusting the laser power setting and adjusting the irrigation or aspiration flow is determined based on the temperature trend or prediction of future surgical site temperature at 701, and the pressure at the surgical site P falls below the upper pressure limit P at 705. max The surgical site pressure P may be based at least in part on whether the pressure P reaches a level substantially close to P. max If it is less than (for example, P and P max If the difference between P and P exceeds a threshold, the irrigation flow rate may be increased at 706. maxIf it is close to (for example, ±10%, P max Prioritization of temperature control measures may be determined based on whether an option to increase aspiration flow is available at 707. If aspiration flow is not available or is not activated by the user, the laser power setting may be adjusted at 708, such as by reducing the laser power. However, if aspiration flow is available and activated by the user at 707, the aspiration flow rate may be increased at 709. Following temperature control operation at any of steps 706, 708, and 709, other temperature control measures may be attempted in an on-demand mode (e.g., activated by the user). Monitoring of the temperature at the surgical site may continue at 620.

[0106] 7B is a flow chart illustrating an example of a temperature management plan with a prioritization means for controlling surgical site temperature, which may be an embodiment of step 640 of adjusting at least one operating parameter associated with an endoscopic surgical system to substantially achieve or maintain a desired temperature at the surgical site. At 710, the tissue whitening identified at 630 may be evaluated against a tissue whitening criterion, such as a tissue whitening threshold exceeding a rate threshold or a degree of tissue whitening ΔRGB falling below a rate threshold. If the criterion is not met at 710, the surgical site temperature may be considered normal, no parameters may be adjusted, and monitoring of the surgical site temperature may continue at 620. If the criterion is met at 710, an option is provided at 720 to cool the irrigation fluid before it flows to the surgical site. If the irrigation fluid cooling option is available and selected (e.g., by a user), at 722, the irrigation fluid may be cooled before reaching the surgical site, such as with a cooling system (e.g., a radiator or in-line cooler included in irrigation fluid processing unit 342) or by mixing at least two irrigation fluid sources of different temperatures. Cooled irrigation may be applied to the surgical site to enhance convective heat transfer at the surgical site. Monitoring of the temperature of the surgical site may continue at 620.

[0107] If the irrigation and / or aspiration option is not available or is not selected in 720, the option of using an irrigation and / or aspiration system (such as irrigation and / or aspiration system 240 or irrigation and / or aspiration system 340) is provided in 730. As discussed above with reference to FIGS. 2 and 3, the irrigation and / or aspiration system can provide irrigation inflow to the surgical site and / or aspiration flow (outflow) of fluid from the surgical site. In addition to assisting in the removal of tissue debris, stone fragments, and other undesirable material during the procedure, the irrigation and aspiration flows also have a cooling effect on the tissue at or near the surgical site. If the irrigation and / or aspiration option is not available or is not selected (e.g., by the user) in 730, the laser power settings may be adjusted in 732. For example, the average power of the laser pulses may be reduced, such as by reducing one or more of the pulse width of the laser pulses, the peak power of the laser pulses, or the pulse frequency, which represents the number of laser pulses per unit time. Reducing the average power of the laser pulses can reduce the laser-induced heating effect at or near the surgical site, thereby preventing thermal tissue damage and improving patient safety during the procedure. The amount (aggressiveness) of adjustments to the laser power settings, including one or more laser firing parameters, can depend on the degree or speed of tissue whitening. In an example, the laser firing parameters adjusted in 732 can include pulse sequencing parameters that describe the timing or temporal distribution of laser pulses within a specific time period. As previously described with reference to Figures 5A and 5C, a constant pulse sequencing of the laser can facilitate the equilibrium progression of laser-induced vapor bubbles toward a consistent point of contact with the tissue wall. Under such equilibrium conditions, a predictable turbulent flow of bubbles toward the same tissue region can consistently impinge on that tissue region, causing heat accumulation.As previously described with reference to Figures 5B and 5D, adjusting the laser pulse sequence can help redistribute bubbles over a wider range of tissue areas, preventing bubbles from traveling in equilibrium and continuing to strike the same area of ​​tissue. Non-equilibrium flow can also promote bubble collapse due to evaporation and reduce the number and size of evaporative bubbles, thereby reducing the temperature at the surgical site and preventing thermal tissue damage.

[0108] In addition to or instead of adjusting the laser power settings, including one or more laser delivery parameters, in some examples, the position or orientation of a distal portion of the optical pathway relative to an anatomical target at the surgical site can be adjusted, such as via actuator 338, to adjust the position or orientation of the distal end 336 of the optical pathway 334. The position or orientation can be adjusted by increasing the fiber-to-target distance and / or by increasing the aiming angle to reduce the density of laser energy incident on the surgical site and laser-induced heat transmitted to the surgical site. Monitoring of the temperature at the surgical site can continue at 620.

[0109] If irrigation and / or aspiration options are available and selected at 730, pressure may be sensed at the surgical site at 740, such as with pressure sensor 224. Depending on the sensed pressure (P) at the surgical site, one or both of the irrigation flow or aspiration flow may be selectively activated or adjusted to achieve temperature control at the surgical site temperature. At 750, the measured surgical site pressure is adjusted to a predetermined upper pressure limit P max , or the user-specified pressure limit P max The measured pressure at the surgical site is compared with P max When it exceeds (P>P max), at 752, only the aspiration flow rate is increased (and the irrigation flow rate is not increased) to reduce the temperature at the surgical site. Additionally or alternatively, the irrigation flow rate may be decreased to reduce the pressure at the surgical site. Because an increase in irrigation flow to the surgical site may induce a positive pressure change at or near the surgical site, further increases in irrigation flow should be avoided to prevent further increases in surgical site pressure. If the measured surgical site pressure is P max If so, the measured surgical site pressure is below the predetermined lower pressure limit P min Or the user-specified pressure lower limit P min The measured surgical site pressure can be further compared to P min and P max If it is within the range defined by (P min <P<P max ), at 770, one or both of the irrigation flow rate or the aspiration flow rate may be increased to reduce the temperature at the surgical site. However, if the measured surgical site pressure at 560 exceeds the lower pressure limit P min If it drops below (P <P min ), at 762, only the irrigation flow rate to the surgical site is increased (and not the aspiration flow rate) to reduce the surgical site temperature but to avoid increasing the aspiration flow and preventing a further drop in surgical site pressure. Additionally or alternatively, the aspiration flow rate may be decreased to increase pressure at the surgical site. Because increases in aspiration flow can induce negative pressure changes at or near the surgical site, further increases in aspiration flow should be avoided to prevent a further drop in surgical site pressure. After adjustment of the irrigation or aspiration flow at 752, 762, or 770, monitoring of the surgical site temperature may continue at 620.

[0110] 8 generally illustrates a block diagram of an example machine 800 in which any one or more of the techniques (e.g., methodologies) discussed herein may be implemented. Portions of this description may apply to the computational framework of various portions of endoscopic surgical system 200 or endoscopic surgical system 300.

[0111] In alternative embodiments, machine 800 may operate as a standalone device or may be connected (e.g., networked) to other machines. In a network deployment, machine 800 may operate in a server-client network environment as a server machine, a client machine, or both. In an example, machine 800 may operate as a peer machine in a peer-to-peer (P2P) (or other distributed) network environment. Machine 800 may be a personal computer (PC), a tablet PC, a set-top box (STB), a personal digital assistant (PDA), a mobile phone, a web appliance, a network router, switch, or bridge, or any machine capable of executing instructions (sequential or otherwise) that specify actions to be taken by that machine. Furthermore, while only a single machine is shown, the term “machine” is intended to include any collection of machines that individually or together execute a set (or sets) of instructions to implement any one or more of the methodologies as discussed herein, such as cloud computing, software as a service (SaaS), other computer cluster configurations, etc.

[0112] Examples such as those described herein may include or operate on logical or several components or mechanisms. A circuit set is a collection of circuits embodied in tangible objects, including hardware (e.g., simple circuits, gates, logic circuits, etc.). The components of a circuit set may be flexible over time and over variations in the underlying hardware. A circuit set may include components that, when operating, can perform specific operations, either singly or in combination. In examples, the hardware of a circuit set may be invariably designed (e.g., implemented by hardware) to perform specific operations. In examples, the hardware of a circuit set may comprise variably connected physical elements (e.g., execution units, transistors, simple circuits, etc.) including computer-readable media that are physically altered (e.g., magnetically, electrically, movable arrangements of invariable mass particles, etc.) to encode instructions for specific operations. When connecting physical components, the basic electrical properties of the hardware components are changed, for example, from insulator to conductor, or vice versa. The instructions enable embedded hardware (e.g., an execution unit or loading mechanism) to create a member of a circuit set in hardware via variable connections to perform a portion of a particular operation when in operation. Thus, the computer-readable medium is communicatively coupled to other components of the circuit set members when the device is in operation. In examples, any of the physical components may be used in more than one member of more than one circuit set. For example, during operation, an execution unit may be used in a first circuit of a first circuit set at one point in time and may be reused by a second circuit in the first circuit set or a third circuit in the second circuit set at a different time.

[0113] The machine (e.g., a computer system) 800 may include a hardware processing unit 802 (e.g., a central processing unit (CPU), a graphics processing unit (GPU), a hardware processor core, or any combination thereof), a main memory 804, and a static memory 806, some or all of which may communicate with each other via an interlink (e.g., a bus) 808. The machine 800 may further include a display unit 810 (e.g., a raster display, a vector display, a holographic display, etc.), an alphanumeric input device 812 (e.g., a keyboard), and a user interface (UI) navigation device 814 (e.g., a mouse). In an example, the display unit 810, the input device 812, and the UI navigation device 814 may be touchscreen displays. Machine 800 may additionally include a storage device (e.g., a drive unit) 816, a signal generating device 818 (e.g., a speaker), a network interface device 820, and one or more sensors 821, such as a global positioning system (GPS) sensor, a compass, an accelerometer, or other sensor. Machine 800 may include an output control device 828, such as a serial (e.g., Universal Serial Bus (USB), parallel, or other wired or wireless (e.g., infrared (IR), near field communication (NFC), etc.) connection, for communicating with or controlling one or more peripheral devices (e.g., a printer, a card reader, etc.).

[0114] Storage device 816 may comprise machine-readable medium 822 on which is stored one or more sets of data structures or instructions 824 (e.g., software) that embody or are utilized by any one or more of the techniques or functions described herein. The instructions 824 may reside, completely or at least partially, within main memory 804, static memory 806, or hardware processing unit 802 during execution thereof by machine 800. In an example, one or any combination of hardware processing unit 802, main memory 804, static memory 806, or storage device 816 may constitute a machine-readable medium.

[0115] Although machine-readable medium 822 is shown as a single medium, the term "machine-readable medium" may comprise a single medium or more media (e.g., a centralized or distributed database and / or associated caches or servers) configured to store one or more instructions 824.

[0116] The term "machine-readable medium" may include any medium capable of storing, encoding, or carrying instructions for execution by machine 800, causing machine 800 to perform any one or more of the techniques of this disclosure, or data structures used by or associated with such instructions. Non-limiting examples of machine-readable media may include solid-state memory, optical media, and magnetic media. In an example, a mass machine-readable medium comprises a readable medium with a plurality of particles having an unchanging (e.g., stationary) mass. Thus, a mass machine-readable medium is not a transitory, propagating signal. Specific examples of mass machine-readable media may include non-volatile memory such as semiconductor memory devices (e.g., electrically programmable read-only memory (EPROM), electrically erasable programmable read-only memory (EEPROM)) and flash memory devices, magnetic disks such as internal hard disks and removable disks, magneto-optical disks, and CD-ROM and DVD-ROM disks.

[0117] The instructions 824 may further be transmitted or received over a communications network 826 using a transmission medium via a network interface device 820 utilizing any one of several transport protocols (e.g., frame relay, Internet Protocol (IP), Transmission Control Protocol (TCP), User Datagram Protocol (UDP), Hypertext Transfer Protocol (HTTP), etc.). Example communications networks may include a local area network (LAN), a wide area network (WAN), a packet data network (e.g., the Internet), a mobile telephone network (e.g., a cellular network), a plain old telephone (POTS) network, and a wireless data network (e.g., a wireless data network), the Institute of Electrical and Electronics Engineers (IEEE) 802.11 family of standards known as Wi-Fi®, the IEEE 802.16 family of standards known as WiMax®, the IEEE 802.15.4 family of standards, a peer-to-peer (P2P) network, among others. In an example, network interface device 820 may include one or more physical jacks (e.g., Ethernet jacks, coaxial jacks, or telephone jacks) or one or more antennas for connecting to communications network 826. In an example, network interface device 820 may include multiple antennas for wireless communication using at least one of single-input multiple-output (SIMO), multiple-input multiple-output (MIMO), or multiple-input single-output (MISO) technologies. The term “transmission medium” is intended to include any intangible medium capable of storing, encoding, or carrying instructions for execution by machine 800, including digital or analog communication signals or other intangible media to facilitate the communication of such software.

[0118] Additional notes The above detailed description includes references to the accompanying drawings, which may form a part of the detailed description. The drawings show, by way of example, specific embodiments in which the invention may be practiced. These embodiments are also referred to herein as "examples." These examples may include elements in addition to those shown or described. However, the inventors also contemplate examples in which only the elements shown or described are provided. Furthermore, the inventors also contemplate examples using any combination or permutation of the elements shown or described (or one or more aspects thereof), either with respect to the specific example (or one or more aspects thereof) or with respect to any other example (or one or more aspects thereof) shown or described herein.

[0119] The terms "a" or "an" are used herein, as is common in patent documents, to include one or more, independently of any other instance or use of "at least one" or "one or more." The term "or" is used herein to refer non-exclusively to include "A or B," "A but not B," "B but not A," and "A and B," unless otherwise indicated. The terms "including" and "in which" are used herein as the plain English equivalents of the terms "comprising" and "wherein," respectively. Also, in the appended claims, the terms "including" and "comprising" are intended to be open-ended, i.e., systems, devices, articles, compositions, formulations, or processes that include elements in addition to the elements listed after such terms in a claim are still deemed to be within the scope of that claim. Furthermore, in the appended claims, terms such as "first," "second," and "third," etc., are used merely as labels and are not intended to impose numerical requirements on their objects.

[0120] The foregoing description is intended to be illustrative, not limiting. For example, the examples (or one or more aspects thereof) of the foregoing description can be used in combination with each other. Other embodiments may be utilized by those skilled in the art, or others, upon review of the foregoing description. The Abstract is provided to comply with 37 CFR §1.72(b), allowing the reader to quickly ascertain the nature of the present disclosure. The Abstract has been submitted with the understanding that it will not be used to interpret or limit the scope or meaning of the claims. Also, in the foregoing Detailed Description, various features may be grouped together to streamline the disclosure. This should not be construed as intending that an unclaimed disclosed feature is essential to any claim. Rather, inventive subject matter may lie in less than all features of a particular disclosed embodiment. Accordingly, the appended claims are hereby incorporated into the Detailed Description as an example or embodiment, with each claim standing on its own as a separate embodiment, and it is contemplated that such embodiments can be combined with each other in various combinations or permutations. The scope of the invention should be determined with reference to the appended claims, along with the full scope of equivalents to which such claims are entitled. [Explanation of symbols]

[0121] 100 Laser Energy Delivery System 101 Feedback Control System 102 First Laser System 104 Second Laser System 106 First Laser Source 108 First Optical Path 110 First Output 116 Second Laser Source 118 Second Optical Path 120 Second Output 122 Surgical site 130 Feedback Signal 200 Endoscopic Surgery System 210 Feedback Control System 212 Feedback Analysis Device 214 Image analysis circuit 216 Tissue Whitening Detection Circuit 218 Control circuit 220 Sensors 222 Imaging sensors, image sensors 224 Pressure Sensor 230 Laser System 232 First Laser Source 234 Second Laser Source 240 Irrigation and / or Suction Systems 250 User Interface Devices 252 output / display units 254 input units 300 Endoscopic Laser Lithotripsy System 301 Endoscope 310 Feedback Control System 312 Feedback Analysis Device 318 Control Circuit 324 Lighting source 325 Cameras, imaging devices 332 Laser Source 334 Optical Path 336 Distal end 338 Actuator 340 Irrigation and / or Suction Systems 342 Irrigation fluid treatment unit 344 Irrigation and / or suction passages 346 Distal end 350 Illumination optical path 360 Visualization Optical Pathway 370 Illumination 410 Endoscopic Images 412 Aiming Beam Footprint 413 Distal Tip 501 distal end 502 Organization 510 First Pulse Profile 512 Pulses of the first pulse profile 510 520 Second Pulse Profile 522 laser pulse of second pulse profile 520 530 Predictable Steady Turbulence 532 Evaporation bubbles 540 Unpredictable Irrigation Flow 542 Evaporation bubbles 800 machines 802 Hardware Processing Unit 804 Main storage 806 Static Memory 808 Interlocking 810 Display Unit 812 alphanumeric input device 814 User Interface (UI) Navigation Devices 816 Storage Devices 818 Signal Generating Device 820 Network Interface Device 821 Sensor 822 Machine-Readable Medium 824 Data Structures, Instructions 826 Communication Network 828 Output Control Device A Tissue site, tissue area T time period

Claims

1. 1. An endoscopic surgery system, comprising: an energy source configured to generate therapeutic energy at a surgical site during an endoscopic procedure; a light source configured to direct an aiming beam having specific color components toward the surgical site; an imaging sensor configured to generate images or video frames of at least a portion of the surgical site during the endoscopic procedure; A control circuit comprising: Detecting color component characteristics of the aiming beam footprint from the generated image or video frame; and determining a degree of heat accumulation at the surgical site in response to the treatment energy delivered to the surgical site based on characteristics of the color components of the detected footprint; a control circuit configured as follows: An endoscopic surgical system.

2. 2. The endoscopic surgery system of claim 1, wherein the detected color component characteristics include a brightness metric of the color component characteristics of the aiming beam footprint, the brightness metric indicating a presence or degree of tissue whitening at the surgical site in response to the treatment energy delivered to the surgical site.

3. The endoscopic surgery system of claim 2 , wherein the brightness metric is color intensity or saturation.

4. The endoscopic surgery system of claim 2 or 3, wherein determining the degree of heat accumulation at the surgical site includes detecting an increase in temperature at the surgical site when the brightness of the color components of the aiming beam footprint exceeds a threshold value indicating an increase in the degree of tissue whitening.

5. the aiming beam is a green aiming beam; The endoscopic surgery system according to any one of claims 2 to 4, wherein the detected characteristics of the color components include a brightness of a green footprint of the aiming beam.

6. the aiming beam is a red aiming beam; The endoscopic surgery system according to any one of claims 2 to 4, wherein the detected characteristics of the color components include a brightness of a red footprint of the aiming beam.

7. The endoscopic surgical system of any one of claims 1 to 6, wherein the control circuit is further configured to determine, based on the determination of the degree of heat accumulation, whether to adjust at least one operating parameter associated with the endoscopic surgical system to achieve or maintain a therapeutic effect at the surgical site.

8. the energy source comprises a laser source, and the at least one operating parameter comprises a laser power setting of the laser source; The endoscopic surgery system of claim 7, wherein the control circuit is configured to adjust the laser power setting to generate a non-equilibrium irrigation flow or to promote collapse of evaporation bubbles induced by the treatment energy.

9. The endoscopic surgery system of claim 8 , wherein the laser power settings that are adjusted include pulse sequencing that describes a temporal distribution of laser pulses within a specific time interval.

10. The endoscopic surgical system of claim 8, wherein, for adjusting the laser power setting, the control circuit is further configured to prioritize adjusting pulse shape or pulse sequencing over adjusting average power of the laser pulses.

11. further comprising an irrigation and / or aspiration system configured to provide irrigation fluid to the surgical site and to aspirate fluid from the surgical site; The endoscopic surgical system according to any one of claims 7 to 10, wherein the at least one operating parameter associated with the endoscopic surgical system includes at least one of irrigation flow or aspiration flow associated with an irrigation system and an aspiration system, respectively.

12. further comprising a pressure sensor configured to sense pressure at the surgical site during the endoscopic procedure; The control circuit increasing the aspiration flow but not increasing the irrigation flow when the sensed pressure exceeds an upper pressure limit; increasing one or both of the irrigation flow and the suction flow when the sensed pressure is within a range determined by the upper and lower pressure limits; and increasing the irrigation flow but not increasing the aspiration flow when the sensed pressure falls below the lower pressure limit; The endoscopic surgery system of claim 11 , further configured to selectively increase the irrigation flow or the aspiration flow through the irrigation and / or aspiration system to include:

13. an irrigation and / or aspiration system configured to provide irrigation fluid to the surgical site and to aspirate fluid from the surgical site; and an irrigation fluid treatment unit configured to alter the temperature of the irrigation fluid; The endoscopic surgery system of any one of claims 7 to 12, wherein when the control circuit determines that the degree of heat accumulation at the surgical site exceeds a predetermined threshold, the control circuit is configured to generate a control signal so that the irrigation fluid treatment unit adjusts the temperature of the irrigation fluid before it reaches the surgical site.

14. the at least one operating parameter includes two or more operating parameters associated with the endoscopic surgical system; The endoscopic surgery system of any one of claims 7 to 13, wherein the control circuit prioritizes the adjustment of the two or more operating parameters in an order based at least in part on the degree of heat accumulation at the surgical site.

15. an optical pathway with an adjustable distal portion, the optical pathway configured to direct the treatment energy to the surgical site; The endoscopic surgical system of any one of claims 1 to 14, wherein the control circuit is configured to generate a control signal to an actuator coupled to the optical pathway to adjust a position or orientation of a distal portion of the optical pathway relative to the surgical site when the control circuit determines that the degree of heat accumulation exceeds a predetermined threshold.

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