Systems for tissue retraction during endoscopic procedures

Abstract

A system for endoscopic surgery including an instrument guide having a lumen configured to receive an endoscopic instrument, the instrument guide configured to be mountable to or positionable alongside an endoscope and having a first bending section and a second bending section distal of the first bending section, the second bending section bendable relative to the first bending section, wherein the first bending section is bendable to diverge from a longitudinal axis of the instrument guide to create a lateral offset and define a fixed position. The system can also include a bendable scope sleeve.

Description

SYSTEMS FOR TISSUE RETRACTION DURING ENDOSCOPIC PROCEDURESBACKGROUND OF THE INVENTIONThis application claims priority to provisional application 63 / 655, 129, filed June 3, 2024, the entire contents of which are incorporated herein by reference.Field of the InventionThis application relates to systems for endoscopic surgery, and, more particularly, to systems mountable to endoscopes containing more or more channels for instrumentation to access target tissue.BackgroundEndoscopic interventions, such as Endoscopic Submucosal Dissection (ESD), have emerged as promising minimally-invasive techniques for the removal of gastrointestinal (GI) tract tumors through the body’s natural orifices trans-orally or trans-anally without incisions. These procedures lead to quicker patient recovery, shorter hospital stays, and reduced healthcare costs. However, despite their significant benefits, the widespread adoption has been hindered by limitations in available instrumentation, which often lacks adequate triangulation.In laparoscopy, triangulation means placing the camera in the center and the surgical instruments on either side to form a triangle. At least two instruments, one active (e g., scissors or electrosurgical knife) and one assisting / retracting (e.g., a grasper or forceps fortissue tensioning), are typically inserted via individual cannulas through small surgically created openings in the abdominal wall. The locations of these openings / cannulas / trocars / laparoscopic ports establish instrument articulation / insertion / pivot / convergence points that ensure that the instruments can move freely without clashing, helping surgeons to perform effective and precise tissue manipulation. Effective triangulation is characterized by establishing 1) an adequate manipulation angle between the instruments, i.e., the angle formed where the instruments converge at the target site, and 2) an optimal working distance, i.e. the distance to the target tissue for a range of motion necessary for comprehensive coverage and optimal visualization of the target area. The preferred manipulation angle is 45°-75°, with 60° being ideal. Manipulation angles below 45° or above 75°and excessively short or long working distance can result in increased difficulty and a likelihood of instrument collisions, less precise movements and degraded overall performance. The optimal manipulation angle and a working distance appropriate for a specific clinical situation therefore geometrically define the necessary inter-instrument distance between the instrument articulation points.Once instrument articulation points are created surgically, the inter-instrument distance is established / fixed, and the locations between them remain static / immobile / unaffected / unchanged when the instruments are manipulated. The instruments can move linearly in and out of the body cavity (towards and away from the target tissue site), preferably via cannulas, and pivot / articulate relative to the openings, such that they can converge on the target tissue.Triangulation is equally applicable in ESD. Optimal endoscopic instrument triangulation would enable precise surgical maneuvers during minimally invasive procedures. It would allow surgeons to work effectively within confined spaces, for example a colon or stomach, while minimizing tissue disruption. In commercially available endoscopic systems, instruments are typically introduced directly adjacent to the scope, resulting in an intra-instrument distance that is too narrow for effective triangulation. Some approaches attempt to bend or articulate instruments to increase this distance, but such configurations typically result in articulation points that shift during instrument manipulation, making precise control difficult.The need therefore exists to further improve the maneuverability and accessibility of flexible endoscopic instruments within confined body working spaces such as the colon or other body lumens. Such improvement can be effected by improved systems to achieve optimal triangulation to thereby enable surgeons to more effectively work in confined spaces, e.g., body cavities and lumens.SUMMARYThe systems of the present invention address the foregoing limitations of the commercially available systems by enabling a greater intra-instrument distance with static articulation points, thereby improving stability and control during endoscopic procedures.The present invention provides systems which improve the maneuverability and accessibility of flexible endoscopic instruments within confined body working spaces, such as thecolon or other body lumens, by achieving optimal triangulation in such spaces. To facilitate insertion through narrow anatomical pathways, the system is designed to maintain a compact profile with minimal cross-sectional area during insertion / introduction / advancement. Once positioned at the target site, the components are deploy ed / activated to expand / be spaced apart (laterally) to increase the inter-instrument distance, thereby enabling effective triangulation. This is achieved by the various components of the systems which, working, where appropriate, in conjunction with the endoscope and endoscopic instruments, form preferred manipulation angles with respect to each other and the target tissue so that advantageous instrument articulation points are achieved and, where beneficial to users, maintained stationary (static) during surgical manipulations.In certain embodiments, the system includes a first (proximal) bending section that displaces the articulation path laterally away from the endoscope axis to establish a fixed interinstrument spacing, functionally analogous to trocar placement in laparoscopy. A second (distal) bending section then articulates within that defined geometry, enabling dynamic tissue manipulation from a stable, predetermined virtual insertion point.While embodiments described below relate to gastrointestinal applications, the disclosed systems may be adapted for use in any endoscopic or natural orifice transluminal procedure, including urological, gynecological, and thoracic interventions. Articulation mechanisms may include mechanical, electromechanical, hydraulic, or thermally responsive systems. The system may be deployed manually, robotically, or autonomously.The system may also be used in non-resection endoscopic interventions, including but not limited to stent deployment, foreign body removal, submucosal dissection, and drug delivery.In summary, the system provides components which operate to achieve triangulation in confined spaces to simulate the triangulation achieved in cannula / port placement in laparoscopic surgery. This is achieved through the various embodiments of instrument channels, bendable instrument guides, bendable endoscopic sleeves, and / or bendable endoscopic instruments, all of which are discussed in detail below. (Note “bent”, “bendable”, “deformed”, “deflected” and “articulated” are used throughout the application interchangeably). The systems disclosed herein in preferred embodiments work in conjunction with a standard / conventional endoscope, however,it is also envisioned that the systems disclosed herein can work with especially designed or dedicated visualization systems such as a built in camera or an integrated scope.In accordance with one aspect of the present invention, a system for endoscopic surgery comprising an instrument guide is provided having a lumen configured to receive an endoscopic instrument, the instrument guide configured to be mountable to or positionable alongside an endoscope and having a first bendable section and a second bendable section distal of the first bendable section, the second bendable section bendable relative to the first bendable section, wherein the first bendable section is bendable to diverge from a longitudinal axis of the instrument guide to create a lateral offset and define a fixed position.In some embodiments, the first bendable section defines a fixed position for a proximal end of the second bendable section, the second bendable section bendable to converge toward the longitudinal axis of the instrument guide.In some embodiments, the second bendable section is bendable to form a diverging section proximal of a converging section.In some embodiments, the system includes a first instrument receiving channel configured for connection to an endoscope, the first instrument receiving channel having a first lumen dimensioned to receive the instrument guide.In some embodiments, the system includes a second instrument channel having a lumen to receive a second instrument guide, the second instrument guide having a first bendable section and a second bendable section, the second bending section positioned distal of the first bendable section.In accordance with another aspect of the present invention, a system for endoscopic surgery is provided comprising an instrument receiving channel connectable (configured for connection) to or mountable over or positionable alongside an endoscope and having a first lumen dimensioned to receive a first instrument guide therethrough and a second lumen dimensioned to receive a second instrument guide therethrough, the first instrument guide having a first bending section and a second bending section positioned distal of the first bending section and the second instrument guide having a first bending section and a second bending section positioned distal of the first bending section wherein the first bending sections diverge and the second bending sections converge.In some embodiments, the instrument channel has a distal opening, and the distal opening is located adjacent to or in the vicinity of the scope to which it is connected to. In some embodiments, the distal opening has a distal opening is outside a diameter of the scope.In some embodiments, when the first bending section and the second bending section of an instrument guide are in the bent / deployed / activated state, they, preferably, form an S-curve / shape or a similar shape.In some embodiments, the first bending section of the first instrument guide is, preferably, bent outwardly and the first bending section of the second instrument guide is, preferably, also bent outwardly, such that their distal ends are moving away from each other increasing / optimizing / maximizing the distance between their distal ends for defining the “inter-instrument distance” and the “articulation points”. The second bending section of the first instrument guide is, preferably, bent inward / in the opposite direction relative to the first bending section and the second bending section of the second instrument guide is preferably, bendable inwardly, such that they are preferably move towards each other converging to form a desired / desirable / effective / optimal “manipulation angle”, and triangulation is effected / established / formed. The terms “outwardly” and “inwardly are defined relative to the longitudinal axis of the instrument guide such that outwardly would be in a direction away from the endoscope and inwardly would be in a direction toward the endoscope.In some embodiments, both instrument guides could first bend inwardly (relative to the scope) crossing over to the opposite side of the system (with their distal points still moving away from each other), then bend towards each other. In this manner, the guides bend to cross over the central axis of the scope but are then redirected to the target tissue to achieve triangulation.In some embodiments, the geometry of the first bending section of the instrument guide is not adjustable, i.e. the bending section having two states: 1) a passive state, where it sufficiently flexible to comply with the shape of the instrument channel during the its insertion into torturous anatomical structures, such as a colon, and 2) an active / deployed / activated state, where it becomes more rigid and assumes a predetermined shape / bend / curvature. In such embodiments, the first and second articulation points are stationary / not adjustable, providing a constant / fixed inter-instrument distance. In other embodiments, the geometry of the first bending section of the instrument guide is adjustable. Therefore, the location of the articulation points are also adjustable, i.e. the bendingangle / curvature of the first bending section could be altered by users to establish / set a better interinstrument distance and more optimal position / location for the articulation points. In some embodiments, once users adjust the position of the articulation points, the position will not change / becomes fixed / stationary / static until users adjust it again.In some embodiments, the system further comprises a sleeve has a longitudinal axis and a scope receiving lumen dimensioned to receive an endoscope therein, the sleeve extends over a portion or the entire length of the endoscope. In some embodiments, the sleeve is having a distal portion bendable with respect to the longitudinal axis to bend the endoscope. In some embodiments, a distal end of the sleeve is proximal of an articulation region of the endoscope, such that bending / articulation of endoscope does not bend the sleeve. In some embodiments, at least one instrument guide is bendable independent of the sleeve. In some embodiments, the instrument receiving channel is proximal of the bending region of the sleeve such that bending of the scope does not bend the instrument channel. In some embodiments, the distal end of the instrument receiving channel is proximal of the bending region of the sleeve such that bending of the sleeve does not bend the instrument channel.In some embodiments, the first bending section of an instrument guide is, preferably, bent outwardly and the bending sleeve, preferably, bent outwardly, such that the distal end of the first bending section of the instrument guide and the scope are moving away from each other increasing / optimizing / maximizing the distance between them, which defines the “inter-instrument distance” and the “articulation points”. The second bending section of the instrument guide is, preferably, bent inward / in the opposite direction relative to the first bending section and the endoscope is, preferably, articulated inwardly using its articulation mechanism, such that the second bending section of the instrument guide and the distal end of the scope are preferably move towards each other converging to form a desired / desirable / effective / optimal “manipulation angle”, and triangulation is effected / established / formed.In some embodiments, the first and second instrument guides in bent positions have outer regions creating a fixed distance therebetween for instruments inserted therethrough. The fixed distance can be defined by the fixed articulation points.In some embodiments, the first and second bending sections of the first instrument guide and of the second instrument guide are independently bendable / controlled, i.e., bending / articulation of one bending section of the instrument guide is done without affecting / bending / having any effect on the other bending section.In some embodiments, the first and second instrument guides are deflectable independent of articulation of the endoscope such that bending of the first and second instrument guides does not affect shape / position / orientation / movement of the endoscope.In some embodiments, the instrument channel has at least one connector / hub with an opening dimensioned to frictionally / slidably secure an outer surface of the endoscope. In other embodiments the connector is not movable / fixed on the scope, for example attached using an adhesive tape for the duration of the procedure.In some embodiments, the fixed articulation points defined by the bent instrument guides allows for an instrument manipulation angle of between about 45 degrees and about 75 degrees and create a fixed inter-instrument distance such that linear movement of the instruments to converge on target tissue does not affect the manipulation angle.In some embodiments, the instrument receiving channel includes at least one connector configured to attach to a sleeve positioned over an endoscope extending through the sleeve. The sleeve in some embodiments can be bendable.In some embodiments, the first and / or second instrument guide has a third bending section bendable independently of the first and second bending sections.In some embodiments, the first and second bending portions are locked in place, i.e., become fixed / not movable without a user input, to create fixed / static / stationary articulation points.In some embodiments, at least one cable is connected at a first end to the first instrument guide and at a second end to an actuator, the actuator actuable to tension the at least one cable to effect bending of the first instrument guide. Another or the same actuation system can be used to actuate the second instrument guide. The actuator can be configured to lock in the desired position to lock the bending portions in place.In accordance with another aspect of the present invention, a system for endoscopic surgery is provided comprising a sleeve having a longitudinal axis and a scope receiving lumen dimensioned to receive an endoscope therein, the sleeve having a distal portion having a distal end, a proximal end, and a bendable region between the proximal end and distal end, wherein the bendable region is bendable with respect to the longitudinal axis and bends the endoscope in a firstdirection when the bendable region of the sleeve is bent in the first direction. In some embodiments, the sleeve has at least one hub located at or near the distal and / or proximal end.In some embodiments, the bendable region comprises a laser cut tube. In other embodiments, the bendable region comprises a plastic tube with optional reinforcement, for example a metal wire coil.In some embodiments, the sleeve is bendable in a single direction; in other embodiments, the sleeve is bendable in multiple directions.In some embodiments, at least one cable is attached to the sleeve, for example at the distal end, and a mechanism for tensioning at least one cable to bend the sleeve. The mechanism can be a rotation knob, a lever, or other type of actuator.In some embodiments, the sleeve bends distal of the proximal hub such that the distal hub bends with respect to the proximal hub when the bending region is bent.The system can further include in some embodiments one or more instrument guides cooperating with the sleeve to achieve triangulation. The sleeve in some embodiments can be bendable.In some embodiments, the system includes sensors that detect the angular deflection and / or the shape of instrument guides or the proximity between instruments, allowing real-time feedback for triangulation.In some embodiments, instrument articulation may be powered or robotically actuated, allowing automated or semi-automated triangulation adjustments under software control.In some embodiments, the system includes modular instrument channels or guides that can be interchanged during a procedure to accommodate different clinical needs or anatomical constraints.BRIEF DESCRIPTION OF THE DRAWINGSSo that those having ordinary skill in the art to which the subject invention appertains will more readily understand how to make and use the surgical systems / apparatus disclosed herein, preferred embodiments thereof will be described in detail hereinbelow with reference to the drawings, wherein:Figure la is a side view of an assembly (system) having a distal sleeve for bending a flexible instrument such as a flexible endoscope in accordance with an embodiment of the present invention, the sleeve shown in the straight position;Figure lb is a side view similar to Figure la showing the sleeve in a bent / deformed / deflected position;Figure 2 is a side view of the assembly of Figure 1A shown positioned over a flexible endoscope;Figure 3 is a view similar to Figure 2 showing actuation of the assembly knob to deflect the endoscope within the sleeve; the scope’s distal portion is articulated using the scope’s articulation mechanism;Figure 4a is a close up side view of an alternate embodiment of the sleeve of the present invention bendable in a single plane;Figure 4b is a side view similar to Figure 4a showing the sleeve in a bent / deformed / deflected position;Figure 5 is a side view of an alternate embodiment of the assembly (system) of the present invention having a sleeve for bending a flexible endoscope and a side channel;Figure 6 is a side view of the assembly (system) of Figure 5 shown positioned over a flexible endoscope and an instrument guide positioned in the side channel, the sleeve shown in the bent position to deflect the endoscope and the instrument guide shown advanced distally in the side channel with a bent distal tip showing convergence to create triangulation;Figure 7 is a side view similar to Figure 6 showing an endoscopic grasper inserted through the instrument guide and an endoscopic dissector inserted through the endoscope to illustrate how triangulation is achieved;Figure 8 is a close up view of the distal region of an alternate embodiment of the system of the present invention showing the endoscope bent into a retrograde position, the instrument guide shown advanced distally in the side channel with a bent distal tip showed bent outwardly, an endoscope and a bent distal tip showing convergence to create triangulation;Figure 9a is a side view of an alternate embodiment of the assembly of the present invention having an instrument channel a knob and cables for bending the sleeve and a gear rack;Figure 9b is a close up view of the gear rack area of detail of Figure 9A;Figure 10 is a side view of an instrument guide in accordance with an embodiment of the present invention having a knob and cables mechanism for bending the instrument guide and a second knob with a gear pinion for interaction with the gear rack, the instrument guide shown in the straight position;Figure 11 is a side view of the assembly of Figure 9a showing the instrument guide of Figure 10 positioned in the instrument channel, the assembly shown positioned over a flexible endoscope with the endoscope sleeve and instrument guide deflected;Figure 12a is a side view showing an embodiment of an instrument guide, the instrument guide shown in the straight position;Figure 12b is a side view similar to Figure 12a showing the instrument guide in a bent position;Figure 12c is a side view similar to Figure 12a showing an endoscopic graspers inserted through the instrument guide in the straight position;Figure 13 is a side view of the assembly of Figure 11 shown positioned over a flexible endoscope, wherein the sleeve is shown in the outwardly bent position to deflect the endoscope outwardly, the endoscope is shown deflected / articulated inwardly, the first instrument guide inserted via the instrument channel is shown bent outwardly, a second instrument guide inserted via the first instrument guide is shown bent outwardly and inwardly to achieve triangulation of the instruments extending through the endoscope and the instrument guide, the fixed distance between the instruments shown by line D-E;Figure 14 is a side view of an alternate embodiment of the instrument guide having two independently bendable sections and further showing a mandrel to aid insertion;Figure 15 is a side view of an alternate embodiment of the assembly of the present invention shown positioned over an endoscope wherein the sleeve is shown bent outwardly, the endoscope is shown bent inwardly, and the instrument guide is shown with first independently bendable section bent outwardly and then second independently bendable section bent inwardly to achieve triangulation;Figure 16 is a side view of a distal portion of the assembly of Figure 15 showing an endoscopic grasping instrument inserted through the instrument guide for convergence with aninstrument extending through a working channel of the endoscope to achieve triangulation, the fixed distance between the instruments shown by line G2-J2;Figure 17 illustrates a typical surgical laparoscopic setup of the prior art which includes a laparoscope and two hand instruments forming an imaginary triangle;Figure 17a is a view similar to Figure 17 showing the inter-instrument distance and working distances;Figure 18 is a side view of an alternate embodiment of the assembly (system) of the present invention having two instrument channels, two bendable instrument guides and a bendable scope sleeve, wherein the endoscopic instruments are shown extending through respective instrument guides and extending toward each other converging to achieve triangulation;Figure 19 is a side view of an alternate embodiment of the assembly (system) of the present invention having a single instrument guide and showing an endoscopic instrument extending through the instrument guide and bent outwardly and then inwardly toward the endoscope to achieve triangulation due to convergence with the instrument extending through the endoscope channel;Figure 20 is a side view of an alternate embodiment of the system of the present invention having two bendable instrument guides and showing instruments extending toward each other, converging to achieve triangulation, and showing the inter-instrument distance and working distances similar to such distances in a laparoscopic setup shown in Fig. 17a;Figure 20a is a transverse cross-sectional view taken along section A-A of Figure 20;Figures 2 la-2 If illustrate use of the system of Figure 20 whereinFigure 21a shows the two instrument channels attached to / placed over an endoscope;Figure 21b shows an instrument guide having two independently controlled bendable sections inserted into one of the instrument channels with the assistance of a mandrel; the instrument guide in the straight position;Figure 21c illustrates the mandrel removed after insertion of the instrument guide;Figure 21d illustrates bending of one of the instrument channels outwardly (diverging) and inwardly (converging); andFigure 21e illustrates insertion of a first flexible endoscopic instrument through the first bent instrument guide with two independently controlled bendable sections; andFigure 21 f illustrates a second instrument guide having two independently controlled bendable sections inserted into the other side channel and a second flexible endoscopic instrument inserted through the second instrument guide;Figure 22 is a view similar to Figure 20 but showing an alternate embodiment of the system which includes an endoscope bending sleeve;Figure 23 is a side view similar to Figure 21d showing an alternate embodiment of the instrument guide having three independently controlled bendable sections;Figure 24 is a side view similar to Figure 23 showing an embodiment of the instrument guide in the form of a vertebrae and laser cut tube;Figure 25 is a side view of a system in accordance with an embodiment of the present invention showing an assembly with a side channel, a bendable instrument guide, a bendable endoscope sleeve and sensors embedded in the instruments;Figure 26 illustrates a monitor displaying the shape and relative position of the instruments detected by the instrument sensors of Figure 25;Figure 27 is a side view of an alternate embodiment of the assembly (system) of the present invention having a single instrument guide and linkages to pivot / bend the instrument guide, and showing an endoscopic instrument extending through the instrument guide extending inwardly toward the endoscope to achieve triangulation due to convergence with the instrument extending through the endoscope channel;Figure 28 is a side view of an alternate embodiment of the assembly (system) of the present invention having two instrument guides;Figure 29 is a perspective view of a control module in accordance with an embodiment of the present invention;Figure 30 is a perspective view of the control module of Figure 29;Figure 31 is a top perspective view of the control module of Figure 29;Figure 32 is a close up top view of components of the control module of Figure 29;Figure 33 is a close up view of the levers of the control module of Figure 29; andFigure 34 is a top perspective view of the control module of Figure 34; andFigure 35 is a close up view of an instrument guide of Figure 28 with an endoscopic grasping instrument extending therethrough.DETAILED DESCRIPTIONThe present invention provides systems (assemblies) to achieve convergence of endoscopic instruments within confined spaces such as body cavities or body lumens, for example the GI tract, e.g., colon, stomach, esophagus, etc. This is achieved by the various components of the systems which, working in conjunction with the endoscope and endoscopic instruments, form preferred inter-instrument distances and instrument articulation points with respect to each other and the target tissue so that advantageous manipulation angles are established. Thus, instrument triangulation is achieved in the confined space.The systems include a sleeve placeable over an endoscope. In some embodiments, the sleeve has a length such that it is only placed over or in the vicinity of the distal portion of the scope. The sleeve is detachably attached to the endoscope. In other embodiments, the sleeve extends over the entire or substantially the entire length of the scope from its proximal to its distal portion. However, other length options covering just a portion of the scope are also contemplated. In such embodiments, the sleeve could be either detachable, temporarily attached, for example connected by an adhesive tape or a locking / unlocking mechanism, or slidably attached to the scope.In some embodiments, the sleeve is intended for bending / deforming / deflecting an endoscope positioned therein, such that a preferred instrument articulation point is established. In such embodiments, the sleeve is placed over the endoscope proximally, and preferably positioned just proximally to the scope’s built-in / integrated articulation mechanism. This deflection by the sleeve shifts the scope from its main axis, allowing its built-in articulation mechanism to provide a better viewing angle for tissue visualization. In other embodiments, the scope sleeve is not intended for bending / deforming / deflecting the endoscope positioned therein. In some embodiments, the scope sleeve is intended for placement over a scope to facilitate insertion of the system, which for example includes an instrument channel, and / or an instrument guide, and / or endoscopic instrument, into a body lumen / cavity, i.e. when the scope is advanced / pushed / inserted into a body, the scope sleeve and, preferably, the system are advanced with it. In the embodiments where the scope sleeve extends over the entire or substantially the entire length of the scope from its proximal to its distal portion, the user advances the scope, the sleeve and preferably the systemsimultaneously / in a coordinated manner from outside of the body. In some embodiments, the scope is used for navigation through anatomical structures and as a support and guidance for the sleeve and the system. In such embodiments, the scope is advanced first without the sleeve allowing its distal articulation section to navigate tortuous anatomy before the sleeve is advanced over it. In some embodiments, the scope is advanced in partial distance increments, while in other embodiments the scope is advanced fully to the target site, before the sleeve is advanced over the scope using the scope as a guide.In some embodiments, the system includes a scope sleeve and at least one instrument receiving channel attached to the sleeve. The scope sleeve has a lumen therethrough so it can receive an endoscope therein; the instrument channel has a lumen therethrough for receiving an endoscopic instrument, for example an endoscopic grasper, either directly or through an instrument guide which is received in the instrument channel. In some embodiments, the scope sleeve is used for attachment of the instrument channel and is not used or configured to bend / deform / deflect the scope. In other embodiments, the scope sleeve is used for attachment of the instrument channel and is used or configured to bend / deform / deflect the scope. In such embodiments, the scope sleeve and the instrument guide placed via the instrument receiving channel are used for independently bending / articulating the scope and the instrument, respectively, preferably outwardly / away from each other / in opposite directions, to achieve advantageous instrument and scope articulation points. The endoscope and instruments are independently bendable / deflectable / directed / articulated at an angle inwardly to achieve an optimal manipulation angle and triangulation at the points of convergence. In some embodiments, an additional endoscopic instrument is introduced via a working channel of the scope. This triangulation is illustrated in the drawings, with the triangle apex denoted in “N” series and the triangle shown in phantom throughout the several views. Note that a single instrument channel can be provided in some embodiments; in other embodiments, two instrument channels are provided. Additional instrument channels are also contemplated. In some embodiments an instrument guide is mounted directly over the scope without an instrument channel. In some embodiments, an instrument channel or an instrument guide is mounted directly over the scope without a scope sleeve. In some embodiments, the instrument guide is not mounted to the scope but is positionable alongside / adjacent the scope for the surgical procedure.The sleeve and / or instrument guides are bendable in a single plane in some embodiments; in other embodiments the sleeve and / or instrument guides are bendable in multiple planes.In the embodiments wherein the instrument guide is positioned within the instrument receiving channel and an endoscopic instrument is received in the instrument guide, the instrument guide, or at least a portion thereof, is positioned between the instrument receiving channel and the endoscopic instrument. In some embodiments, the instrument guide has a bendable / articulating portion, preferably located at its distal end and a proximal portion that is preferably flexible. The instrument guide has an internal channel / lumen configured to receive the endoscopic instrument.In some embodiments, the articulating portion of the instrument guide can have more than one section, for example a distal articulating (bending) section and a proximal articulating (bending) section which is located between the distal articulating section and the proximal portion of the instrument guide. Both articulating sections could have a common control mechanism that manipulates them simultaneously. Alternatively, each section can be controlled independently of each other which would allow an activation of the proximal articulating section without activation / affecting the distal articulating section and vice versa. For example, after the proximal articulating section is deployed / activated / bent outward, it can be locked / set in place, therefore establishing a fixed / stationary instrument articulation point, similar to the fixed points in laparoscopy defined by surgical abdominal openings. The locking can occur by locking the actuation mechanism at a proximal region of the instrument guide. Once locked, the independently-controlled distal section can continue operating / articulating dynamically allowing an endoscopic instrument inserted via an internal channel of the instrument guide to move linearly or rotationally, articulate with it and manipulate tissue similar to laparoscopic instruments moving relative to the cannulas. Alternatively, the proximal articulating section could be set, such that it does not change shape unless further manipulated by users.In some embodiments, the location of the instrument articulation points is predetermined and not adjustable with the proximal articulating section having only two preset positions / states: one is “off’, preferably used during the system deployment / insertion into the body via the instrument channel, and the second one is non-adjustable “on” and used during the system operation to establish the instrument articulation point. In other embodiments, the clinician can decide / adjust the instrument articulation point by controlling the bending of the instrument guide.That is, the shape of the proximal articulating section is adjustable for optimizing / customizing the instrument articulation point location to adopt to a specific anatomy. Such shape adjustment can either be continuously variable within its operating range or have several / numerous discrete fixed positions between its limits.In some embodiments, the articulating portion of the instrument guide is comprised of one articulating section; in other embodiments, the instrument guide is comprised of two articulating sections; in still other embodiments the articulating portion of the instrument guide is comprised of three sections with an additional intermediate section located between the distal and the proximal articulating sections. (Note “articulating,” “articulation” and “bending” sections are used interchangeably herein). In such embodiments with the multiple articulating sections, each section can be controlled independently of each other. Alternatively, two or more sections could have a common control mechanism that manipulates them simultaneously. More than three articulating sections are also contemplated which can be commonly or independently controlled.In embodiments featuring two articulation (or bending) sections, the first (proximal) bending section serves primarily to displace the instrument laterally away / create a lateral offset from the axis of the endoscope, creating the spatial separation necessary for triangulation. However, in some embodiments, this section does not itself initiate convergence toward the target tissue. Instead, it establishes the position and orientation from which the second (distal) bending section begins to redirect the instrument’s trajectory from diverging to converging. Therefore, in such embodiments, the effective inter-instrument distance relevant to triangulation is defined by the distance between the points at which the second bending sections begin to converge, rather than by the distal ends of the first bending sections.In embodiments featuring three articulation (or bending) sections, the first (proximal) section serves to laterally displace the instrument laterally away from the scope axis, as described above. The second (intermediate) section then redirects the instrument’s trajectory from diverging to converging, forming an S-shaped path. Together, these two sections establish the spatial geometry for triangulation and are configured to remain passive or fixed or static during operation. Once positioned, they are locked to maintain a stable geometry. The distal end of the intermediate section, which defines the transition from divergence to convergence, effectively serves as a virtual insertion point, functionally analogous to the cannula entry site in laparoscopy. The third (distal)section is independently bendable and remains actively controllable during the procedure, enabling dynamic tissue manipulation from that fixed articulation point.In some embodiments, instead of a bendable proximal articulation section as described herein bendable via cables or other mechanisms, the instrument guide includes one or more mechanical links or linkages configured to laterally displace (bend) a distal portion of the guide relative to the longitudinal axis of the endoscope. This displacement serves to reposition the second, actively bendable articulation section away from the scope axis to establish a lateral offset similar to that achieved by the proximal articulation section in previously described embodiments. Once deployed, the mechanical link or linkage maintains the displaced position in a fixed configuration, thereby defining a stable articulation point from which the second section can articulate (bend) and converge toward the target tissue. This arrangement enables triangulation while using a structural linkage mechanism to achieve the necessary spatial separation.In some embodiments, the instrument channel has a bendable / articulating portion similar to the bendable / articulating portion of the instrument guide described above. In such embodiments, the systems can operate / articulate endoscopic instrum ents / achi eve optimal manipulation angle and triangulation with or without the instrument guide. In some embodiments, both the instrument channel and the instrument guide are equipped with such articulating portion.It is understood that the systems in each embodiment disclosed herein could have more than one instrument channel, more than one instrument guide, and / or more than one instrument.While the embodiments described in this application use tensioning cables to articulate the bending sections, it is understood that articulation / steerability could be achieved in other ways. For example, a bending mechanism could be based on the use of multiple concentrically arranged (coaxial) tubes, each of which is slotted or cut with specific patterns along its length. These patterns allow the tubes to bend when selectively advanced or rotated relative to each other. The core principle of steerability arises from differential stiffness and flexibility created by the cut geometries, which can be strategically designed to enable controlled, multi-directional bending. In operation, one or more of these patterned tubes are moved (pushed, pulled, or rotated) relative to the others. The interaction of the cut patterns between the coaxial layers allows the overall structure to deform predictably, forming a steerable segment that can navigate through tortuous paths, such as in surgical or endoscopic applications. Such structure can be beneficial because itmore compact than cable assemblies, yet capable of transmitting force and maintaining precise directional control.Various embodiments of the systems are described in detail below.Note as used herein, the term “proximal” refers to the portion, region or component closer to the user and the term “distal” refers to the portion, region or component further from the user.Referring now to the drawings, wherein like reference numerals identify similar structural features of the systems and devices disclosed herein, and with initial reference to Figures 5-7, one embodiment of the system of the present invention is disclosed. The system includes an assembly 110 having an instrument channel and a scope receiving sleeve.More specifically, the assembly 110 includes a control assembly 114 and a sleeve 112 having a lumen dimensioned to receive an endoscope 120 therethrough. In this manner, the sleeve 112 is mounted over the endoscope 120. The endoscope 120 includes one or more working channels to receive instruments therethrough. The sleeve 112 can be deformed in various ways. Note the terms “deformed,” “bent,” “articulated” and “deflected” are used interchangeably herein. In the illustrated embodiment, the sleeve 112 is deformable by moving, i.e., rotating, knob 116 of control assembly 114 to control cables 118a and 118b. More specifically, cables 118a and 118b extend longitudinally and are spaced apart with a proximal end operatively connected to the control knob 116 (or other actuator / activating mechanism) and a distal end connected to end region 112a of sleeve 112. Axial movement of cable 118a can bend the sleeve 112 in a first direction. The movement is controlled by turning knob 116 and tensioning cable 118a (Figure 5a). A lever 154 or other connector / tensioner is attached to knob 116 with a pivot pin 152. When knob 116 is turned clockwise as viewed in Figure 5a, attached lever 154 pivots to tensions cable 118a by pulling on its proximal end 118a’ in a proximal direction. The proximal end 118b’ of cable 118b is simultaneously advanced distally avoiding tension on the opposite side of the sleeve 112. In some embodiments, axial movement of cable 118a bends the sleeve 112 in one direction and axial movement of cable 118b bends the sleeve in an opposite direction. Other types of mechanisms to control bending are also contemplated. It should be appreciated that control assembly 114, as well as any of the other control assemblies disclosed herein, and their alternatives disclosed herein, can be used in any of the various sleeve and instrument guide (where one or two cable control is contemplated) embodiments disclosed in the present application.Assembly 110 includes an instrument port 126, also referred to herein as an instrument channel or instrument receiving channel. The instrument channel 126 has a lumen extending therethrough to receive a surgical instrument therethrough, i.e., an endoscopic instrument such as a grasper. In this manner, an endoscopic instrument extends through instrument channel 126 and an endoscope extends through sleeve 112 as shown in Figure 7 for operation as described below. Channel 126 can attach to the sleeve 112 by various methods. This could be achieved for example by a hub 124a which is attached to hub 112b of sleeve 112. The attachment can be by slidable or frictional engagement as hub 124a partially encircles hub 112b. Other modes of attachment are also contemplated. Channel 126 can in some embodiments include one or more additional hubs, such as hubs 124b and 124c which are placed over scope 120 as shown in Fig. 6. The attachment can be by slidable or frictional engagement as hubs 124b, 124c partially or fully encircle the outer surface of the scope 120) or other modes of attachment. In this and other embodiments, instrument port (channel) is optionally collapsible as described in paragraph

[0283] and Figs. 37-40 of patent application US2023 / 0389784A1.The distal hub 124a is attached to the sleeve 112 proximal of its bendable section 111. In this manner, bending of the sleeve 112, and thus bending of the scope 120, does not cause bending of the instrument channel 126. If multiple hubs 124 are provided, all the hubs are preferably positioned proximal of the bendable section 111 of sleeve 112. This can be appreciated by reference to Figure 6 where the sleeve bending region 111 is distal of hub 126a.It should be appreciated that sleeve 112, along with its one or more hubs, if provided, can be used in any of the various assemblies / system disclosed in the present application.With continued reference to Fig. 6, sleeve 112 is shown placed over flexible (deflectable / bendable) scope 120, with the scope 120 extending distally out of the sleeve 112 beyond the distalmost end of the sleeve 112. An instrument guide 128 is inserted through instrument channel 126 and extends distally out of instrument channel 126 and has a distal bend directed toward distal portion 120b of scope 120 forming angle 8 between its distal section 128a and distal portion 120b of scope 120. As shown, distal section 128a is oriented towards scope 120 due to its bent angle with respect to the longitudinal axis of the instrument guide 128.Instrument guide 128 is movable in the axial direction and rotatable (about its axis) relative to channel 126 as illustrated by the arrows. The rotation enables the bent distal section 128 to beoriented toward the scope 120, and more particularly to bent / articulated distal region 120b, to achieve triangulation as described herein. Distal section 128a of instrument guide 128 is bent to angle Pi, however, it could be straight in an alternative embodiment or bent at alternate angles than that shown. In embodiments where it is straight, triangulation can be achieved due to articulation (bending / deflection) of the endoscopic instrument 132 emerging distally of the instrument / working channel of scope 120. Distal section 128a can be pre-bent as shown, or alternatively, it could be bendable via manual control, e.g., cables tensioned via an actuator. It should be appreciated that this pre-bent instrument guide or manually controlled bending of the instrument guide can be utilized with the other embodiments of the systems disclosed herein.Distal section 128a of instrument guide 128 and distal portion 120b of scope 120 converge and form angle 5i between them and create an imaginary apex Bl representing an imaginary tissue target. In principle similar to a laparoscopic setup, this creates triangulation between a) instrument guide 128 that serves as a first instrument port for a first endoscopic instruments and b) a working channel of scope 120 that serves as a second instrument port for a second endoscopic instruments.In some embodiments, hub 124a of instrument channel 126 can be attached to the sleeve 112. In other embodiments, the hub 124a of channel 126 can be attached to the scope 120.In some embodiments, channel 126 using hub 124a could be placed / attached to scope 120 adjacent / proximally to sleeve 112 instead of being attached directly to sleeve 112. In such embodiments, sleeve 112 could be integrated into / be a part / component of scope 120 creating a dual-bend scope.In this and other embodiments of systems disclosed herein, the distal end 126a of channel 126 and similar channels is preferably located proximally to the articulating / bending portion of the scope 120 (proximal to the sleeve bending portion 111), such that scope 120 can be bent / articulated without affecting the shape / position / orientation of the channel 126 and instrument guide 128. This can be appreciated for example in Figure 6 wherein, as shown, the distal end of the instrument channel 126, (and the distalmost end of hub 124a if positioned at the distal end of instrument channel 126), is generally axially aligned with hub 112b (or proximal of a distalmost end of hub 112b) so it does not extend distally beyond the hub 112b where the bendable portion of the sleeve 112 begins at bendable region 111. Distal hub 112c is at the distal end of bendable region 111 and is bent with respect the proximal hub 112b as bendable region is bent via the bending mechanism.Fig. 7 shows assembly 1 10 placed over scope 120 and an instrument extending through instrument guide 128 which is positioned within instrument channel 126. Scope 120 with assembly 110 is placed / inserted into a body cavity / lumen 140, such as a colon, until it reaches target tissue site 142. By rotating sleeve knob 116 (or actuating another actuator), sleeve 112 is bent in a direction away (outwardly) from the longitudinal axis of sleeve 112, thereby bending scope 120 in a direction away (outwardly) from the longitudinal axis; and by rotating scope knob 122 of scope 120 (or actuating another actuator of the scope 120), bendable portion 120a of scope 120 is also bent, in a direction back toward (inwardly) the longitudinal axis of the sleeve 112, thereby positioning distal portion 120b of scope 120 at angle y relative to the axis of scope 120. Thus, as shown, the end result is the scope bending outwardly(diverging) then redirected inwardly (converging) to face the target tissue at the illustrated angle. Instrument guide 128 is inserted from proximal portion 126b of instrument channel 126 (through an opening at a proximal end) and advanced through channel / lumen 126 towards target tissue site 142. Such insertion can occur either before or after the sleeve 112 is bent, or occur either before or after the endoscope 120 is bent, or occur substantially simultaneously with the bending of the sleeve 112 and / or bending of the scope 120.Instrument guide 128 can rotate and move axially relative to channel 126. Axial movement adjusts the distance from the target site; rotation adjusts the distal bend orientation toward / relative to the target tissue. Proximal portion 128b of guide 128 preferably extends outside of the patient’s body. Instrument 130, such as a flexible endoscopic grasper, is inserted into instrument guide 128 at the proximal portion 128b of channel 126 and is advanced / extends thought the instrument guide 128 to extend beyond the distal portion 128a of guide 128 and placed in proximity to target site 142. Guided by distal section 128a of guide 128, distal portion 130a of instrument 130 is deformed / flexed / directed for positioning at angle p2relative the axis of guide 128. In some embodiments, depending on mechanical characteristics / flexibility / rigidity of instrument 130, instrument 130 could deform distal section 128a of instrument guide 128 resulting in the angle p2being different / slightly different from the angle | . In other embodiments, angle p2can be substantially the same as angle Pi. Instrument 130 is movable linearly (axially) relative to / coming in and out of guide 128 to adjust the distance to the target site and rotatable (about its axis) relative to guide 128 to adjust the orientation of the end effector 132a, for example jaws of a grasper,relative to the target site as illustrated by the arrows. Optionally, a second instrument 132, such as a flexible endoscopic knife, is inserted via a working channel of scope 120 to emerge out a distal end of the scope 120. Distal portion 130a of instrument 130 is positioned at the angle 62relative to distal section 120b of scope 120. Distal portion 130a of instrument 130 and distal portion 132a of instrument 132 converge on target tissue 142 and create an imaginary apex B2thus achieving triangulation. Angle 82is the same or similar to angle 8i. Apex B2is collocated or adjacent to imaginary apex B As can be appreciated, the distal end of the instrument guide 128 converges toward the longitudinal axis of the scope and tissue site and the scope 120 diverges then converges toward the site.Preferably, angle 52is in the range from about 30 to about 150 degrees and more preferably between about 45 and about 75 degrees, however it could be in the range between about 0 (zero) to about 180 (one hundred eighty) degrees. Other angles are also contemplated.When bendable portion 111 of sleeve 112 is bent in one direction and the distal portion 120b of scope 120 is bent in the opposite direction, the distal end of scope 120 with portions 120a and 120b form an “S” shape. Alternatively, if bendable portion 120a and distal portion 120b are bent in the same direction, they form a “J” shape. In some embodiments, both bent sections are in the same plane; in other embodiments, the bent sections are in different planes.As discussed above, the instrument channel 126 is proximal of the bending region of the sleeve 112. Also, the opening in the instrument channel 126 is outside the diameter of the endoscope and thus radially spaced therefrom and radially spaced from the working channels of the endoscope.Note that since the instrument channel 126 is attached to the sleeve and the scope, when the scope and sleeve are inserted into the body cavity, it carries the instrument channel with it. In this and some other embodiments of this application, the distance between the scope axis and axis of the instrument channels during insertion is preferably smaller to maintain a compact profile with minimal cross-sectional area during advancement than the inter-instrument distance that is achieved when the system is deployed to facilitate insertion through narrow anatomical pathways.In an alternate embodiment, bendable portion 120a of scope 120 is bent into retrograde position as shown in Fig. 8. This bend combined with the scope bend that results from bending sleeve 112 forms a “?” (question mark”) shape positioning distal portion 120b of scope 120 atangle s relative to the axis of scope 120. In such embodiment, distal portion 120b could be diverging from the axis of scope 120. That is, distal portion 120b extends inwardly toward the longitudinal axis of the scope, and can cross over the longitudinal axis of the scope 120 as shown. Distal section 128a of instrument guide 128 can be oriented away from scope 120, (bending outwardly away from the longitudinal axis of the scope 120), such that distal portion 130a of instrument 130, extending through and out of instrument guide 128, is converging with and positioned at angle relative to distal portion 132a of instrument 132. This provides an example of another way to achieve triangulation of the instrument 130 extending thought instrument guide 128 and the instrument 132 extending through the endoscope working channel.Figures la-3 illustrate the scope bending sleeve 112 of Figure 5. The hub 124 and instrument channel 126 attachable to the sleeve 112 are not shown. Note in an alternate system the scope bending sleeve is used by itself to improve maneuverability of the scope and thus in such embodiment, the assembly is used for bending the endoscope but unlike the system of Figures 5- 7, does not have an instrument receiving channel. For this reason, the assembly of Figures la-3 is provided with different reference numerals than the sleeve of Figure 5, but it should be understood that the sleeve could be the same structurally as the bending sleeve 112 of Figure 6.More specifically, assembly 10 is intended for bending / deformation of a flexible instrument, such as a flexible endoscope. Assembly 10 is mounted / attached / placed over a scope 20 and includes a bending sleeve 12. Note sleeve 12 can be used as the sleeve / overtube in the other embodiments disclosed herein. The below described alternatives to sleeve 12 could also be utilized as the sleeve in the other systems disclosed herein.Sleeve 12 is bendable / deformable and has a distal section which includes a proximal hub 12a and a distal hub 12b that are movable, i.e., deflectable, relative to each other. In some embodiments, proximal hub 12a and distal hub 12b are pivotably connected. Optionally, sleeve 12 can also have one or more sections 12c to increase the distance between proximal hub 12a and distal hub 12b. Sleeve 12 is connected to control unit / assembly 11 which includes cables 18a 18b and control 14, preferably located outside of the patient’s body. Control 14 includes a knob / control feature 16 operatively connected to sleeve 12 via one or more connecting cables 18a, 18b. Knob 16 rotation tensions the cable 18a to bend the distal section of the sleeve 18 in a similar manner as described above with respect to rotation knob 116 and cable(s) 118a for bending sleeve 118. Insome embodiments, cable 18a (as well as the cables from the other systems disclosed herein) could be enclosed in a flexible tubular channel that connects control unit 14 with proximal hub 12a. In other embodiments, assembly 10 does not have sleeve 12, and instead of being connected to sleeve 12, proximal hub 12a of bending sleeve 12 is attached / connected to scope 20. Preferably this connection / attachment is temporary, and can be achieved, for example, by using an adhesive tape, such that assembly 10 can be dismounted from scope 20 at the end of the procedure. Alternatively, distal hub 12b could be connected to scope 20.In use, rotation / movement of knob / control 16 tensions cable 18a and bends sleeve 12 with respect to the longitudinal axis of the sleeve 12 (in the same manner as cables 118a, 118b) as shown in Fig. lb. Movement of knob 16 in the opposite direction will relieve the tension on cable 18a and allow sleeve 12 to return to its “normal” “straightened” state shown in Fig. la. In some embodiments, assembly 10 has more than one cable, for example, cable 18a and cable 18b. When such optional cable 18b is present, movement of knob 16 in the first direction, e.g., clockwise (or alternatively counterclockwise), could, for example, result in tensioning of cable 18a and loosening / releasing of cable 18b allowing sleeve 12 to deform. Movement of knob 16 (like knob 116) in the opposite direction will reverse this deformation by tensioning cable 18b and releasing the tension on cable 18a allowing sleeve 12 to return to its linear configuration. The use of multiple cables for either sequential or simultaneous tensioning of some cables and release of other cables is contemplated. Further, multiple cables can be provided to bend sleeve 12 in multiple directions. In some embodiments, sleeve 12 deforms in a single plane. However, use of more than one cable allows deformation of sleeve 12 in multiple directions and multiple planes.Fig. 2 shows assembly 10 placed over a flexible instrument 20, such as a flexible endoscope. Endoscope 20 has a distal bending section 20a that has a length Ll. Distal hub 12b of sleeve 11 is preferably positioned adjacent to endoscope bending section 20a, and, more preferably, positioned proximally to the proximal edge of bending section 20a. Alternatively, it could be positioned either within / over or distally to bending section 20a. If positioned proximally of bending section 20a, distal hub 12b will interfere with or will not bend when the scope deflected mechanism bends the scope 20 with respect to the sleeve 12. This is advantageous in this and other embodiments with the instrument channel as described above.When knob 16 is rotated, sleeve 12 bends and forces scope 20 to deflect and form user- adjustable angle on between the main / longitudinal axis of the scope and bending section 20a as shown in Fig. 3. This diverges the scope away (outwardly) from its main axis. Preferably, angle on is in the range from about 10 to about 90 degrees and more preferably between about 20 and about 75 degrees, however it could be in the range from about 0 (zero) to about 180 (one hundred eighty) degrees. Other degrees are also contemplated. Sequentially or simultaneously with bending of scope 20 by sleeve 12, bending section 20a is bent to user-adjustable angle a? using scope knob 22 which is part of scope 20 and independent of sleeve 12. Rotation of scope knob 22 converges the scope 20 back towards (inwardly) its main (longitudinal) axis and creates an imaginary apex A. As a result, the distal portion of scope 20 is “S-shaped” allowing distal tip 20b of scope 20 to converge toward the main axis of the scope 20 forming angle a. Because angles ai and oi2 are user-adjustable, users can select angle a that is optimal for visualization and tissue manipulation.Preferably, angle a is in the range from about 10 to about 90 degrees and more preferably between about 30 and about 75 degrees, however it could be in the range from about 0 (zero) to about 180 (one hundred eighty) degrees. Other degrees are also contemplated.In some embodiments, the angle of bending of the sleeve 12 is continuously adjustable and controlled by a knob. In other embodiments, the angle is fixed / predetermined, for example 45 degrees, and a lever that is used instead of a knob and moves between two positions could be used to activate the bending of sleeve 12 and moving it from a straight to bent state. In some embodiments, sleeve 12 is fabricated using the design that is similar to the design of bending sections of conventional endoscopes. In other embodiments, it is fabricated as a flexible member, for example a laser-cut metal tube.Various actuators can be utilized in this embodiment / system as well as the other emb odiments / sy stems disclosed herein to bend the sleeve and / or to bend the scope.While sleeve 12 shown in Figures l-3a is intended for bending in multiple planes and directions, an alternative sleeve 32 in Fig. 4a is simplified for bending just in a single plane and a single direction. Fig. 4a shows the sleeve 32 in an unbent linear state; Fig. 4b shows sleeve 32 in the bent state at an angle to the longitudinal axis of sleeve 32. In some embodiments, bending portion 32c of sleeve 32 are laser cut in the hypotube, made, for example, from stainless steel ornitinol material. In other embodiments, multiple bending portion 32c are pivoted / riveted together to allow for their relative rotation, thus enabling bending in one direction and restricting bending in the opposite direction. The sleeve 32 can be used in any of the systems disclosed herein.An alternative embodiment of the system, and its use, is illustrated in Figures 9a-13. Figure 9a shows an alternative flexible assembly of the system 200; Figure 10 illustrates the instrument guide of the system 200; and Figure 12a illustrates an additional (inner) instrument guide of the system 200.Flexible assembly 210 has an instrument channel 226 and a bendable sleeve 212 (also referred to herein as an overtube) having a distal section 212c and distal end / hub 212b. Similar to assemblies 10 and 110, sleeve 212 can be bent by pulling on cables 218a and 218b using rotation knob 216 of control unit 214. That is, rotation of knob 216 tensions the cable 218a or 218b to effect bending (n the same manner as knob 116 or in the manner of the aforedescribed alternate actuator mechanisms). As in the embodiment of Figure 5, the control unit 214 and cables 218a, 218b can be configured to effect bending in a single direction or alternatively in multiple directions. Additional cables could also be provided to achieve such directional bending. Other types of mechanisms to effect bending are also contemplated.Channel 226 of assembly 210 is attached to sleeve 212 either directly integral with sleeve 212 or attached with an optional element / hub 224a. Hub 224a can attached / placed over or frictionally / slidably engage sleeve 212 in a channel dimensioned to frictionally fit over the outer diameter / surface of sleeve 212 in a similar manner as described above with respect to hub 124a. Other attachment methods for hub 224a are also contemplated. Instrument channel 226 can also include additional hubs 224b and 224c to connect channel 226 to other regions of the sleeve 212 and thus to the scope 220 (shown in Fig. 11). Although three axially spaced hubs 224a, 224b, 224c are shown, a fewer or greater number of scope engaging hubs are also contemplated. In the illustrated embodiment, instrument channel 226 includes a distal sleeve engaging hub 224a and two proximal scope engaging hubs 224c, 224b.Assembly 210 has a slider bar 232 with a gear rack 234 and a guiding slot 236, shown in the close-up view of Figure 9b. The instrument guide 250 of the system is shown in Figure 10. Instrument guide 250 has a bendable / articulating section 252 at a distal region and an instrument lumen 254 extending therethrough configured to receive an endoscopic instrument. Bendingsleeve 252 has proximal portion / hub 252a, a distal portion / hub 252b and a bendable section 252c located between them. Bending sleeve 252 is operated by rotation of knob 256 and tensioning cables (not shown) similar to the mechanism illustrated in Fig. 5a. Knob 262 has an integrated pinion 292 which interacts with gear rack 234 (Fig. 1 la) of assembly 210. Rotation of knob 262 rotates pinion 292, which due to its engagement with teeth of rack 234, effects axial movement of slider 264. That is, it causes slider 264 to move relative to stationary slider bar 232 of assembly. Instrument guide 250 is attached to slider 264 so it moves with slider 264. A rotation knob 260 (or other actuator / activating mechanism) can be provided to rotate instrument channel 254 relative to its axis. In a preferred embodiment, instrument guide 250 is sized to be compatible with the internal diameter of instrument channel 226 of assembly 210 so that it can be received and supported in the lumen of instrument channel 226.The system 200 that includes assembly 210 and instrument guide 250 is shown in Figure 11 placed over scope 220. Instrument guide 250 is inserted through instrument channel 226, preferably until proximal portion 252a aligns with / overlaps with (located within) hub 224a that provides stability and support from scope 220. Sleeve 212 is bent by moving (e.g., rotating) knob 216 which bends the bendable distal section 212c to thereby bend scope 220 positioned therein to angle K2relative to the main axis. The bendable distal section 212c of sleeve 212 in the illustrated embodiment can extend from the distal edge of proximal section 212a to distal section 212b. (In some embodiments, distal section 212b bends with the bendable section 212c). The bendable section 212c can be formed by a laser cut tube. Bendable section 252c of the instrument guide 250 in the illustrated embodiment extends from the distal edge of proximal portion 252a to distal portion 252b. (Distal portion 252b bends with bendable section 252c while proximal section 252a does not bend). The bendable section 252c can be formed by a laser cut tube. Bendable section 252c is bent by moving (e.g., rotating) knob 256, thereby positioning distal portion 252b at the angle KLAS a result, distal section 212b of overtube 212 and distal portion 252b of instrument channel 250 are diverging and positioned at the angle K relative to each other and separating them by a distance L2at their distalmost ends (i.e., at their distal openings). This distance L2between distal section 212b and distal portion 252b is greater than the distance L3between the axis of scope 220 and instrument lumen 254 of instrument channel as shown in Figure 1 1 . This divergence is seen as the instrument guide 250 distal end extends outwardly away from the longitudinal axis ofthe instrument guide 250 and the sleeve 212 distal end extends outwardly away from the longitudinal axis of the sleeve 212. Note the distal section 220a of scope 220 can be deflected / articulated inwardly as shown utilizing the scope deflecting / articulation mechanism.Figures 12a-12c show an additional instrument guide 270 (also referred to herein as an inner instrument guide) having a bendable / articulating section 272 and an instrument guide lumen 278 to receive an endoscopic instrument therein / therethrough. Section 272 is bendable to angle by turning knob 276 of control unit 274 which tensions cables attached to the guide 270. This mechanism is similar to the mechanism illustrated on Fig. 5a. An instrument, such as a grasping instrument 280, is inserted through lumen 278 of guide 270 until its distal portion 280a extends beyond distal portion 272b of instrument guide 270 as shown in Figure 12c. In some embodiments of the system 200, the instrument guide 270 is inserted into the instrument guide 250. In these embodiments, the two instrument guides 270, 250 are provided. In alternate embodiments, the instrument guide 270 is not utilized and the endoscopic instrument is inserted directly through the instrument guide 250. In still other embodiments, neither instrument guides 250, 270 are provided and the endoscopic instrument 280 extends directly through channel 226 (without intervening guides). In some embodiments, instrument 280 can be fully integrated with instrument guide 270, such that the end effector, for example, jaws of a grasper, is mounted directly on the distal hub 272b.The triangulation / points of convergence of the system 200, utilizing the instrument guides 250 and 270, are shown in use in Fig. 13 which illustrates the distal portion of system 200 with assembly 210, instrument guide 250 and instrument guide 270. Endoscopic instrument 280 extends through the lumen 278 of inner instrument guide 270 which is positioned within outer instrument guide 250 and endoscopic instrument 282 extends through a working channel (lumen) of scope 220. The instruments 280, 282 extend distally from the respective guide 270 and the working / instrument channel of scope 220 so that they can manipulate the target tissue. As a result of controlled deforming (bending) instrument channel 250, instrument guide 270 and scope sleeve 212, the instruments 280 and 282 are triangulated and positioned at angle p relative to each other with an imaginary apex C and form an imaginary triangle CDE. Such deforming / bending as shown in Figure 13 achieves this triangulation as the two instruments 280, 282, after bending outwardly from the longitudinal axis of their respective instrument guide channel and scope channel, bendinwardly toward each other, directed to convergence point C. Stated another way, instrument channel 250 is bent outwardly away from the longitudinal axis of the channel 226 to direct instrument guide 270 and the instrument 280 therein outwardly. Instrument guide 270 is bent inwardly back toward the longitudinal axis of the channel to direct instrument guide 270 and the instrument 280 therein toward the instrument 282. When bent in such manner, instrument guides 250 and 270 form S-shape curve. Instrument guides 250 and 270 are controlled / activated / bent independently of each other, i.e. bending / deforming one instrument guide does not affect / activate the other instrument guide. Sleeve 212 is bent outwardly away from the longitudinal axis of the sleeve 212 to direct the sleeve 212 and scope 220 so the instrument 282 therein extends outwardly. Scope 220 is bent inwardly back toward the longitudinal axis of the sleeve 212 so the instrument 280 therein extends toward the instrument 280. This achieves the point of convergence referenced above. The distance between the instrument (inter-instrument distance) is represented by line DE defining static / fixed articulation points in a manner similar to cannulas / ports which provide fixed points for laparoscopic instruments for laparoscopic surgery.Fig. 14 shows an alternative embodiment of the instrument guide 350 which has two bending sections. This instrument guide of Figure 14 with two bending sections can be used in any of the embodiments / sy stems disclosed herein.With reference to Figures 14 and 15, instrument guide 350 of system 300 has a distal region 352 with a distal section 352a and a proximal section 352b axially spaced from distal section 352a. The bending region can be defined as distal region 352, however, in embodiments having the proximal hub 352f, the bending section can be defined as region 352c. Region 352 includes sections 352a, 352b. Note hub 352e (and 352d and 3521) demarcate the bending sections, i.e., separate the distal and proximal bending sections 352a, 252b, however, it is also envisioned that one or more of the hubs are not provided and the separation can be by other ways such as different cut patterns to alter the bendability and directional characteristics of the sections 352a, and 352b. Such variations apply to each of the embodiments disclosed herein utilizing hubs.Preferably, distal bending section 352a and proximal bending section 352b are operated independently, however, in alternate embodiments, distal bending section 352a and proximal bending section 352b are operated simultaneously or sequentially by a single control element. The lengths of the distal section 352a and proximal section 352b can be the same, or, in alternateembodiments, of different lengths. Bending portion 352 and instrument lumen 354 of instrument guide 350 are optionally rotatable relative to slide 364 using an optional rotation knob 360 attached to instrument lumen 354. Similar to bending sections 12, 112, 212, 252, and 272, distal section 352a and proximal section 352b are controlled by two cables each (not shown). Two cables are controlling bending of distal section 352a and preferably located within the bending portion 352 and are attached to distal portion 352d. Two other cables are controlling bending of proximal section 352b and preferably located within the bending portion 352 and are attached to the intermediate portion 352e located between distal section 352a and proximal section 352b. Knob 362 is similar to knob 262 of the embodiment of Figure 10 and is used for moving instrument guide 350 linearly (axially) relative to assembly 210 using a rack-and-pinion mechanism. For brevity, the rack and pinion mechanism are not described herein since the aforementioned description of the knob 262 and mechanism for moving the instrument channel 250 of Figure 10 is fully applicable to this embodiment of Figure 14. Knob 316 functions in a similar manner as knob 116 of Fig. 5-5a and 216 of Figure 10 to bend sleeve 312.Fig. 15 shows system 300 mounted over scope 320 in a similar manner as in Figure 11. Assembly 310 of system 300 is similar to assembly 210 of system 200. Instrument channel 326 is shown mounted to scope 320. It should be appreciated that use of assembly 110 in place of assembly 310 is also contemplated. It should also be appreciated that scope 320 can be the same as scope 20, 120 and scope 220.Similar to knobs 16, 116, 216, 256, and 276, by tensioning cables, knob 356 controls preferably outward bending / deflection / articulation of proximal bending section 352b of instrument channel 350 to a preferably adjustable angle i. In similar manner, knob 358 controls preferably inward bending of distal section 352a to a preferably adjustable angle 2. Assembly 310 is placed over scope 320. Instrument guide 350 is placed into instrument channel 326 of assembly 310. Optionally, a removable mandrel 370 (Figure 14) can be inserted into channel 368 of instrument guide 350 to provide a stiffening member to improve pushability and torqueability of the system, and facilitate the insertion of instrument channel 350 into channel 326. The mandrel 370 can be used with any of the embodiments / systems disclosed herein. Instrument channel 326 is mounted to scope 320 via one or more optional hubs 324a in a similar manner as hub 224a described above.In a preferred embodiment, assembly 300, with scope 320 positioned within sleeve 312, is placed into the patient before instrument channel 350 is inserted. Alternatively, instrument guide 350 can be inserted before scope 320 with assembly 310 is placed in the patient. In either case, when activated, bending portion 352 of instrument guide 350 has an “S” shape and forms angle 3 with the main axis of scope 220. Using sleeve knob 316, bendable sleeve (overtube) 312 is bent preferably outwardly forming a preferably adjustable angle 7ti with the main axis of scope 320. Articulation in other directions and to predetermined fixed instead of adjustable angles by knobs 316, 356, and 358 are also contemplated. Using scope knob 322, bending section 320a of scope 320 is adjusted to angle ^2 and forming angle K3with the main longitudinal axis of scope 320, bending inwardly back toward the longitudinal axis of the scope 320. In some embodiments, any of the angles 1, 2, and TT 1 are not adjustable, but fixed. In such embodiments, a two-position lever or another mechanism could be used instead of a continuously rotatable knob.As a result of such bending / deflection, distal portion 352d of bending portion 352 of instrument guide 350 and distal portion 320b of scope 320 are triangulated by converging at the angle Vi towards the imaginary apex (convergence point) Fl and forming an imaginary triangle F1G1J1. This also forms the dimension L4 between the furthest points of axes of distal portion (hub) 352d and distal portion 320b, and, defines the inter-instrument distance. This dimension is larger than the dimension L5 between main axes of scope 320 and channel 326 (same as or adjacent to the axis of channel 354). As can be appreciated, the larger dimension enables the triangulation described herein as the greater separation enables the instruments to converge at a larger / increased / optimal / user preferred angle toward each other. When instrument 380 is introduced via instrument channel 350 and instrument 382 is inserted via a working channel of scope 320 as shown in Fig. 16, they are triangulated and converge at the angle V2 at the imaginary apex (convergence point) F2 forming an imaginary triangle F2G2J2. Line G2J2 illustrates the interinstrument distance.To better understand the triangulation / convergence of the systems of the present invention in body cavities such as the colon, a description of laparoscopic surgery systems will be presented. With reference to Figures 17 and 17a, a typical surgical laparoscopic setup 400 that includes laparoscope 420 and two hand instruments 480 and 482 is illustrated. Such systems are common in performing laparoscopic surgical procedures. To establish triangulation, a surgeon insertslaparoscope 420 into an abdominal cavity for imaging, for example via an umbilicus marked as an apex K while laparoscopic hand instruments 480 and 482 are inserted at instrument insertion sites marked as apexes Li and MbTypically, the instruments are inserted via a surgically-created opening / puncture in the abdominal wall using laparoscopic ports / cannulas. The insertion sites form an imaginary triangle K4L1M1. When hand instruments 480 and 482 are inserted, they are directed at target tissue site 442 and form an imaginary triangle LiMiNi. The distance L]Mi (the inter-instrument distance) is the base of triangulation and creates sufficient separation between the instruments allowing them to converge at an optimal “manipulation angle” TbInstruments 480 and 482 also form “azimuth’ angles pi and o, between them and laparoscope 420. To manipulate tissue, users move / pivot / rotate instruments 480 and 482 relative to insertion sites Ltand M, which are at fixed locations and provide fixed fulcrum points. Users can move / pivot / rotate the instruments side to side within the angleindependently (sequentially or simultaneously) from moving them linearly / axially toward and away from target tissue site 442, while the distance foM and location of apexesand M remain unaffected. Similarly, laparoscope 420 can be pivoted relative to the apex Ki within the angle coi and moved linearly / axially toward and away from target tissue site 442. Pivoting / moving laparoscope 420 does not affect the position / orientation / movement of instruments 480 and 482. This makes tissue manipulation more intuitive. Fixed locations of insertion sites Li and Mxand independence of linear / axial movement of instruments from their rotation assure that the “manipulation angle” remains in an optimal range. Figure 17a illustrates points / apexes LI, Ml forming fixed instrument articulation points with the inter-instrument distance remaining the same as the instrument s) is moved axially (distally and proximally) through the port to change a working distance. The working distance is also fixed, and the instruments 480 and 482 can move in and out of the abdominal cavity allowing the user to reach and manipulate the target tissue with the end effectors. That is, the movement of the instruments does not affect the ergonomics of the system as the handles 480a, 482a of the respective instruments 480, 482 grasped by the clinician can remain at a comfortable distance apart.Fig. 18 shows a system 500 that allows users to achieve similar triangulation in endoscopic or laparoscopic procedures as surgical laparoscopic setup 400 of Figures 17 and 17a. System 500includes 1) a bendable overtube (sleeve) 512 which is similar to overtube 312 for positioning over a scope; 2) an instrument receiving assembly 510 which includes a first instrument receiving channel 526; 3) an instrument receiving assembly 510’ which includes a second instrument receiving channel 526’, preferably on an opposite side; 4) a first instrument guide 550 which is similar to instrument guide 350 and extends through instrument channel 510; and 5) a second instrument channel 550’ (on an opposite side) which is also similar to instrument channel 350 and extends through instrument channel 510’. The instrument receiving assembly is attached to the sleeve 512 via one or more hubs 524, such as hub 524a. Alternatively, instrument receiving assembly 510 and 510’ are placed over / attached / mounted on to scope 520.Two endoscopic instruments 580 and 582 are shown in use with the system - instrument 580 shown extending through instrument guide 550 and instrument 582 shown extending through instrument channel guide 550’. Both instruments 580, 582 extend out the distal openings past the distal ends of the respective instrument guides 550, 550’. A scope 520 (which can be the same as scopes 20, 120, 220, 320) is shown positioned within sleeve 512. The endoscopic instruments 580, 582, as in the other embodiments disclosed herein, can be for example endoscopic graspers, scissors, dissectors, etc.Scope 520 can be deflected using bendable sleeve 512 within angle u in the same manner as overtube (sleeve) 312 bends scope 320, while users can also independently, sequentially or simultaneously, bend the distal portion of the scope within angle co2via the scope deflection mechanism, e.g., a knob (and cables) similar to knob 322 of Figure 15). In a preferred embodiment, the deflection plane of scope 520 is different from the deflection plane of instrument guides 550 and 550’, in other embodiments they are the same. In some embodiments, the deflection planes of instrument guides 550 and 550’are different, when in other embodiments they are the same.In a preferred embodiment, using proximal controls that are similar to controls of instrument guide 350, proximal bending sections 552b and 552b’ of respective instrument guides 550, 550’, are deformed outward by a fixed angles aa and 0P defining location of the imaginary apexes L2and M2that have static locations relative to each other. Using the analogy to a laparoscopic set of Fig. 17 and 17a, establishing these static locations is similar to creating surgical puncture in the abdominal wall and defining the location of cannulas and inter-instrument distance.Preferably subsequently to establishing an optimal inter-instrument distance L2M2, and while the locations of these imaginary apexes L2and M2remain static / stable / unchanged / fixed, and using distal controls that are similar to controls of instrument guide 350, distal bending sections 552a and 552a’ of respective instrument guides 550, 550’are deformed / rotated / pivoted / articulated by the user inward converging toward the imaginary apex N2within adjustable angles c|)2and n2. Such manipulation of distal bending sections 552a and 552a’ is preferably fully independent from manipulations of proximal bending sections 552b and 552b’, therefore, any maneuvering of bending sections 552a and 552a’ has no effect on locations of imaginary apexes L2and M2. Using the analogy to a laparoscopic set of Fig. 17 and 17a, movements of distal bending sections 552a and 552a’ are similar to movements of the surgical cannulas relative to the surgical abdominal openings Ltand MbIn some embodiments, an additional instrument guide 570, which is similar to internal instrument guide 270, could be deployed via instrument guide 550 and / or 550’. In such embodiments, the instrument would be inserted through instrument guide 570 which is inserted through instrument guide 550 (or 550’) which is inserted through instrument channel 526 (or 526’). If instrument guide 570 is not provided, then the instrument would be inserted through instrument guide 550 (or 550’) which is inserted through instrument channel 526 (or 526’). In either case, instruments 580 and 582 are inserted and form “azimuth’ angles p2and G2between them and endoscope 520 and converge at an optimal “manipulation angle” T2relative to each other. These angles could be adjusted / affected by adjusting angles <j)2and w2, and when instrument guide 570 is used, by adjusting it within angle yy.Instruments 580 and 582 are moved linearly / axially toward and away from apex N2independently (sequentially or simultaneously) from pivoting action of distal sections 552a and 552a’. Such axial movement as well as side to side pivoting movement does not change the interinstrument distance L2M2 or location of the fixed apexes L2 and M2. In some embodiments, each proximal bending section 552b and 552b’ is articulated / deformed by one control feature, while articulation / rotation / pivoting of each distal section 552a and 552a’ is controlled by another control feature and movement and rotation of each instruments 580 and 582 is controlled / performed / operated by another control feature. Using the analogy to a laparoscopic set of Fig. 17 and 17a, coordinated and, where beneficial, simultaneous movements of endoscopic instruments 580 and582 and distal bending sections 552a and 552a’ while the imaginary apexes L2and M2. remain static are similar to movements of the laparoscopic instruments 480 and 480 relative to the surgical abdominal openings Li and MbAn alternative system 600 is shown in Fig. 19 and includes 1) one assembly 610 (as opposed to two assemblies of system 500 of Figure 18), which is similar to assembly 210; and 2) one instrument channel 650 (as opposed to two instrument channels of the system 500 of Figure 18) which is similar to instrument channel 350. The assembly 610 is shown attached to scope 620 (which can be similar to scope 520 and other scopes disclosed herein) via one or more hubs 624a in a similar manner as hub 326a described above. An endoscopic instrument 680 is shown inserted via instrument guide 650. An endoscopic instrument 682, as shown, is inserted via the instrument (working) channel of scope 620. In this embodiment of Figure 19, a bendable overtube (sleeve) for the endoscope is absent, and scope 620 is deformed using its internal articulation mechanism within angle < (It should be appreciated that the overtube (sleeve) can also not be included in any of the other systems disclosed herein and rely just on the scope articulation features / control to deflect the scope).Instrument guide 650 is articulated in a fashion similar to instrument guide 550 as the proximal bending section 652a is deformed outward (away from the longitudinal axis of the channel 350) first to establish an imaginary apex L3creating an imaginary distance L3M3between it and scope 620. This distance is greater than the distance L4M4between the non-bendable portion of the instrument channel 350 and the scope 620. The distance L3M3allows scope 620 and instrument 680 to converge resulting in their triangulation and forming “azimuth” angle ss and “manipulation angle” 56, which are similar. If the scope 620 is bendable in multiple planes and multiple angles, in some uses, it can be deflected outwardly and inwardly by the scope control components.As shown, the instrument guide 650 is bent outwardly at proximal bending region 652b and inwardly at bending region 652a, keeping the distance L3M3. In this manner, opening 650a is spaced from the scope instrument channel opening 620a and is spaced from the scope 620 so that opening 650a is outside the diameter of the scope 620 to provide sufficient space to achieve the foregoing triangulation. This distance L3M3remains fixed as the instruments 680, 682 are moved axially, providing fixed articulation points to achieve the triangulation described herein.In this embodiment as well as in other embodiments disclosed herein featuring two articulation (or bending) sections, the first (proximal) bending section 652b serves primarily to displace the instrument laterally away / create a lateral offset from the axis of the endoscope, creating the spatial separation necessary for triangulation. This bending section 652b as shown in the illustrated embodiment, does not itself initiate convergence toward the target tissue. Instead, it establishes the position and orientation from which the second (distal) bending section 652a begins to redirect the instrument’s trajectory from diverging to converging. Therefore, in this illustrated embodiment, the effective inter-instrument distance relevant to triangulation is defined by the distance between the points at which the second bending sections begin to converge, rather than by the distal ends of the first (proximal) bending sections. In is however also contemplated that in alternative embodiments, applicable to his instrument guide as well as instrument guides of other embodiments disclosed herein, the proximal bending section terminates at a point where convergence begins so the distal bending section converges without the initial divergence.In the embodiment of Figure 20, in addition to the instrument guide 850 within instrument receiving channel 826, a second instrument guide 850’ is provided which is the same as instrument channel 650 except located on the opposing side of the scope 820 in a similar manner as instrument guides 550 and 550’ of Figure 18. In this two-channel embodiment, the second instrument guide 850 can be used instead of or in addition to the working channel of the scope 820 for advancement of the second endoscopic instrument. The system 800 of Figure 20 can be viewed as similar to the system 600 of Figure 19 except for the addition of a second instrument channel 826’ and second instrument guide 850’inserted into the second instrument channel 826’. System 800 can also be viewed as similar to system 500 of Figure 18 except it does not include a bendable sleeve to bend the scope, but like system 600, relies solely on the deflection mechanisms which are part of the scope itself.Figures 21a-21f illustrate use of the system 800 of Figure 20. With reference to Figure 21a, the instrument receiving channels 826 and 826’ are attached / placed over / mounted on to the scope 820 (which can be the same as scope 620) via one or more optional hubs 824a which can be similar to hub 624a of Figure 19. Next, with the assistance of a mandrel 830, a first instrument guide 850 is inserted into first instrument channel 826 (Figure 21b). Instrument guide 850 includes a proximal bending section 852b and distal bending section 852a separated by tube or hub 852cand terminating in tube or hub 852d. Other ways to separate the bending sections without the hub as described above are also envisioned. After insertion of the instrument guide 850, the mandrel 830 is removed (Figure 21c) leaving the instrument guide 850 within the instrument channel 826. Next, a knob or other actuator at a proximal portion of the instrument guide 850 is actuated to bend proximal bending portion 852b outwardly (diverging) to establish inter-instrument distance and static articulation points, preferably before the same or another actuator is actuated to bend the distal bending portion 852a inwardly as shown in Figure 21d (forming an S like shape). Proximal tube 852e remains within instrument channel 826 to provide stability during tissue manipulation and does not bend with the instrument guide bending regions 852b, 852a. Note the bending sections 852b, 852a can be independently controlled so each section is bent independently, or alternatively, a single control can control bending of both sections 852b, 852a.Next, with the instrument guide 850 bent as shown, a flexible endoscopic instrument 880, such as a grasper, is inserted through the instrument guide 850, following the bending angles of the instrument guide 850, and extending out the distal opening and beyond the distal end 852f of the instrument guide 850 as shown in Figure 21e. As described above, the instrument 880 can be moved distally and proximally relative to the distal end 852f of instrument guide 850 and can be rotated within the instrument guide 850 but the articulation point established by bending region 852b remains fixed (stationary) to maintain the manipulation angle and maintain ergonomic endoscopic instrument handle positioning as described herein.Next, a second instrument guide 850’ is inserted through second instrument channel 826’, bending outwardly and inwardly at bending sections 852b’ and 852a (forming an S like shape) via proximal control(s) like instrument guide 850, and a flexible endoscopic instrument 882, such as a dissector, is inserted therethrough, extending beyond the distal end 852f in the same manner as the instrument 880 extends through instrument guide 850. Note proximal portion 852e’ (like portion 852e) is positioned adjacent hub 824a and does not bend with the bendable sections 852a’, 852b’ of instrument guide 850’. Line QR shows the inter-instrument distance. Note the above sequence of steps can be altered, e.g., second instrument guide 850’can be inserted before first instrument guide 850, the second instrument 882 can be inserted before the first instrument 880, the first and second guides 850, 850’ can be inserted into the instrument channel 826 followed by insertion of the instruments 880, 882, etc.The system 900 of Figure 22 is identical to system 800 except a bendable sleeve 840, having bendable region 842 between distal portion 844 and proximal portion 846is provided for bending the scope 820. The bendable sleeve 840 can be the same as bendable sleeve 512 of Figure 18. Since otherwise the system 900 is the same as system 800, for brevity, further discussion will not be provided since the discussion of the system of 800 is fully applicable to that of system 900 except for the addition of the bendable sleeve 840. Triangulation can be achieved in a similar manner as in the system 500 of Figure 18.Figure 23 illustrates an alternate embodiment of the instrument guide. The instrument guide 870 has three bendable sections rather than two bendable sections. More specifically, instrument guide 870 has a distal bending section 872b, a proximal bending section 872a, and an intermediate bending section 872c between the bending sections 872a, 872b. As shown, proximal bending section 872a bends outwardly, intermediate bending section 872b bends outwardly then curves to bend slightly inwardly and distal bending section 872b bends inwardly toward a longitudinal axis of scope 820. Portion 874a is positioned between proximal bending section 872a and intermediate bending section 872c; portion 874b is positioned between intermediate bending section 872c and distal bending section 872b. Instrument guide 870 is inserted though instrument channel 826. In all other respects, the system of Figure 23 is the same as the system of Figure 21 d therefore for brevity, further discussion of the other components, fixed points, triangulation, etc. of the system is not provided.Thus, in this embodiment the first (proximal) bending section 872a serves to laterally displace the instrument laterally away from the scope axis, the second (intermediate) bending section 872b then redirects the instrument’s trajectory from diverging to converging, forming an S-shaped path. Together, these two bending sections 872a, 872b establish the spatial geometry for triangulation and are configured to remain passive or fixed or static during operation. Once positioned, they are locked to maintain a stable geometry. The distal end of the intermediate bending section 872b, which defines the transition from divergence to convergence, effectively serves as a virtual insertion point, functionally analogous to the cannula entry site in laparoscopy. The third (distal) bending section 872b is independently bendable and remains actively controllable during the procedure, enabling dynamic tissue manipulation from that fixed articulation point.Figure 24 illustrates an alternate embodiment of the instrument guide. The instrument guide 880 has two bendable sections - a distal bending section 882b and a proximal bending section 882a separated by portion 884a. As shown, proximal bending section 882a bends outwardly and distal bending section 882b bends inwardly toward a longitudinal axis of scope 820. The bending sections 882a, 882b are designed as vertebra and laser cut tube. Instrument guide 880 is inserted though instrument channel 826. In all other respects, the system of Figure 24 is the same as the system of Figure 21d therefore for brevity, further discussion of the system is not provided.With the system 800 of Figure 20 (and other systems described above), inboard / inward articulation / bending can be controlled without affecting articulation / bending of the outboard / outward section. Distal articulation / bending is fixed with respect the proximal section. The proximal section is bent outwardly to create a distance between the instruments.It should be appreciated that although some of the systems, e.g., the systems of Figures 19 and 20, do not include a sleeve for the scope 620, it is also contemplated that the systems can include a non-bendable sleeve or a bendable sleeve such as sleeve 512 of Figure 18.Fig. 27 shows an alternate embodiment of a system 1000. System 1000 has an instrument guide 1050 mountable to or positionable alongside an endoscope 1020 and configured to receive an instrument 1080 therethrough. It has an optional connector 1024 for locating instrument guide 1050 near endoscope 1020. Instrument guide 1050 has a bendable proximal section 1052a, a bendable / articulating distal section 1052b, and a mid-section (intermediate section) 1052c. Bendable proximal section 1052a is preferably made, for example, out of a flexible plastic tubing. In some embodiments, the plastic tubing is extruded and optionally reinforced by a coil or braided structure. Instrument guide 1050 includes a link 1054a configured to laterally displace mid-section 1052c relative to the longitudinal axis of the instrument guide 1050 and the longitudinal axis of endoscope 1020. This displacement serves to reposition the articulating distal section 1052b away from the scope axis to establish a lateral offset. Link 1054a is activated / rotated relative to a pivot point 1056 by tensioning a cable / wire / link 1018 that is attached to link 1054 at a connection point 1058. In some embodiments, a second link 1054b can be provided which rotates passively when link 1054a is activated. Once deployed, link 1054a maintains the displaced position in a fixed configuration, thereby defining a stable articulation point from which the second section 1052a can articulate and converge toward the target tissue. This arrangement enables triangulationbetween instrument 1080 and instrument 1082, which is introduced via a working channel of scope 1020, while using a non-bending structural mechanism to achieve the necessary spatial separation of the systems elements obtained by bending / articulating the bendable sections of the instrument guide 1050.A perspective view of a system control module (or “user interface module”) 1100 is shown in Figs. 29 - 34. System control module has a main plate 1110 that is preferably mounted to the operating table and remains stationary during the procedure. Main plate 1110 has an instrument guide bracket 1112 for holding at least one of each, but preferably two instrument guides 1150 and 1150’ and instrument controls 1140 and 1140’. An instrument channel bracket 1114 is engaged with a proximal end of an instrument channel 1126. Instrument channel bracket 1114 is movable relative to instrument guide bracket 1112 using a knob 1116 using a rack and pinion mechanism 1120. When instrument channel bracket 1114 is moved closer to instrument guide bracket 1112, instrument guide 1150 moves a corresponding distance out of the instrument channel 1126.Control module 1100 controls a system 1170 shown in Fig. 28. System 1170 preferably has two instrument channels 1126 and 1126’ and two instrument guides 1150 and 1150’. Instrument guides 1150 and 1150’ are controlled by control assemblies 1140 and 1140’, respectively. The instrument guides 1150 and 1150’ are similar to instrument guide 870 shown in Fig. 23 and described above, however, use of other instrument guides disclosed herein, for example at least one or combination of instrument guides 350, 550, and 850, is also contemplated. When only one instrument guide 1150 is utilized, the system 1170 can also have a scope bending sleeve, for example sleeve 112 or 212.Referring to Figs. 28 and 29, instrument guide 1150 has a proximal bending section 1152a, a distal bending / articulation section 1152b, and optional intermediate bending section 1152c. Instrument guide 1150 has a lumen 1156 that connects the distal bending sections to control assembly 1140. A transition section 1154a is located between lumen 1156 and proximal bending section 1152a. A transition section 1154b is located between proximal bending section 1152a and intermediate bending section 1152c. A transition section 1154c is located between distal bending section 1152b and intermediate bending section 1152c. One or more of the transition sections can be hubs as described above or other connectors or other regions uncut or not cut in the same manner as the bending sections. In a preferred embodiment, proximal bending section 1152a andintermediate bending section 1152c are each individually controlled by one tension cable. Use of two or more cables for control / bending / deflection / articulation of bending sections 1152a and 1175c is also contemplated.Proximal bending section 1152a is controlled by a cable 1118a enclosed within a coil / casing / jacket 1128a. The distal end of cable 1118a is attached to distal portion of proximal bending section 1152a, while the distal end of casing 1128a is attached to transition section 1154a. Theproximal end of cable 1118a is attached to concentric lever 1136, such that pushing on / rotating lever 1136 tensions cable 1118a deforming proximal bending section 1152a and forcing it to bend outwardly.Intermediate bending section 1152c is controlled by a cable 1118b enclosed within a casing 1128b. The distal end of cable 1118b is attached to distal portion of intermediate bending sections 1152c, while the distal end of casing 1128a is attached to transition section 1154b. The proximal end of cable 1118b is attached to concentric lever 1138, such that pushing on / rotating lever 1138 tensions cable 1118b deforming proximal bending sections 1152c and forcing it to bend inwardly. When an instrument guide without an intermediate bending section, for example instrument guide 850, is used as a part of system 1100, then cable 1118b, casing 1128b, and concentric lever 1138 are absent or disabled.In a preferred embodiment, distal bending section 1152b articulates in multiple directions located within multiple planes and is, preferably, controlled by four cables 1118c, 1118d, 1118e, and 1118f (collectively cables 1118). The distal end of cables 1118c, 1118d, 1118e, and 1118f are attached to the distal portion of distal bending section 1152b or, to an optional hub 1154d at 3, 6, 9, and 12-o’clock positions. The distal ends of casings 1128c, 1128d, 1128e, and 1128f are attached / placed against transition section 1154c. On the proximal end, cables 1118c, 1118d, 1118e, and 1118f are attached to a ball joint 1144.The proximal ends of casings 1128a, 1128b, 1128c, 1128d, 1128e, and 1128f are attached / placed within a shaft 1124 of a ball joint socket 1142.An endoscopic instrument 1180, for example, a grasper, has a handle 1132 with a movable trigger 1164 and a rotational knob 1134. Movement of the trigger 1164 activates / opens / closes the jaws of the grasper, while rotation of knob 1134 rotates the jaws relative to hub 1154d. Aninstrument hub 1148 is connected to a shaft 1 146 of ball joint 1144 and engaged with a front portion 1132a of handle 1132.Linear movement of front portion 1132a of handle 1132 in and out of instrument hub 1148 moves distal portion of instruments 1180 linearly in and out relative to hub 1154d.Movement of handle 1132 activates ball joint 1144 relative to ball joint socket 1142 results in tensioning appropriate cables articulating distal bending section 1152b.In any of the embodiments of this application, fiber optics shape sensor could be embedded / inserted / integrated in channels, guide, instruments, and other components to assist users in visualizing the position / relative position and the shape of various system elements. Such sensors are described in paragraphs

[0326] -

[0353] and Figs. 67-78 of patent application US2023 / 0389784A1, the entire contents of which are incorporated herein by reference. Fig. 25 shows the distal section of system 700 that is similar to system 300 and includes assembly 710 (similar to assembly 210), scope 720, and instrument guide 750 (similar to instrument guide 350). Instrument 780 is introduced via instrument guide 750 and instrument 782 is inserted via a working channel of scope 720. Sensors are embedded into distal sections of instruments 780 and 782, although in some embodiments the sensors are inserted / placed through / via / over the entire length of the system. Data collected from the sensors are displayed on a monitor 790, such that a user / physician / surgeon / gastroenterologist could assess the shape and relative position of these instruments. Alternatively, sensors could be embedded or inserted into the distal section of instrument channel 750 and / or the scope 720 or its working channel, or similar placement that would share the sensors similar to the shape of the sections of the system / channels / instruments for which demonstrating their shape could be beneficial for users.Although the systems, devices, apparatus and methods of the subject invention have been described with respect to preferred embodiments, those skilled in the art will readily appreciate that changes and modifications may be made thereto without departing from the spirit and scope of the present invention as defined by the appended claims.It will be understood that the above particular embodiments are shown and described by way of illustration only. The principles and the features of the present disclosure may be employed in various and numerous embodiments thereof without departing from the scope and spirit of the disclosure as claimed. The above-described embodiments illustrate the scope of the disclosure butdo not restrict the scope of the disclosure and it should be understood by those skilled in the art that various changes may be made (and equivalents may be substituted) without departing from the true spirit and scope of the present invention. In addition, many modifications may be made to adopt a particular situation, material, composition of matter, process, process step or steps, to the objective spirit and scope of the present disclosure. All such modifications are intended to be within the scope of the claims appended hereto. Persons skilled in the art will understand that the elements and features shown or described in connection with one embodiment may be combined with those of another embodiment without departing from the scope of the present invention and will appreciate further features and advantages of the presently disclosed subject matter based on the description provided.Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limit of that range and any other stated or intervening value in that stated range is encompassed by the present disclosure. The upper and lower limits of these smaller ranges which may independently be included in the smaller ranges is also encompassed by the present disclosure, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either both of those included limits are also included in the present disclosure.It must be noted that as used herein and in the appended claims, the singular forms “a”, “and”, and “the” include plural references unless the context clearly dictates otherwise.Throughout the present disclosure, terms such as “approximately,” “generally,” “substantially,” and the like should be understood to allow for variations in any numerical range or concept with which they are associated. For example, it is intended that the use of terms such as “approximately”, “generally” and “substantially” should be understood to encompass variations on the order of 25% (e.g., to allow for manufacturing tolerances and / or deviations in design).Although terms such as “first,” “second,” “third,” etc., may be used herein to describe various operations, elements, components, regions, and / or sections, these operations, elements, components, regions, and / or sections should not be limited by the use of these terms in that these terms are used to distinguish one operation, element, component, region, or section from another. Thus, unless expressly stated otherwise, a first operation, element, component, region, or sectioncould be termed a second operation, element, component, region, or section without departing from the scope of the present invention.Each and every claim is incorporated as further disclosure into the specification and represents embodiments of the present disclosure. Also, the phrases “at least one of A, B, and C” and “A and / or B and / or C” should each be interpreted to include only A, only B, only C, or any combination of A, B, and C.Various combinations of all devices and methods described above may be utilized in the same procedure, sequentially and / or simultaneously.

Claims

WHAT IS CLAIMED IS;1. A system for endoscopic surgery comprising an instrument guide having a lumen configured to receive an endoscopic instrument, the instrument guide configured to be mountable to or positionable alongside an endoscope and having a first bending section and a second bending section distal of the first bending section, the second bending section bendable relative to the first bending section, wherein the first bending section is bendable to diverge from a longitudinal axis of the instrument guide to create a lateral offset and define a fixed position.

2. The system of claim 1, wherein the first bending section defines a fixed position for a proximal end of the second bending section, the second bending section bendable to converge toward the longitudinal axis of the instrument guide.

3. The system of claim 1, wherein the second bending section is bendable to form a diverging section proximal of a converging section.

4. The system of claim 1, further comprising a first instrument receiving channel configured for connection to an endoscope, the first instrument receiving channel having a first lumen dimensioned to receive the instrument guide.

5. The system of claim 4, further comprising a second instrument channel having a lumen to receive a second instrument guide, the second instrument guide having a first bending section and a second bending section, the second bending section positioned distal of the first bending section and bendable independent of the first section.

6. The system of claim 1, wherein the instrument receiving channel has a distal opening, and the distal opening is outside a diameter of the endoscope to which it is connected.

7. The system of claim 1, wherein the first bending section of the instrument guide provides a first fixed articulation point and a second bending section of a second instrument guide provides a second fixed articulation point, the first and second articulation points defining a working distance for a first instrument inserted through the first instrument guide and a second instrument inserted through the second instrument guide, wherein axial movement of the first and second instruments does not alter the first and second articulation points.

8. The system of claim 1, further comprising a sleeve having a longitudinal axis and an endoscope receiving lumen dimensioned to receive an endoscope therein, the sleeve having a distal portion bendable with respect to the longitudinal axis of the sleeve to bend the endoscope.

9. The system of claim 5, wherein the first and second instrument guides in a bent position create a fixed distance therebetween for instruments inserted therethrough.

10. The system of claim 4, wherein the first instrument receiving channel is proximal of the bending region of the endoscope such that bending of the endoscope does not bend the instrument receiving channel.

11. The system of claim 8, wherein a distal end of the sleeve is proximal of an articulation region of the endoscope, such that bending of endoscope via an endoscope articulation mechanism does not bend the sleeve.

12. The system of claim 5, wherein the first and second instrument guides are bendable independent of articulation of the endoscope.

13. The system of claim 1, wherein bending of the first instrument guide does not affect movement of the endoscope.

14. The system of claim 7, wherein the fixed articulation points create an instrument manipulation angle within a preset range.

15. The system of claim 8, wherein the first instrument guide is bendable independent of the sleeve.

16. The system of claim 4, wherein the first instrument receiving channel includes at least one connector configured to attach to a bendable sleeve, the bendable sleeve configured for positioning over the endoscope.

17. The system of claim 8, wherein a first instrument receiving channel which receives the instrument guide is proximal of the bending region of the sleeve.

18. The system of claim 4, wherein the first instrument receiving channel has at least one connector with an opening dimensioned to frictionally secure an outer surface of the endoscope.

19. The system of claim 14, wherein the instrument manipulation angle is between about 45 degrees and about 75 degrees.

20. The system of claim 1, further comprising a mounting plate mountable to an operating table and a guide bracket holding the instrument guide.

21. The system of claim 20, further comprising a plurality of cables for bending the instrument guide.

22. The system of claim 1, wherein the instrument guide has a third bending section bendable independently of the first and second bending sections.

23. The system of claim 1, wherein the first bending section is lockable in a selected position.

24. The system of claim 1, further comprising a least one cable connected at a first end to the instrument guide and at a second end to an actuator, the actuator actuable to tension the at least one cable to effect bending of the instrument guide.

25. A system for endoscopic surgery comprising: a) an instrument receiving channel configured for connection to an endoscope, the instrument receiving channel having a first lumen dimensioned to receive a first instrument guide therethrough and a second lumen dimensioned to receive a second instrument guide therethrough; b) a first instrument guide having a first proximal bending section and a second distal bending section, the second bending section positioned distal of the first bending section; and c) a second instrument guide having a first bending section and a second bending section, the second bending section positioned distal of the first bending section; d) wherein the first bending section of the first instrument guide is bendable outwardly and the second bending section of the first instrument guide is bendable inwardly and the first bending section of the second instrument guide is bendable outwardly and the second bending section of the second instrument guide is bendable inwardly such that triangulation is effected.

26. The system of claim 25, wherein the first instrument receiving channel has a distal opening, and the distal opening is outside a diameter of the endoscope to which it is connected.

27. The system of claim 25, wherein the proximal bending section of the first instrument guide provides a first fixed articulation point and the distal bending region of the second instrument guide provides a second fixed articulation point, and one of the distal bending section or proximal bending section of the first and second instrument guides defines a working distance for a first instrument inserted through the first instrument guide and asecond instrument inserted through the second instrument guide, wherein axial movement of the first and second instruments does not alter the first and second articulation points.

28. The system of claim 25, further comprising a sleeve having a longitudinal axis and an endoscope receiving lumen dimensioned to receive an endoscope therein, the sleeve having a distal portion bendable with respect to the longitudinal axis to bend the endoscope.

29. A system for endoscopic surgery comprising a sleeve having a longitudinal axis and a endoscope receiving lumen dimensioned to receive an endoscope therein, the sleeve having a distal portion having a distal transition section, a proximal transition section, and a bending region between the proximal and distal transition section, wherein the bending region is bendable with respect to the longitudinal axis and bends the endoscope in a first direction when the bending region of the sleeve is bent in the first direction.

30. The system of claim 29, wherein the bending region comprises a laser cut tube.

31. The system of claim 29, wherein the sleeve is bendable in a single direction.

32. The system of claim 29, wherein the sleeve is bendable in multiple directions.

33. The system of claim 29, further comprising at least one cable attached to the sleeve and an actuator to tension at least one cable to bend the bending region.

34. The system of claim 29, wherein the sleeve bends distal of the proximal transition section such that the distal transition section bends with respect to the proximal transition section when the distal bending region is bent.

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