Multi-portal robotic system and multi-portal instrument holders

Abstract

A multi-portal robot system has instrument holders into which and from which a user can manually insert and remove cannulas and working instruments. The robotic system has instrument triangulation software that positions working instruments based on endoscopic viewing. The robotic system repositions endoscopic camaras based on user input and reconciles surgical plans with instrument positioning. The multi-portal robot system has navigation programs for endoscopic fusion procedures, decompression procedures, and other spinal procedures.

Description

MULTI-PORTAL ROBOTIC SYSTEM AND MULTI-PORTAL INSTRUMENT HOLDERSCROSS-REFERENCE TO RELATED APPLICATION

[0001] The present application claims the benefit of U.S. Provisional Patent Application No.: 63 / 679,989, filed August 6, 2024, the disclosure of which is incorporated herein by reference in its entirety.TECHNICAL FIELD

[0002] The present disclosure relates generally to automated and robotic surgical procedures and specifically to robotic systems and instrument holders for performing multi-portal surgical procedures.BACKGROUND

[0003] Individuals often suffer from damaged or displaced spinal discs and / or vertebral bodies due to trauma, disease, degenerative defects, or wear over an extended period of time. One result of this displacement or damage to a spinal disc or vertebral body may be chronic back pain. A common procedure for treating damage or disease of the spinal disc or vertebral body may involve partial or complete removal of an intervertebral disc. An intervertebral implant (commonly referred to as an interbody spacer or cage) can be inserted into the cavity created where the intervertebral disc was removed to help maintain height of the spine and / or restore stability to the spine. An interbody spacer may also provide a lordotic correction to the curvature of the spine. An example of an interbody spacer that has been commonly used is a fixed dimension cage, which typically is filled with bone and / or bone growth-inducing materials. Unfortunately, it may be difficult to implant the interbody spacer at the intended implantation site between vertebral bodies. Additionally, conventional surgical techniques can cause a significant amount of trauma at or near the implantation site (e.g., injury to nerve tissue), which can significantly increase recovery time and / or lead to patient discomfort.

[0004] Spinal nerve compression can be caused by narrowing of the spinal canal associated with arthritis (e.g., osteoarthritis) of the spine, degeneration of spinal discs,125752.8020.WO00\182882826.1and thickening of ligaments. Arthritis of the spine often leads to the formation of bone spurs, which can narrow the spinal canal and press on the spinal cord. In spinal disc degeneration, inner tissue of the disc can protrude through a weakened fibrous outer covering of the disc and can press on the spinal cord and / or spinal nerve roots. Ligaments located along the spine can thicken over time and press on the spinal cord and / or nerve roots. Unfortunately, spinal nerve compression can cause lower back pain, hip pain, and / or leg pain and may also result in numbness, depending on the location of the compressed nerve tissue. For example, spinal stenosis that causes spinal cord compression in the lower back can cause numbness of the legs. It is difficult to visualize internal tissue when removing tissue, often resulting in injury or removal of nerve tissue. Accordingly, there is a need for improved surgical systems, visualization techniques, and / or related technologies.BRIEF DESCRIPTION OF THE DRAWINGS

[0005] Figure 1 illustrates a multi-portal robotic system, in accordance with one or more embodiments.

[0006] Figure 2 illustrates a detailed view of a multi-portal end effector of the multiportal robotic system of Figure 1 at a working site.

[0007] Figure 3 illustrates a console of the multi-portal robotic system of Figure 1 .

[0008] Figure 4 illustrates a user interface of a multi-portal robotic system, in accordance with one or more embodiments of the technology.

[0009] Figure 5 illustrates subcomponents of the multi-portal robotic system of Figure 1.

[0010] Figure 6 illustrates an end effector of a multi-portal robotic system with twist lock instrument holders, in accordance with one or more embodiments of the technology.

[0011] Figure 7 illustrates the end effector of Figure 6 holding instruments.

[0012] Figure 8 illustrates an end effector of a multi-portal robotic system with clamp instrument holders, in accordance with one or more embodiments.

[0013] Figure 9 illustrates the end effector of Figure 8 holding instruments.- 2 -125752.8020.WO00\182882826.1

[0014] Figure 10 illustrates a multi-portal robotic system surgical kit, in accordance with one or more embodiments of the technology.

[0015] Figure 11 illustrates a surgical robot with multiple moveable robotic arms, in accordance with one or more embodiments of the technology.

[0016] Figure 12 illustrates a surgical robot with a multi-modality visualization system, in accordance with one or more embodiments.

[0017] Figure 13 is a flow diagram illustrating an example process for using a multiportal robotic system, in accordance with one or more embodiments.

[0018] Figure 14 is a flow diagram illustrating an example process for using a multiportal robotic system, in accordance with one or more embodiments.DETAILED DESCRIPTION

[0019] The following disclosure describes various embodiments of medical systems, devices, and associated methods of use. At least some embodiments of a multi-portal robotic system provide intraoperative visualization capability. The system can include multi-portal instrument holders configured to attach to one or more robotic arms to hold multiple instruments, including cannulas, working instruments (e.g., surgical instruments), visualization instruments, cameras, combinations thereof, or the like. For example, the multi-portal instrument holders can be coupled to a robotic arm such that the robotic arm can hold one or more working instruments used to alter tissue (e.g., shape, crush, separate, cut, debulk, break, fracture, or remove tissue), create working spaces, create delivery paths, prepare an implantation site, implant a device, combinations thereof, or the like. A visualization device can be positioned in one of the instrument holders to provide viewing of a working space inside the patient. In some embodiments, the multiportal instrument holders hold cannulas while a series of instruments are delivered through the cannulas.

[0020] The multi-portal instrument holders can be unlocked to adjust one or more triangulation parameters that affect a working envelope between the instruments, for example, the distance between the instruments, orientation between the instruments, depth of the instruments, etc. The multi-portal instrument holders can be locked to hold- 3 -125752.8020.WO00\182882826.1the instruments at, for example, a position with respect to each other, a position relative to the patient, a position relative to a target area, etc. The multi-portal instrument holders can be selected based on the number of ports / incisions, instrument configurations (e.g., configuration of surgical instruments, visualization instruments, etc.), number of robotic arms to be used, surgical techniques to be used, nerve tissue near the target area, or the like.

[0021] Instrument and / or tissue visualization can be used for intraoperative planning to help a physician identify target tissue, identify non-target tissue, remove tissue, and / or prevent or limit injury or damage to non-targeted organs and tissues. In endoscopic- assisted robotic surgeries, instruments and implantable devices can be precisely positioned using multi-portal robotic techniques to improve outcomes and reduce recovery times. Certain details are set forth in the following description and in the figures to provide a thorough understanding of such embodiments of the disclosure. Other details describing well-known structures and systems often associated with, for example, surgical procedures are not set forth in the following description to avoid unnecessarily obscuring the description of various embodiments of the disclosure.A. OVERVIEW

[0022] Methods, apparatuses, and systems for planning and performing robotic surgery using multi-portal techniques are disclosed herein. At least some embodiments are directed to multi-portal robotic systems configured to treat patients with, for example, nerve compression, damaged or displaced spinal features (e.g., spinal discs and / or vertebral bodies), or other conditions. For example, the multi-portal robotic systems can be used to reduce or eliminate nerve compression, implant a fixed or expandable interbody device (e.g., devices to space apart vertebral bodies, restore stability of the spine, provide lordotic correction, etc.), perform discectomies, perform microdiscectomies, perform laminotomies, combinations thereof, or other robotic surgical procedures. Multi-portal instrument holders can be robotic end effectors configured to hold, for example, multiple surgical instruments, multiple cannulas, cannulas and surgical instruments, or the like. In some embodiments, the surgical instruments include working instruments and / or visualization instruments. Working instruments can be used to alter- 4 -125752.8020. WOOO\182882826.1tissue in the patient. Working instruments can be selected based on the location of the working space. The sizes of the cannulas and / or instruments can be selected based on the location (e.g., depth) of the tissue, anatomical structures surrounding access paths and / or targeted tissue, and / or configuration of instruments. In some embodiments, visualization instruments are used to view working spaces, tissue contributing to nerve compression, and / or the working instruments. The multi-portal robotic system can use visualization from the visualization instruments to adjust position of the working instrument(s) and / or to reconcile surgical plans. In some embodiments, the visualization instrument is positioned within a first port along the patient and working instruments can be sequentially delivered through a second port along the patient. The distance between the first and second ports can be included in a multi-portal visualization plan (e.g., a preoperative multi-portal visualization plan, an intraoperative multi-portal visualization plan, etc.) for the procedure.

[0023] In some embodiments, one or more images of a patient are obtained, and a preoperative model of the surgical site is generated. The multi-portal robotic system can identify a target area(s) and non-target areas (e.g., nerve tissue) in the preoperative model using historical data (e.g., data from previous procedures, previous patient data, physician preferences, etc.). The multi-portal robotic system can also access one or more databases (e.g., triangulation databases, procedural databases, patient databases, etc.) to identify targeted tissue, non-targeted tissue, working envelopes, surgical procedure parameters, and / or target patient outcomes. Additionally or alternatively, a physician can input visualization criteria and / or manually identify and / or adjust targeted tissue, nontargeted tissue, working envelopes, surgical procedure parameters, and / or target patient outcomes using a user interface. The visualization criteria can include, without limitation, targeted tissue to be viewed before, during, and / or after a surgical step, a threshold quality of obtained image data (e.g., images, video), scoring routines, viewing angles of endoscopic viewing instruments, type of viewing instrument, irrigation settings, etc. In some procedures, the user can input targeted visualization tissue (e.g., nerve tissue, nerve roots, spinal cord, etc.) and / or anatomical elements (e.g., vasculature, organs, etc.) to be continuously visualized during one or more surgical steps. In some procedures, the- 5 -125752.8020.WO00\182882826.1user can input one or more targeted features to be viewed (before, during, and / or after) for associated surgical steps.

[0024] The multi-portal robotic system can be configured to operate using one or more navigation programs associated with various multi-portal surgical procedures and techniques such as endoscopic fusion procedures, decompression procedures, different surgical approaches, or the like. In some decompression procedures, the navigation program can include surgical steps for minimizing or reducing pressure applied to nerve tissue and / or surgical steps for removing tissue contributing to stenosis, tissue pushing against nerve tissue, bulging sections of intervertebral cartilage disc, or the like. For example, tissue can be removed to enlarge an epidural space to reduce spinal cord compression. In some respects, the navigation program can include surgical steps to perform a multi-portal spinal surgical procedure using first and second cannulas (e.g., split cannulas). The multi-portal spinal surgical procedure can be a decompression procedure, an oblique lumbar interbody fusion (OLIF) procedure, a lateral lumbar interbody fusion (LLIF) procedure, a posterior lumbar interbody fusion (PLIF) procedure, a transforaminal lumbar interbody fusion (TLIF) procedure, an anterior lumbar interbody fusion (ALIF) procedure, or combinations thereof. The user can select, via the user interface, the navigation program(s) for the surgical procedure. Each navigation program can be associated with, for example, a different set of end effectors, multi-portal instrument holders, instruments, triangulation parameters, or other parameters used for planning procedural visualization and / or obtaining plans (e.g., surgical plan, visualization plan, etc.) specific to the type of procedure being performed, etc. The plans can be, for example, generated by a robotic system, received from an external source (e.g., a remote server, a third-party database, user, etc.), or the like. For example, a surgical plan can be generated by the robotic system and a visualization plan can be obtained from a navigation system. The visualization plan can be a multi-portal endoscopic visualization plan for positioning one or more endoscopes for viewing instruments positioned through spaced apart port. The multi-portal endoscopic visualization plan can position the endoscope based on, for example, user input, the position of an instrument, orientation of instrument, surgical step (e.g., currently performed surgical step, tissue (e.g., targeted tissue, non-targeted tissue, critical tissue or anatomy), etc. For example, the multi-portal- 6 -125752.8020.WO00\182882826.1endoscopic visualization plan can be executed to position the endoscope to view a distal end of an instrument while concurrently viewing non-targeted tissue. The distal end can be positioned based on the data obtained by the endoscope. The image data can be annotated to identify the nerve tissue, targeted tissue to be manipulated, etc. In some embodiments, the multi-portal robotic system generates executable instructions or programs based on the multi-portal endoscopic visualization plan to move and position surgical robotic arms, operate imaging devices, control navigation systems, capabilities of the surgical robot, etc. A pre-operative validation simulation can be performed with a virtual surgical robot to score performance of the surgical procedure. If a score meets or exceeds a threshold score, the executable instructions or programs can be approved. If the score is below the threshold score, the executable instructions or programs and / or the plan can be modified. The positions of ports and surgical steps can be modified (e.g., by the user, a ML module, etc.) iteratively. This process can be repeated until an acceptable score is achieved.

[0025] The multi-portal robotic system can use the labeled preoperative model to perform one or more virtual simulations. The virtual simulations can be used to identify and plan visualization of the target area throughout the surgical procedure. For example, the virtual simulations can simulate one or more steps of the surgical plan to identify what the physician will see at each step. The physician and / or the system can adjust one or more triangulation parameters, instruments, instrument holders, end effectors, irrigation flow rates, or the like based on the virtual simulations. The virtual simulations can be saved and referenced throughout the surgical procedure to monitor adherence to the surgical plan and / or to modify one or more triangulation parameters, instruments, instrument holders, end effectors, or irrigation flow rates, to maintain visualization and / or to reach a threshold outcome score.

[0026] The multi-portal robotic system can include replaceable robotic arms and / or end effectors. The robotic arm / end effectors can be configured to hold one or more endoscopes, working instruments, or the like. Components of the robotic system can be replaced to accommodate different types of tools, instruments, surgical techniques, etc. In some embodiments, an end effector can be installed to releasably hold one or more endoscopes so that the one or more endoscopes can be removed or repositioned by a- 7 -125752.8020.WO00\182882826.1user during a surgical procedure. The robotic arm / end effector can be used to locate and manage some or all of the instruments used in a working portal. In some procedures, all of the instruments used in a surgical procedure are held by a single robotic arm / end effector. In other embodiments, different robotic arms / end effectors are used to hold different instruments at different stages of the surgical procedure. The robotic arm / end effectors can be moved any number of times to reposition instruments relative to the working portal, surgical site, target zone, etc. In some procedures, a navigation system performs a registration process for positioning robotic arm(s) / end effector(s).

[0027] In some embodiments, surgical actions performed by a user on the preoperative model can be identified and saved as surgical actions in the surgical plan. Each surgical action can be associated with at least one working instrument. In some embodiments, each surgical action is associated with at least one working instrument and at least one visualization instrument. Additionally or alternatively, the surgical plan can include surgical steps from historical procedures similar to the procedure to be performed. The surgical robot can be configured to perform the surgical steps on the patient based on the surgical plan. The surgical plan (e.g., a pre-operatively generated surgical plan) can be adjusted or modified intraoperatively based on visualization from a visualization instrument. For example, the position of a working instrument can be modified based on endoscopic viewing to maintain a threshold outcome score. In some embodiments, the surgical plan is designed for the positions of the ports and patient’s anatomy. The user can modify (e.g., preoperatively modify) the position of the ports, and robotic system can modify the surgical plan based on the user modification. For example, a triangulation calculation can be performed based on the surgical steps to be performed and the anatomy of the patient to determine positions of ports, number of ports, instrument delivery paths, safe working space in the patient, etc. In some embodiments, creating the surgical plan can include generating triangulation parameters based on a spinal reference frame (e.g., the midsagittal plane, the coronal plane, the axial plane, vertebral body landmarks, pedicle axes, etc.).

[0028] In some embodiments, the surgical robot includes at least one arm and at least one multi-portal instrument holder. The surgical robot can be configured to receive user inputs and / or network data containing surgical actions for performing robotic- 8 -125752.8020.WO00\182882826.1movements, in accordance with the surgical plan. Information regarding the multi-portal surgical procedure (e.g., endoscopic viewing, irrigation flow rates, patient models, etc.) and intraoperative notifications can be displayed on the user interface throughout the procedure. The surgical robot can be used to perform the multi-portal surgical procedure and / or to assist a surgeon with planning or executing the procedure.

[0029] The multi-portal instrument holders can be compatible with a plurality of instruments and can be used to position instruments within a working envelope or region within the patient. The multi-portal instrument holders can be configured to reposition the instruments to keep distal ends of the instruments along a target path or within a target region. For example, the multi-portal instrument holders can be rotatably coupled to an end effector such that the angular orientation of the instruments can be adjusted. Additionally or alternatively, the multi-portal instrument holders can be spaced apart by a track that one or both instruments can slide along to reposition the instruments. In some embodiments, the surgical robot can automatically reposition the multi-portal instrument holders to modify the position of the instruments. If the multi-portal instrument holder is locked, the relative position of the instruments can be maintained. If the multi-portal instrument holder is unlocked, the surgical robot can adjust the relative position between the instruments. This allows for flexibility when repositioning instruments. In some embodiments, instruments can move slightly with respect to one another to increase the range of motion of the instruments. The physician, nurse, or member of the surgical team can also manually adjust cannulas or instruments at any desired time to assist with positioning.

[0030] In some embodiments, multi-portal robotic endoscopy-assisted methods can be used to alter tissue at different locations along the spine. Bony features (e.g., facets and surrounding bone) of vertebrae can be removed to perform, for example, transforaminal procedures. The implantation site can be prepared by using the surgical robot to perform a discectomy, an interbody preparation procedure, or the like.

[0031] In some embodiments, multi-portal robotic endoscopy-assisted methods can include performing at least a portion of a multi-portal robotic surgical procedure using a first portal site. The first portal site can serve as a working portal for working instruments.- 9 -125752.8020.WO00\182882826.1At least a portion of the multi-portal robotic surgical procedure can use an endoscope positioned via a second portal site (e.g., a visualization portal) spaced apart from the first portal site. The spacing can be a triangulation parameter selected based on location and accessibility of the treatment site(s), whether along the spine or at another location. For example, the portals can be spaced apart to allow equipment (e.g., cannulas, endoscopes, working instruments, etc.) to be directed generally toward a working space within the subject while maintaining a predetermined working envelope. The multi-portal robotic system can include triangulation software configured to continuously determine the position of the instruments relative to one another and / or to the target area(s). In some embodiments, the multi-portal robotic system automatically adjusts one or more of the working instruments or the endoscope or the irrigation flow rates if the instruments appear to be outside of the working envelope. Additionally or alternatively, the multi-portal robotic system can alert a user to manually adjust the position of one or more of the working instruments or the endoscope or the irrigation flow rates.

[0032] The multi-portal robotic endoscopy-assisted methods can be used to position instrument(s), locate one or more anatomical features, monitor surgical steps, or the like. In some embodiments, endoscopic visualization can be used to endoscopically view working instruments performing one or more actions. In some embodiments, endoscopic imaging can be used to locate one or more anatomical features, identify anatomical features, assess surgical steps, confirm completion of surgical step(s), and perform other tasks. For example, endoscopic viewing can be used to view bone or tissue being removed, completion of bone or tissue removal, or other actions.

[0033] Endoscopic techniques can be used to view, for example, the spine (e.g., vertebral spacing, vertebral alignment, etc.), tissue (e.g., damaged or displaced sections of intervertebral cartilage disc, tissue contributing to nerve compression, etc.), instruments, and implants before, during, and after implantation, surgical step(s), progress and / or completion of action(s) (e.g., bone / tissue removal, cage implantation, implant position, etc.), or the like. The visualization can help a physician throughout the surgical procedure to improve patient outcomes. In some embodiments, visualization instruments can be delivered through endoscopic cannulas (e.g., tubular closed cannulas, split cannulas, etc.). The cannulas can be held generally stationary or moved during one- 10 -125752.8020.WO00\182882826.1or more steps or the entire surgical procedure. During a surgical procedure, the cannulas can be positioned any number of times based on, for example, imaging, visualization of the surgical site, surgical steps to be performed, etc. In some procedures, the cannulas or instruments can be automatically positioned or repositioned by the surgical robot. Additionally or alternatively, the cannulas or instruments can be manually moved or replaced by the physician.

[0034] In some embodiments, a computer-implemented method for performing a multi-portal robotic surgical procedure includes endoscopic viewing using a visualization instrument positioned in a first port along the patient. A working instrument is positioned in a second port along the patient according to a multi-portal endoscopic visualization plan. A surgical robot can robotically perform at least a portion of the multi-portal robotic surgical procedure on the patient according to a plan based on the endoscopic viewing of the visualization instrument. One or more steps of the surgical plan can be associated with at least one of an instrument holder, the working instrument, or the visualization instrument. The plan can include one or more individual or synchronized surgical plans, visualization plans, navigation plans.

[0035] In some embodiments, a robotic system can store preset or settable instrument locations relative to anatomy (e.g., lamina, facet for the level along the spine, etc.). Additionally or alternatively the surgeon can switch between positions. In some procedures, the robotic system can automatically move the instrument to preset or settable instrument locations during the surgery. The preset or settable instrument locations can include positions for endoscopic viewing instruments, working instruments, or the like. In some embodiments, a user can preoperatively set instrument positions based on preoperative images, simulations, or the like. For example, the preset positions can be programmed based on a desired field of view for endoscopic viewing of instrument(s) and / or anatomy, distal ends of working instrument(s), or the like. In some procedures, a user can select a first program position (“Position 1”) to move an endoscopic instrument that is, for example, positioned within a first port, to a first position. The endoscopic instrument can view a working site in the patient while the robotic system performs one or more surgical actions using a working instrument that is, for example, positioned within a second port. Additionally, a physician can optionally freehand-position- 11 -125752.8020.WO00\182882826.1the endoscopic instrument and / or working instrument. After completion of freehand movement, the robotic system can return the endoscopic viewing instrument and / or working instrument to the programmed Position 1 or another programmed position (“Position 2”). A user can free-hand, select, and / or or plan any number of additional preset positions for sequentially moving instrument(s) to preset positions. A visualization plan can include, without limitation, preset positions (e.g., positions for visualization instruments, cameras, targeted viewing perspective, etc.), correlated preset positions to surgical step(s), planned manual surgical steps, visualization criteria (e.g., criteria for repositioning visualization instruments), and planned movement of instruments to preset positions. The robotic surgery system can move instruments to preset positions based on, for example, the visualization plan, user input (e.g., a physician selecting a preset position), identification of a potential adverse event, or the like. The visualization plan can be generated based on historical data, physician preferences, simulated surgical sites, simulated instrument positions, simulated irrigation, etc.

[0036] Instrument positions can be preoperatively or intraoperatively inputted by a user, determined by an AI / ML module, and / or planned by the robotic system. A physician can study patient images and then input preset position(s) relative to one or more landmarks. The landmarks can be anatomical elements captured in the patient images. In intraoperative programming of positions, a user can intraoperatively set or modify instrument positions based on intraoperative images, including x-rays, endoscopic images, or the like.

[0037] Historical data can be used to determine preset instrument locations matching, for example, historical desired fields of view for the physician. An AI / ML system can compare historical patient data to generate the number of preset locations for a procedure, determine positions of working instruments for surgical actions, and / or generate a plan. The AI / ML module can generate a registration process that can be performed by the robotic system. For example, instruments can be registered with the patient’s anatomy using one or more registration techniques. The AI / ML modules can identify anatomical features, determine positions (including relative positions, preoperative positions, planned postoperative positions, etc.) of anatomical features (e.g.,- 12 -125752.8020.WO00\182882826.1relationships between one or more anatomical features), determine position(s) for working instrument(s), recommended preset positions for surgeons, or the like.

[0038] In spinal procedures, one or more preset positions can correspond to viewing positions for viewing all, or a user selected portion, of the laminar junction, spinous process(es), facet joint area, spinous process laminar junction, or other user-selected fields of view associated with anatomical areas or regions. A user can input a desired angle of view, distance from targeted viewing area(s) or region(s), and / or other viewing parameters. Based on the user’s inputted information, an AI / ML system can determine the relative position between the endoscopic images and one or more landmarks of the patient. A user can adjust the viewing settings intraoperatively for on-the-fly viewing adjustments.

[0039] Embodiments of the present disclosure will be described more fully hereinafter with reference to the accompanying drawings in which like numerals represent like elements throughout the several figures, and in which example embodiments are shown. Embodiments of the claims may, however, be embodied in many different forms and should not be construed as limited to the embodiments set forth herein. The examples set forth herein are non-limiting examples and are merely examples among other possible examples.B. MULTI-PORTAL ROBOTIC SYSTEMS

[0040] Figure 1 illustrates a multi-portal robotic system 100 (“system 100”), in accordance with one or more embodiments. The system 100 can include a user console 120, a surgical robot 140, and a controller 150. The user console 120 can be within an operating room 102 or at a remote location and can communicate (e.g., via a wired connection and / or wirelessly) with the surgical robot 140 and the controller 150 via a network 104 to perform a multi-portal surgical procedure on a patient 155. A user 121 (e.g., a surgeon, physician, member of a surgical team, consultant, etc.) can operate the user console 120. The user console 120 can communicate via the network 104 with the other components of the system 100 and / or with the other components of the operating room 102 not necessarily displayed (e.g., one or more patient sensors, vitals monitoring devices, etc.) to perform and / or monitor progress of the multi-portal surgical procedure.- 13 -125752.8020.WO00\182882826.1The system 100 can manage the flow of traffic over the network 104 to maintain a threshold level of control or operation of instruments 156, 157 (e.g., surgical instruments). The surgical robot 140 can include at least one robotic arm 151 with robotic links and / or motors that are compatible with one or more multi-portal end effectors 152 (“end effectors 152”). As described herein, the end effector 152 can be a multi-portal instrument holder coupled to the surgical robot 140 to perform a plurality of multi-portal surgical procedures. As shown in Figure 1 , the end effector 152 is configured to hold one or more instruments 156, 157. In some embodiments, the instrument 156 is a working instrument (e.g., a tissue altering instrument) and the instrument 157 is a visualization instrument (e.g., an endoscope) used to perform a visualization-assisted multi-portal surgical procedure. Additionally or alternatively, the end effector 152 can hold one or more cannulas (e.g., tubular closed cannulas, split cannulas, etc.) that the instruments 156, 157 can be fed through.

[0041] The surgical robot 140 can communicate via the network 104 with the user console 120 to alert the user 121 of collected data (e.g., sensor readings from one or more of the instruments, patient vitals, etc.) and / or progress of the surgical procedure. In some embodiments, a second user 119 (e.g., an additional surgeon, physician, member of a surgical team, consultant, etc.) operates the surgical robot 140. For example, the second user 119 manually replaces one or more of the end effectors 152 and / or the instruments 156, 157 operated by the surgical robot 140 throughout the multi-portal surgical procedure. In some embodiments, the user 121 operating the user console 120 is also the second user 119 operating the surgical robot 140. The surgical robot 140 can communicate with the controller 150 (e.g., over the network 104) to store or display collected data and / or progress of the surgical procedure in the operating room 102. For example, the surgical robot 140 can include a display 118 and the controller 150 can include a display 122 that can display visualization of a working site for the user 121 , the second user 119, and / or other members of the surgical team to visualize and / or monitor progress of the multi-portal surgical procedure. In some embodiments, the displays 118, 122 display an image 123 for the surgical team to review. For example, the image 123 can be one or more real-time images of the working site taken from a visualization instrument, a preoperative image of the patient 155, a three-dimensional model of the- 14 -125752.8020. WOOO\182882826.1patient preoperatively, intraoperatively, and / or post-operatively, and / or any other image / model / simulation that can assist the surgical team throughout the multi-portal surgical procedure. The image 123 can include one or more annotations, notes (e.g., physician notes), graphical overlays, such as arrows, digital rulers, text, color-coding, and / or the like.

[0042] The controller 150 can interact with, be integrated with, or be utilized in conjunction with one or more external databases, systems, and / or components mentioned herein. For example, the controller 150 can be incorporated into the surgical robot 140. Additionally or alternatively, the controller 150 can be located remotely and can communicate with the surgical robot 140 and / or other hospital equipment via the network 104. In some embodiments, the network 104 is a wireless network, a wide area network, a cellular network, or one or more local networks that can facilitate communication between the hospital equipment and the system 100. The network 104 can be paired with a latency test module to measure latency of the wireless communication between the components of the system 100. A measured / determined latency of a wireless network may be the same as a latency of a network that includes the wireless network, where the network may include a starting point / node for data to be transmitted to an ending point / node, and where the data is communicated by one computer / device associated with a surgical site (e.g., the operating room 102) to another computer / device associated with a location of the remote physician / surgeon (e.g., a remote consultant working on the user console 120). Scheduling of consultants can be based, at least in part, on expected latency (e.g., latency within the network 104 or other network) required to perform the remote or telesurgery based on the received surgery data (e.g., surgical plan, progress of surgery, sensor data, and / or the like). For example, a scheduling module may be configured to determine the requirement of the bandwidth (e.g., 10MHz, 20MHz, 30MHz, etc.) needed and / or expected latency (e.g., ±50 milliseconds, ±70 milliseconds, ±100 milliseconds, etc.). Additionally or alternatively, scheduling participation of consultants on the user console 120 can be based, at least in part, on user input parameters. For example, scheduling participation can be based, in part, on scheduling data inputted by one or more members of a surgical team on site for the procedure, such as a healthcare provider, surgeon, and / or physician. In some- 15 -125752.8020.WO00\182882826.1embodiments, the system 100 includes multiple user consoles 120 to allow for one or more consultants or users to participate and / or view (e.g., simultaneously view) the multiportal surgical procedure, surgery suite, patient vitals, etc.. For example, one of the user consoles 120 could be operated by a remote consultant and another one of the user consoles 120 could be operated by a surgeon in the operating room 102.

[0043] The system 100 can perform multi-portal spinal procedures based on patient data to improve surgical outcomes. For example, image processing can be applied to patient images (e.g., scans, video, or the like) to determine target areas (e.g., one or more intervertebral discs) and non-target areas of the patient’s spine (e.g., cervical, thoracic, lumbar, and / or sacral spinal nerves). Image processing can be done on preoperative images to make a preoperative model of the patient 155 that the users 119, 121 can simulate surgical actions on. The system 100 can be configured to identify the surgical actions of the users 119, 121 and generate a surgical plan based, at least in part, on the surgical actions performed on the preoperative model that meet a target outcome score. The users 119, 121 can perform one or more simulations on the preoperative model. The simulations can predict expected visualization at one or more steps of the surgical plan. The system 100 can store the simulations and / or expected visualizations associated with each step of the surgical plan, for example, within a module of the controller 150 for reference throughout the multi-portal surgical procedure.

[0044] Additionally or alternatively, image processing can be done on intraoperative images (e.g., fluoroscopic images, images from a camera, etc.) taken from a visualization instrument and / or another imaging modality. Intraoperative image processing can be used to modify the surgical plan to maintain target outcome scores and improve patient outcomes. For example, and as described in more detail herein, the system 100 can modify the surgical plan if visualization from a visualization instrument does not substantially match the expected visualization. Intraoperative images can be processed throughout the multi-portal surgical procedure to dynamically modify surgical plans, update virtual models of working sites, notify a surgical team of procedure progress, or combinations thereof. Similarly, intraoperative images can be used to simulate postoperative images, models, and / or simulations that predict post-operative outcomes, success of the procedure, patient recovery time, and / or the like. For example, the system- 16 -125752.8020.WO00\182882826.1100 generates post-operative outcomes based on different types of simulations. The simulations can be performed preoperatively and / or intraoperatively and can include characteristics of the working site taken from preoperative and / or intraoperative images of the patient. The system 100 can simulate post-operative behavior of the target area. For example, the system 100 can simulate behavior of the intervertebral discs, loadbearing capabilities of the spine, musculoskeletal behavior, predicted disc degeneration, and / or the like at several time frames following completion of the multi-portal surgical procedure (e.g., 30 days, 6 months, 2 years, 10 years, etc.). The characteristics of the post-operative simulations can be used to determine which surgical approach to use, which anatomical features to modify, which instruments to use, etc.

[0045] Each step of a surgical plan can be performed with a different set of the instruments 156, 157, and the set of the instruments 156, 157 may be specific to the multiportal surgical procedure performed. In some embodiments, the instruments 156, 157 are identified from historical data regarding the multi-portal surgical procedure performed. Additionally or alternatively, the instruments 156, 157 are selected by at least one of the users 119, 121 when simulating the surgical procedure on the preoperative model. In some embodiments, the surgical robot 140 and / or the controller 150 makes recommendations for the instruments 156, 157 based at least in part on historical, realtime, and / or user-inputted data.

[0046] The system 100 can select the instruments 156, 157 to treat, without limitation, spinal nerve compression (e.g., spinal cord compression, spinal nerve root compression, or the like), spinal disc herniation, osteoporosis, stenosis, or other diseases or conditions. The surgical plan generated can include a plurality of instruments that correspond to each step of a surgical plan. For example, the surgical plan can call for use of a plurality of working instruments (e.g., with a tissue removing tip, etc.) that can remove unwanted tissue, including, without limitation, tissue bulging from discs, bone (e.g., lamina, lateral recesses, facets including the inferior facets, etc.), bone spurs (e.g., bone spurs associated with osteoarthritis), tissue of thickened ligaments, spinal tumors, displaced tissue (e.g., tissue displaced by a spinal injury), or tissue that may cause or contribute to spinal nerve compression. Other instruments (e.g., rongeurs, debulkers, scrapers, reamers, dilators, etc.) can also be used to perform one or more dilation- 17 -125752.8020.WO00\182882826.1procedures, decompression procedures, discectomies, microdiscectomies, laminotomies, or combinations thereof. In procedures for treating stenosis, the working instrument can be used to remove tissue associated with central canal stenosis, lateral recess stenosis, and / or other types of stenosis. In some decompression procedures, the instrument can be a tissue removal device used to, for example, remove bone, separate the ligamentum flavum from one or both vertebrae, cut or debulk the ligamentum flavum, remove loose tissue, and remove at least a portion of the intervertebral disc.

[0047] Similarly, the system 100 can select a visualization instrument as at least one of the instruments 156, 157 used in one or more steps of a surgical plan. The visualization instrument can be, without limitation, an endoscopic instrument that includes fiber optics suitable to image the treatment site and surrounding tissues, such as the spinal cord, nerves branching from the spinal cord, ligaments, vertebrae, intervertebral disc(s), or any other features or anatomical structures of interest, while another one of the instruments 156, 157 removes tissue (e.g., bone from the vertebrae, intervertebral disc, etc.). The visualization instrument can be used to intraoperatively view surrounding non-targeted tissue to ensure that the instrument tips of either of the instruments 156, 157 does not injure the non-targeted tissue. This allows a physician to remove tissue without damaging nerve tissue, the spinal cord, and other non-targeted tissue. Additionally or alternatively, the visualization instrument can have irrigation channels to circulate fluid through the working space to help remove blood, loose tissue, and other anatomical features that may obscure viewing. As described herein, the system 100 can control irrigation parameters according to the surgical plan. For example, the system 100 can modify irrigation parameters based on an intraoperative visualization image taken from a visualization instrument not matching the expected visualization at a surgical step.

[0048] The visualization instrument can be steerable to facilitate navigation around anatomical features and / or can include a fiber-optic scope or a flexible or rigid instrument with one or more illumination elements (e.g., fiber optics for illumination) or imaging elements (e.g., charge-coupled devices for imaging) suitable for visualizing the interior of otherwise inaccessible sites. In some embodiments, the visualization instrument can be a rod-lens endoscope with an outer diameter equal to or smaller than about 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 8 mm, or 10 mm, and a length equal to or shorter than about 15 cm,- 18 -125752.8020.WO00\182882826.120 cm, 30 cm, or 40 cm. The visualization instruments can also have integrated irrigation features (e.g., valves, flow control buttons, fluid lumens, return lumens), connectors (e.g., electrical connectors, fluidic connectors, etc.), access ports (e.g., access ports connected to lumens (e.g., lumens through which instruments can pass)), or the like. In embodiments with an angled lens, the visualization instrument can have approximately 0-degree, 10- degree, 15-degree, 30-degree, or45-degree lens angles, which are toward a light source. In other angled lens embodiments, the visualization instrument can have an approximately 15-degree, 30-degree, or 45-degree lens angled away from a light source. The angle of the lens can be selected based on the working site of the multi-portal surgical procedure (i.e. , the area to be viewed). In some posterior or lateral spinal procedures, a 0-degree lens can provide a wide-angle view suitable for viewing nerve roots, the spinal cord, and intervertebral space. A 30- or 45-degree lens endoscope angled toward the light source can be used to provide an angled view toward, for example, the spine or midsagittal plane to view, for example, the spinous processes, spinal cord, or central regions of the intervertebral space. A 30- or 45-degree lens endoscope angled away from the light source can be used to provide an angled view toward the lateral features or the spine, such as nerve roots at the neural foramen, side regions of the intervertebral space, or the like.

[0049] In some embodiments, the angled view from the visualization instrument can be dynamically adjusted by the system 100 if, for example, intraoperative visualization does not substantially match expected visualization. Additionally or alternatively, the system 100 can notify the users 119, 121 to replace the visualization instrument, and / or a working instrument, to correct visualization. In doing so, the system 100 can also modify one or more of the remaining steps in the surgical plan based on the new instruments and / or the latest visualization.

[0050] In some embodiments, at least one of the instruments 156, 157 is a visualization instrument that continuously captures images of the working site as tissue is altered. The system 100 can use the captured images to dynamically modify the positions of the instruments 156, 157 and / or other procedural parameters (e.g., irrigation parameters), notify users to replace one or more of the instruments 156, 157, and / or to generate an alternate or modified surgical plan. As described in more detail with reference- 19 -125752.8020.WO00\182882826.1to Figure 2, the system 100 can determine the positions of the instruments 156, 157 relative to one another and / or relative to the target area using the intraoperative images, sensor data, etc. The system 100 can be configured to maintain the instruments 156, 157 within a predetermined working envelope range for maintaining visualization of the instruments 156, 157 throughout the multi-portal surgical procedure. The predetermined working envelope range can be inputted by the user or determined by the system 100 based on historical data (e.g., tool data, procedural data, etc.).

[0051] In the multi-portal surgical procedures discussed herein, the system 100 can analyze images from the visualization instrument to determine how to robotically remove spinal tissue and / or deliver a spinal implant without damaging nerve tissue within the working site. Additionally or alternatively, the system 100 can request additional images from one or more external imaging devices, as discussed in more detail with reference to Figure 12. Post-operative simulations can use images captured from the visualization instrument and / or external imaging modalities to predict post-operative outcomes based on the current surgical plan and latest conditions at the working site. The system 100 can modify one or more procedural parameters and / or the surgical plan if the post-operative simulations do not meet a threshold outcome score. The threshold outcome score can be inputted by the user or determined by the system 100 using, for example, historical surgical data of similar multi-portal surgical procedures.

[0052] The system 100 can include surgical control software, a plurality of navigation programs corresponding to different types of multi-portal surgical procedures, surgical planning software, triangulating software, working instrument software, visualization instrument software, and / or other features disclosed herein to plan and / or perform one or more steps of a multi-portal surgical procedure using the surgical robot 140. The multiportal spinal surgical procedure can encompass a variety of operations, including decompression, oblique lumbar interbody fusion (OLIF), lateral lumbar interbody fusion (LLIF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), or a combination of these multi-portal procedures. Through the user interface, the users 119, 121 have the option to choose the navigation program(s) suitable for the multi-portal surgical procedure. Each navigation program can be associated with a unique set of end effectors, instrument holders,- 20 -125752.8020.WO00\182882826.1instruments, triangulation parameters, historical surgical procedures, outcome scores, and / or other parameters disclosed herein. The system 100 can utilize data from the navigation program to plan procedural visualization and / or formulate a surgical plan tailored to the specific procedure being executed. For example, the system 100 can generate a surgical plan based on the one or more actions performed by a user on the preoperative model of the patient. The system 100 can also generate a surgical plan based on historical surgical data from the navigation program or from external databases with multi-portal spinal procedure data. The system 100 can compare the outcome scores of one or more steps of each surgical plan and can combine and / or modify one or more steps of either surgical plan to create the surgical plan used in operation.

[0053] As described above, the system 100 can be controlled by one or more users 119, 121 at remote locations and / or within the operating room 102. The users 119, 121 can control operation of the surgical robot 140 based on a preoperative surgical plan and / or intraoperative notifications. In some embodiments, the navigation programs of the system 100 can generate a preoperative surgical plan based on the multi-portal surgical procedure to be performed. The users 119, 121 can perform one or more steps of the multi-portal surgical procedure according to the surgical plan, and the system 100 can be configured to provide intraoperative notifications of surgical events and / or suggest modifications to the surgical plan to improve surgical outcomes. For example, the system 100 can preoperatively predict visualization at one or more steps of the surgical plan and notify at least one of the users 119, 121 to reposition or replace one or more of the instruments 156, 157 if the current visualization does not substantially match the predicted visualization.

[0054] The surgical robot 140 can be configured to perform one or more of the multiportal spinal procedures disclosed herein. The surgical robot 140 can include the features and components discussed in more detail with reference to Figures 2-10. The surgical robot 140 can receive one or more user inputs, workflow objects, and / or data files containing surgical actions for robotic movements. The user inputs can include, without limitation, type of procedure, targeted outcome, physician notes, or other user inputs disclosed herein. The workflow objects can include surgical techniques, surgical steps, surgical processes, etc. The data files can include executable instructions for performing- 21 -125752.8020.WO00\182882826.1the techniques / processes with the end effectors 152, instrument holders (e.g., the instrument holders 220, 250 of Figure 2), and / or the instruments 156, 157. The surgical robot 140 can be in communication with and / or can include the controller 150 to determine the surgical tools for performing the surgical plan, such as the end effectors 152 and the instruments 156, 157. In some embodiments, the end effectors and / or surgical tools can be displayed via one or more of the displays 118, 122 for selective enabling and / or disabling by the user 119. In some embodiments, the surgical robot 140 can be designed to assist a surgeon in performing a multi-portal surgical operation on the patient 155. For example, the surgical robot 140 can be used to align one of more of the instruments 156, 157 and / or monitor alignment of instruments 156, 157 before a surgeon continues performing the multi-portal procedure.

[0055] The surgical robot 140 can request additional information from the system 100 to, for example, complete a surgical step, confirm completion of a surgical step, plan a surgical step, plan a series of surgical steps, or the like. For example, the system 100 can receive a notification on a user interface (e.g., the user interface 400 of Figure 4) to replace one or more of the instruments 156, 157, manually modify the position of the instruments 156, 157, manually modify irrigation parameters at the working site, and / or perform any additional surgical step not necessarily in the surgical plan. In some embodiments, the notifications are displayed via the displays 118, 122 for viewing by the user 119 and / or a surgical team. Additionally, or alternatively, the notifications can be viewable via the user console 120 by the user 121.

[0056] The user interface may also include controls for accepting inputs from the users 119, 121. For example, a surgeon or other medical professional can accept a transmission request to receive data from and provide data to a cloud for the purpose of training an artificial intelligence (Al)Zmachine learning (ML) model operating within the surgical robot 140 or receiving remote commands from a remote user (e.g., a user operating the user console 120 remotely) or an AI / ML model existing external to the surgical robot 140. The surgical robot 140 may additionally comprise a plurality of sensors or displays for providing feedback to the users 119, 121 or an AI / ML model. The inputs can include, for example, positioning information, visualization parameters, plan selection and / or modification, etc.- 22 -125752.8020.WO00\182882826.1

[0057] The number and configuration of the end effectors 152 can be selected depending on the multi-portal surgical procedure being performed, the navigation program selected, the surgical plan generated, etc. Additionally or alternatively, the number and configuration of end effectors 152 can be selected based on the configuration of the components of the system 100, such as the configuration of the surgical robot 140 and / or the robotic arm(s) 151. The system 100 can be incorporated into or used with technology discussed in connection with Figures 2-12. For example, multi-modality imaging technology (e.g., C-arms, etc.) can integrate with the surgical robot 140 to provide more intelligent and intuitive results, as described in more detail with reference to Figure 10. By way of another example, a user interface and / or imaging device of the system 100 can be part of the user console 120 discussed in connection with Figure 2. Output from the system 100 can be transmitted to controller 150 in Figure 5 and / or various other components disclosed herein. Accordingly, the system 100 can be incorporated into multi-portal robotic surgery systems or utilized to perform and / or assist with manual multiportal surgical procedures.

[0058] For example, the system 100 can be operated in one or more modes. In a user control mode, the user 121 controls, via the user console 120, movement of the surgical robot 140. The user’s movements of the input devices can be translated in real time into movement of the end effector 152, the instrument holders (e.g., the instrument holders 220, 250 of Figure 2) and thus, the instruments 156, 157. In a semi-autonomous mode, the user 121 controls selected steps via the user console 120 and the surgical robot 140 autonomously performs other steps. For example, the user 121 can control preparing the working site for the multi-portal surgical procedure (e.g., aligning the multiportal incisions, clearing tissue, etc.) whereas the surgical robot can perform the endoscopic-assisted surgical steps, automated endoscopic visualization (e.g., automated position of visualization instrument(s) for enhanced viewing), etc. In yet another example, the user 121 can operate the surgical robot 140 to perform the surgical procedure according to the surgical plan and the user 119 can insert one or more additional instruments into the patient 155 to manually access other regions and / or provide alternative access paths throughout the surgical procedure.- 23 -125752.8020.WO00\182882826.1

[0059] In some embodiments, the system 100 can monitor, via one or more sensors, at least a portion of the multi-portal surgical procedure performed by the surgical robot 140. The system 100 can be configured to identify an event, such as a potential adverse surgical event, associated with one or more steps of the surgical plan. For example, a potential adverse surgical event can be determined based on acquired data from one or more components of the system 100 or in the operating room 102 such as one or more sensors on the patient 155, the instruments 156, 157, external monitoring equipment, endoscopic image data, and / or the like. Additionally or alternatively, the system 100 can access data and information about one or more of the components of the system 100 or in the operating room 102 from a medical device report, database, manufacturer, etc. The system 100 can perform one or more actions based on the identified event. The actions can include, without limitation, modifying the surgical plan to address the potential adverse surgical event, thereby reducing the likelihood of the adverse event occurring and thus improving patient outcomes. The adverse surgical event can be identified by one or more operating parameters (e.g., working envelope ranges, triangulation parameters, irrigation parameters, threshold outcome scores, etc.) approaching respective critical thresholds. The adverse surgical events can be identified using an ML model trained using, for example, prior patient data, training sets (e.g., multi-portal surgical procedure data, working instrument data, visualization instrument data, multiportal end effector data, instrument holder data, and / or the like), etc.

[0060] In some embodiments, the system 100 determines whether a detected surgical event (e.g., operational parameters outside a target range or exceeding a threshold, etc.) is potentially an adverse surgical event based on one or more criteria set by the system 100, the users 119, 121 , or both. The adverse surgical event can be an adverse physiological event of the patient, a malfunction of the surgical robot 140, an incomplete surgical step, or other event that can adversely affect the patient 155 or the outcome of the multi-portal surgical procedure. The surgical events can be defined and inputted by the user, surgical team, healthcare provider, manufacturer of the robotic surgery system, or the like. For example, predetermined working envelope ranges (i.e. , the position range of the instruments 156, 157 relative to one another) can be defined by historical multi-portal surgical procedural data and / or can be inputted by the user, surgical- 24 -125752.8020. WOOO\182882826.1team, healthcare provider, manufacturer of one or more components of the system 100, or the like.

[0061] The system 100 can take several actions in response to a determination that an adverse surgical event has been detected. In some embodiments, the system 100 notifies the users 119, 121 via the user interface of a detected surgical event and / or of a recommended corrective action. For example, if the system 100 detects the instruments 156, 157 outside of the predetermined working envelope range and determines that the surgical robot 140 cannot modify the position(s) of the instruments 156, 157 to be within the working envelope range, the system 100 can notify the users 119, 121 to replace at least one of the end effector 152, the instruments 156, 157, the instrument holders, and / or the like. Additionally or alternatively, the system 100 can stop usage of any number of the components of the system 100 if an adverse event is detected. For example, if the end effector 152 malfunctions, the system 100 can stop usage of the end effector 152, and any other malfunctioning equipment, to fix and / or replace the equipment and continue the multi-portal surgical procedure. The system 100 can monitor hospital inventory, available resources in the operating room 102, procedure time, and / or other information to determine how to proceed. In some embodiments, the system 100 modifies the remaining steps of the surgical plan once an adverse event has been detected to include the corrective steps and / or any other additional surgical steps that improve patient outcomes. The system 100 can generate one or more corrective surgical plans that the users 119, 121 can select from based on the patient’s vital(s), physician preferences, procedure timing, available resources, and / or the like. The system 100 can generate one or more adverse event visualization plans to view the outcome (e.g., excessive bleeding, damaged tissue, etc.) of the adverse event. The adverse event visualization plan can include positions and settings for visualization instrument(s) for monitoring predicted effects associated with the adverse event. In some procedures, a set of candidate adverse event visualization plans can be generated for the user. The user can select one or more of the adverse event visualization plans (e.g., fluoroscopy visualization plan, endoscopic visualization plan, external camera visualization plan, etc.) to be performed.

[0062] Figure 2 illustrates a detailed view of the instruments 156, 157 coupled to the end effector 152 of Figure 1 positioned within the patient 155. As described above, the- 25 -125752.8020.WO00\182882826.1end effector 152 can include one or more instrument holders 220, 250 configured to maintain the position of the instruments 156, 157, respectively. One or both of the instrument holders 220, 250 can be moveable to reposition the instruments 156, 157 within the patient 155 ( i. e. , at the working site). In some embodiments, the instrument 156 is a working instrument and the instrument 157 is a visualization instrument (e.g., an endoscope), or vice versa. As shown in Figure 2, the robotic arm 151 can be coupled to the end effector 152 by a coupler 200. The coupler 200 can be one or more couplers (i.e. , joints, pins, jaws, grippers, etc.) that couple the robotic arm 151 to a proximal end of the end effector 152 such that the robotic arm 151 can control movement and / or positioning of the end effector 152, thereby controlling movement and / or positioning of the instruments 156, 157. The instrument holders 220, 250 can be coupled to the end effector 152 by one or more arms 210, 215, respectively. A coupler 205 can couple the arms 210, 215 to the end effector 152 such that the end effector 152 can position and / or reposition the arms 210, 215, thereby positioning and / or repositioning the instrument holders 220, 250 and / or the instruments 156, 157. The coupler 205 can fixedly couple the arms 210, 215 to the end effector 152 to maintain a specific trajectory and / or range of motion. Additionally or alternatively, the coupler 205 can releasably or movably couple the arms 210, 215 to the end effector 152, for example, to reposition, remove, and / or replace one or more of the arms 210, 215, the instrument holders 220, 250, and / or the instruments 156, 157. The coupler 205 can include a locking mechanism (e.g., a pin, bolt, lock cylinder, etc.) that can be locked and unlocked a plurality of times throughout the surgical procedure. For example, the coupler 205 can be unlocked to replace the arms 210, 215 and / or the instrument holders 220, 250 with components that are generally more compatible with the instruments 156, 157 used in the next step of the surgical plan.

[0063] Similarly, the arms 210, 215 can fixedly couple the proximal ends of the instruments 156, 157 such that the arms 210, 215 can keep the instruments 156, 157 positioned along, for example, an imaginary plane toward the working site, within an acceptable range of motion, etc. Additionally or alternatively, the arms 210, 215 can couple the instruments 156, 157 in a manner that allows the instruments 156, 157 to rotate about the instrument holders 220, 250 and / or translate along the arms 210, 215, to reposition the instrument 156, 157. In some embodiments, the arms 210, 215 and / or the- 26 -125752.8020.WO00\182882826.1instrument holders 220, 250 are removably coupled to the end effector 152 such that the arms 210, 215 and / or the instrument holders 220, 250 can be removed and / or replaced one or more times throughout the surgical procedure based on the instruments 156, 157 used and / or the surgical technique performed. As described above in relation to the number and configuration of the end effectors 152, the number and configuration of the instrument holders 220, 250 can be selected depending on the multi-portal surgical procedure being performed, the navigation program selected, the surgical plan, and / or the configuration of the components of the multi-portal robotic system (e.g., the system 100) such as the configuration of the robot (e.g., the surgical robot 140) and / or the robotic arm(s) 151. In some embodiments, the instrument holders 220, 250 are detachable and / or compatible with a number of the end effector 152 described herein.

[0064] One or more components of the end effector 152 and / or the instrument holders 220, 250 can include one or more joints (e.g., manual joints, motorized joints, etc.), linkages, motors, controllers, sensors, or the like that electrically couple the one or more components to the system 100. The configuration of the end effector 152 and / or the instrument holders 220, 250 can be selected based on the desired range of motion, degrees of freedom, or the like. For example, components of a surgical robot (e.g., an end effector, instrument holders, etc.) with a high number of degrees of freedom can be used to perform generally more complicated multi-portal procedures whereas components of a surgical robot with a low number of degrees of freedom can be used to perform generally simpler multi-portal procedures. In some embodiments, the end effector 152 and / or the instrument holders 220, 250 include multiple couplers (e.g., joints, linkages, etc.). The number of couplers and other components of the end effector 152 and / or the instrument holders 220, 250 can be selected based on the desired positioning and range of motion of the instruments 156, 157. Additionally or alternatively, the couplers can include a locking mechanism that is controlled electrically by the system 100 and that can be used to secure and / or fix the position of instruments 156, 157 within the patient 155. The locking mechanism can be unlocked to reposition one or more components of the end effectors 152 and / or the instrument holders 220, 250. The system 100 can dynamically lock and unlock the one or more components of the end effectors 152 and / or- 27 -125752.8020.WO00\182882826.1the instrument holders 220, 250 to position, reposition, and / or replace the instruments 156, 157 a plurality of times throughout the surgical procedure.

[0065] The instrument holders 220, 250 can be made, in whole or in part, of one or more polymers, composites, plastics, metals, or materials suitable for contacting the instruments 156, 157. In some embodiments, the instrument holders 220, 250 can be lined with a compressible material to provide cushioning of the instruments 156, 157. Similarly, one or more components of the robotic arm 151 and / or of the end effector 152 can be lined with a compressible material to provide cushioning and / or protection to the robotic arm 151 and the end effector 152 at the coupler 200. Lining one or more components with compressible material may allow for an increased range of motion of the components, including a slight amount of out-of-plane rotation, thereby providing for position flexibility to adjust the relative position, including distance, angular position, etc., of the distal ends of the instruments 156, 157.

[0066] The instrument holders 220, 250 can be configured to hold one or more working instruments, visualization instruments, and / or cannulas to perform a multi-portal surgical procedure. For example, the end effector 152 and / or the instrument holders 220, 250 can be adjusted to hold one or more cannulas at a fixed or altered position while instruments (e.g., the instruments 156, 157) are delivered through the cannulas. In some embodiments, the end effector 152 and / or the instrument holders 220, 250 can be used to hold and / or position the instruments 156, 157 at an angle toward a vertebral level or working site within the patient 155. For example, the instrument holder 250 can hold a visualization instrument at a desired position for visualization of the working site while the instrument holder 220 holds the working instrument. The system 100 can adjust the positions of the end effector 152 and / or the instrument holders 220, 250 any number of times throughout the surgical procedure. The end effectors 152 and / or the instrument holders 220, 250 can be configured such that the surgical robot 140 can move at least one of the instruments 156, 157 relative to the other instrument while the other instrument is held relatively stationary.

[0067] The end effectors 152 and / or the instrument holders 220, 250 can be unlocked to modify various triangulation parameters that influence the operational space- 28 -125752.8020.WO00\182882826.1between the instruments 156, 157 (e.g., the working envelope range). The triangulation parameters can include distance, orientation, and / or depth of the instruments 156, 157 relative to one another, among other positioning parameters. For example, the instruments 156, 157 can be angled toward each other, as shown in Figure 2, while maintaining a minimum distance of separation. The instruments 156, 157 and / or the instrument holders 220, 250 can include sensors that detect the position of the instruments 156, 157 that the system 100 can use to calculate the position of the instruments 156, 157 throughout the surgical procedure. As described above, the instrument holders 220, 250 can lock to maintain the instruments 156, 157 in a specific position within the predetermined working envelope range. The end effectors 152 and / or the instrument holders 220, 250 can be selected based on factors such as the triangulation parameters and configuration of instruments (for instance, working or visualization instruments), the number of robotic arms to be employed, the surgical techniques to be applied, the proximity of nerve tissue to the target area, etc. The end effectors 152 and / or the instrument holders 220, 250 can be used to position instruments and perform procedures disclosed in U.S. App. No. 18 / 764,784 and PCT App. No. PCT / US24 / 31123, which are incorporated by reference in their entireties. U.S. App. No. 18 / 764,784 and PCT App. No. PCT / US24 / 31123 disclose, for example, triangulation guides, triangulation techniques, multi-portal triangulation parameters, and visualization techniques.

[0068] The end effectors 152 and / or the instrument holders 220, 250 can be repositioned and / or replaced one or more times throughout the surgical procedure depending on the step in the surgical plan, current visualization, and / or whether a modification to the surgical plan is made. For example, the position of a visualization instrument can be repositioned if the distal end of the working instrument is no longer visible, or vice versa. Additional embodiments of the end effectors 152 including different end effectors 152 and instrument holders 220, 250 are described in more detail with reference to Figures 6-9.

[0069] Figure 3 illustrates the user console 120 of the system 100 of Figure 1. The user console 120 allows a user (e.g., the user 121 of Figure 1 ) to position and / or reposition the instruments 156, 157 using one or more hand-operated input tools 304, 306,- 29 -125752.8020.WO00\182882826.1respectively. In some embodiments, the hand-operated input tools 304, 306 are controlled by the user’s left and right hands 307, 308, respectively, to position and / or reposition the instruments 156, 157. The user console 120 can further include a viewer 310 that is configured to display the position of the instruments 156, 157 within the patient’s body. The viewer 310 can include left and right eye displays 314, 316 for the user’s eyes to rest on, against, and / or near. In some embodiments, the image(s) displayed on the viewer 310 are taken from an external imaging modality that captures both of the instruments 156, 157 within the working site. Additionally or alternatively, the viewer 310 displays one or more models and / or simulations of the current working site generated from the latest sensor data, images, and / or other data collected throughout the surgical procedure. It is worth noting that although the images displayed in Figure 3 on the viewer 310 show both of the instruments 156, 157, the viewer 310 could also display real-time images from a visualization device (e.g., an endoscope) of a working instrument within the working site. In some embodiments, the user’s movements of the hand-operated input tools 304, 306 can be translated in real time to mimic operation and / or movement onto the instruments 156, 157 at the working site, respectively. The viewer 310 can also provide the user output data such as alerts, notifications, and / or other procedural information (e.g., surgical plans, patient vitals, working envelope alerts, threshold outcome notifications, surgical team information, surgical equipment data, surgical robot status, predictions, simulations, etc.) over the course of the surgical procedure.

[0070] As described above, the viewer 310 can display a portion or an entirety of a surgical plan in the form of preoperative, intraoperative, and / or post-operative images, models, and / or simulations. For example, the viewer 310 can show a real-time endoscope view of the working site. In yet another example, the viewer 310 can display real-time image data from an endoscope overlayed onto one or more of the expected visualization images stored with the surgical plan being performed. Additionally or alternatively, the viewer 310 can display one or more three-dimensional models of the patient’s preoperative anatomy compared to intraoperative and / or post-operative anatomy. The three-dimensional models can, for example, identify target areas, non-target nerve tissues, conditions of the tissue surrounding the target area, etc.- 30 -125752.8020.WO00\182882826.1

[0071] In some embodiments, the viewer 310 can be a virtual reality / augmented reality (VR / AR) headset, display, and / or the like. The system 100 can include multiple of the viewers 310 operating on one or more of the user consoles 120 such that multiple members of a surgical team can view and / or participate in the multi-portal surgical procedure. The number and configuration of the viewers 310 can be selected based on the number and configuration of components in the system 100 (e.g., the surgical robots 140, the user consoles 120, etc.). The viewers can be used to view, for example, captured image data, plans, surgical sites, robotic arms, virtual models (e.g., anatomical models), etc.

[0072] In some embodiments, at least one of the instruments 156, 157 is a visualization instrument used to position and / or view at least a portion of a disc, vertebral body, and / or the distal portion(s) 317, 318 of the instrument(s) 156, 157, respectively. Additionally or alternatively, at least one of the instruments 156, 157 can be a working instrument used to remove tissue (e.g., intervertebral disc, tissue contributing to stenosis, etc.), form access paths to implantation sites, prepare an implantation site by, for example, moving organs or tissue (e.g., moving nerve tissue), prepare vertebral bodies (e.g., roughening or shaping vertebral endplates), or the like. In some embodiments, at least one of the instruments 156, 157 can be a distraction instrument (e.g., one or more dilators) used to distract adjacent vertebrae, thereby enlarging the intervertebral space. Additionally or alternatively, at least one of the instruments can be replaced with an instrument that can deliver an interbody implant into the enlarged intervertebral space. In some embodiments, at least one of the instruments 156, 157 delivers an expandable interbody fusion implant that can expand to push apart vertebral endplates. One or more of the instruments 156, 157, the instrument holders (e.g., the instrument holders 220, 250 of Figure 2), and / or the end effector (e.g. , the end effector 152 of Figures 1 and 2) can be replaced and / or repositioned to deliver one or more implants into the intervertebral space according to a surgical plan, as described herein.

[0073] The visualization instrument can provide intraoperative endoscopic viewing of workspaces, delivery paths, organs, tissue (e.g., nerve tissue) implantation sites, implants, interbody fusion devices (e.g., before, during, and / or after delivery), instrument(s) (including dispensers, dilators, decompression instruments, etc.), and other- 31 -125752.8020.WO00\182882826.1areas or features of interest. The position of the instruments 156, 157 can be selected based on the procedure and optical characteristics (e.g., field of view, zoom capability, etc.) of the visualization instrument. The visualization instrument can be repositioned throughout the procedure manually and / or using at least one of the hand-operated input tools 304, 306 to provide intraoperative endoscopic viewing of one, multiple, or all of the surgical steps. For example, the visualization instrument can be used to view tissue contributing to nerve compression caused by narrowing of the spinal canal associated with arthritis of the spine, degeneration of spinal discs, and thickening of ligaments. Arthritis of the spine often leads to the formation of bone spurs, which can narrow the spinal canal and press on the spinal cord. This tissue can be viewed using the visualization assembly instrument. In spinal disc degeneration, the visualization instrument can view the inner tissue of the disc protruding through a weakened fibrous outer covering of the disc and pressing on the spinal cord and / or spinal nerve roots. The protruding tissue can be viewed before and / or during removal. The visualization instrument can be used to also view ligaments pressing on the spinal cord and / or nerve roots to assist in treatment.

[0074] Figure 4 illustrates a user interface 400 of a multi-portal robotic system (e.g., the system 100 of Figure 1 ), in accordance with one or more embodiments. In some embodiments, the user interface 400 is one or more of the displays 118, 122 of Figure 1 . Additionally or alternatively, the user interface 400 can be a separate display device (e.g., a mobile device, tablet, etc.) that is paired with the system 100. The user interface 400 can be configured to receive input data from one or more members of a surgical team and to display multiple forms of output data from one or more components of the system 100. The user interface 400 can be within an operating room (e.g., the operating room 102) as the multi-portal surgical procedure is performed. Additionally or alternatively, the user interface 400 can be operated remotely by, for example, a remote consultant. In some embodiments, multiple user interfaces 400 are available such that multiple members of the surgical team, consultants, and / or healthcare professionals can view and / or interact with the system 100 (e.g., simultaneously). The user interface 400 can have a plurality of output viewers, such as an endoscope viewer 410, a patient model viewer 415, an irrigation viewer 420, a patient vitals viewer 430, and / or a notification panel- 32 -125752.8020.WO00\182882826.1435. Additionally or alternatively, the user interface 400 can include a controls input 425 that enables a user to interact with the system 100 (e.g., by selecting and / or approving one or more surgical steps, instruments, modifications, etc.). The user interface 400 can include one or more additional viewers or viewing windows that provide viewing (e.g., real-time or near real-time viewing) of the operating room(s), remote consultant locations, surgical instruments, users, etc.

[0075] In some embodiments, the endoscope viewer 410 can display real-time image data from an endoscope at a working site. Additionally or alternatively, the realtime image data can be annotated with, for example, labeled target intervertebral bodies, non-targeted spinal nerves, working instrument position(s) relative to the endoscope, and / or the like. In some embodiments, the endoscope viewer 410 can display the same data as a viewer of a console associated with the system 100 (e.g., the viewer 310 of the user console 120 of Figure 3). Similarly, the patient model viewer 415 can display one or more three-dimensional models of the patient’s preoperative anatomy, intraoperative anatomy, and / or post-operative anatomy for reference throughout the surgical procedure. The patient model viewer 415 can be continuously updated throughout the surgical procedure by using sensor data, image data, and / or if any changes are made to the surgical plan. In some embodiments, expected visualizations and / or expected intraoperative models / simulations can be overlayed with real-time viewing and patient models in one or both of the endoscope viewer 410 and / or the patient model viewer 415. For example, if one or both of an expected image visualization and / or an expected intraoperative model do not substantially match the real-time image and / or model, the system 100 can modify the surgical plan, as described in more detail with reference to Figure 1.

[0076] In some embodiments, one or more irrigation parameters at the working site are displayed on the irrigation viewer 420. As described herein, the flow rate of irrigation fluid can be modified manually by a user via the controls input 425 and / or the system 100 can dynamically modify the flow rate of irrigation fluid to clear a working site for endoscopic viewing, to maintain visualization, and / or to reach a threshold outcome score.- 33 -125752.8020.WO00\182882826.1

[0077] The patient vitals viewer 430 can display patient data from one or more sensors or patient data modules, such as patient identification number(s), blood pressure, body temperature, health rating, heart rate, other patient vitals, physician notes, and / or additional patient data that may be useful throughout the surgical procedure. To change or receive additional patient data, a user can use the controls input 425 to send a notification to a member of the surgical team in the operating room.

[0078] The notification panel 435 can be used to notify the user of multiple output notifications, for example, the step of the surgical plan, procedure progress reports, procedural statuses, threshold limits, current outcome scores, predictions, modifications to the surgical plan, or combinations thereof. In some embodiments, the system can suggest one or more modifications to the surgical plan for the user to view via the notification panel 435. The user can approve, modify, and / or disapprove the modifications using the controls input 425. In some embodiments, the controls input 425 can include an approval interface 426, a disapproval interface 427, and / or a control panel 428 that the user can interact with to view, input, manipulate, and / or control any one of the viewer windows on the user interface 400 and / or one or more additional components in the system 100. For example, the control panel 428 can be used to, for example, position one or more working instruments, position viewing instruments, adjust triangulation parameters, or the like. Additionally, the user can use the controls input 425 to input access codes, pins, credentials, multi-portal surgical procedure data, and / or the like to manipulate, approve, and / or access information for and / or in the system 100. The controls input 425 can also be used to approve and / or adjust permissions rights for the members of the surgical team (e.g., multiple consultants on multiple user interfaces). In some embodiments, some users may be able to access additional equipment data (e.g., from robotic arms, instruments, etc.) and / or patient data (e.g., patient vitals, patient images, etc.) that can be used, for example, in cases where an adverse event is identified. The user interface 400 can dynamically update user controls, allowing one user to acquire additional information without disrupting the consultation session on other user interfaces, reducing latency risk and / or network issues. The control panel 428 can be used to control movement and / or position of one or more components of the system 100 (e.g., surgical robot arms, end effectors, instrument holders, instruments, etc.) and / or to adjust- 34 -125752.8020.WO00\182882826.1parameter settings (e.g., working envelope ranges, triangulation parameters, irrigation parameters, etc.).

[0079] Figure 5 illustrates subcomponents of a system 100 of Figure 1 , in accordance with one or more embodiments. The controller 150 can have one or more processors 504, a memory 506, input / output devices 508, and / or subsystems and other components 510. The processor 504 can perform any of a wide variety of computing processing, image processing, robotic system control, surgical plan generation or modification, visualization simulations, triangulation calculations, and / or other functions. Components of the controller 150 can be housed in a single unit, for example, within a hospital or operating room (e g., the operating room 102), or distributed over multiple, interconnected units via a communications network (e.g., the network 104). Thus, the components of the controller 150 can include local and / or remote devices.

[0080] As shown in Figure 5, the processor 504 can include a plurality of functional modules 512, such as software modules, for execution by the processor 504. The various implementations of source code (i.e., in a conventional programming language) can be stored on a computer-readable storage medium (e.g., non-transitory computer-readable storage medium) or can be embodied on a transmission medium in a carrier wave. The modules 512 of the processor 504 can include a user input module 514, a patient module 516, a surgical procedure module 518, a processing module 520, an output module 522, a display module 524, and / or a triangulation module 526. The processing module 520 can perform edge computing to locally process data, generate intraoperative data (e.g., intraoperative plans, intraoperative modifications to plans, etc.), or the like.

[0081] In operation, the user input module 514 receives and accepts a user input 528 via one or more input devices of the system 100 (e.g., user interfaces, consultant devices, etc.). The user input 528 can include, without limitation, procedure information, visualization settings, threshold visualization scores for surgical steps, surgical plan modifications, user approval (e.g., approval of surgical steps, plans, etc.), triangulation parameters, instrument positioning, etc. The user input 528 can be provided preoperatively, intraoperatively, and / or post-operatively. The user input module 514 can communicate and / or select from the received and accepted information which information- 35 -125752.8020.WO00\182882826.1to communicate to other components for further processing (e.g., by the processor 504). For example, the patient module 516 can organize patient records and / or patient data, such as patient images, patient models, patient simulations, health records, patient vitals, and / or the like. The surgical procedure module 518 can organize surgical information for the multi-portal robotic surgical procedure, such as robotic control plans, multi-portal surgical plans, surgical equipment data (e.g., end effector and / or instrument specifications), control programs, operating records and other operator activities, equipment maintenance records, historical treatment data, and / or the like. One or more of the modules 512 can facilitate storing and / or retrieving of received information and / or records to and from a data storage device (e.g., internal memory 506, external databases, etc.). Any type of database organization can be utilized, including a flat file system, hierarchical database, relational database, distributed database, etc.

[0082] In the illustrated example, the processing module 520 can generate control variables based on robotic sensor readings 530, patient vitals signals 532, output visualization signals / data 534, and / or output working instrument signals / data 536 from sensors on one or more components of the system 100 or in the operating room 102 (e.g., sensors on the end effector 152, patient monitoring equipment, etc.). Additionally or alternatively, the user input 528 (e.g., input from the user console 120 and / or other input data sources) and the output module 522 can communicate user input to external computing devices and control variables to controllers. The display module 524 can control one or more displays of the system 100 (e.g., the displays 118, 122) and can be configured to convert and transmit processing parameters, robotic sensor readings 530, patient vitals signals 532, output visualization signals / data 534, and / or output working instrument signals / data 536, user input data, surgical plans, triangulation parameters, irrigation parameters, etc. through one or more connected display devices, such as a display screen, touchscreen, printer, speaker system, and / or the like. The triangulation module 526 can organize or control triangulation parameters and positions of instruments (e.g., visualization instruments, working instruments, etc.) based on the user input 528, robotic sensor readings 530, patient vitals signals 532, output visualization signals / data 534, and / or output working instrument signals / data 536. In some embodiments, the triangulation module 526 can accept and transmit information to the processor 504 for- 36 -125752.8020.WO00\182882826.1further processing. For example, the processor 504 can calculate one or more triangulation parameters between the visualization instrument and the working instrument, such as instrument orientation, angle, trajectory, and / or distance from one another. In some embodiments, the processor 504 can further detect whether the instruments are within a predetermined working envelope.

[0083] In various embodiments, the processor 504 can be a standard central processing unit or a secure processor. Secure processors can be special-purpose processors (e.g., reduced instruction set processor) that can withstand sophisticated attacks that attempt to extract data or programming logic. The secure processors cannot have debugging pins that enable an external debugger to monitor the secure processor’s execution or registers. In other embodiments, the system can employ a secure field- programmable gate array, a smartcard, or other secure devices.

[0084] The memory 506 can be standard memory, secure memory, or a combination of both memory types. By employing a secure processor and / or secure memory, the system can ensure that data and instructions are both highly secure and that sensitive operations such as decryption are shielded from observation. In various embodiments, the memory 506 can be flash memory, secure serial EEPROM, secure field- programmable gate array, or secure application-specific integrated circuit. The memory 506 can store, for example, plans (e.g., surgical plans, visualization plans, navigation plans, etc.), instructions for causing the surgical robot 140 to perform acts disclosed herein, simulations, etc. Additionally or alternatively, the memory 506 can store one or more visualization images / models / simulations for one or more steps of a surgical plan that can be referenced throughout the execution of a multi-portal surgical procedure, as described herein.

[0085] The input / output device 508 can include, without limitation, a touchscreen, a keyboard, a mouse, a stylus, a push button, a switch, a potentiometer, a scanner, an audio component such as a microphone, or any other device suitable for accepting user input and can also include one or more video monitors, a medium reader, an audio device such as a speaker, any combination thereof, and any other device or devices suitable for providing user feedback. For example, if an instrument moves outside of a predetermined- 37 -125752.8020.WO00\182882826.1working envelope during the multi-portal surgical procedure, the input / output device 508 can alert the subject and / or operator via an audible alarm. The input / output device 508 can be a touchscreen that functions as both an input device and an output device.

[0086] The controller 150 can output instructions to command the surgical robot 140 and communicate with one or more external databases 500. The surgical robot 140 or other components disclosed herein can communicate to send collected data (e.g., robotic sensor readings, patient vitals, visualization instrument data, working instrument data, surgical robot data, etc.) to the external database 500. The external database 500 can store patient data, plans (e.g., surgical plans, visualization plans, or the like), instrument information, etc. This information can be used to, for example, create new training data sets, generate multi-portal surgical plans, generate navigation programs for multi-portal surgical procedures, perform future simulations, post-operatively analyze multi-portal surgical procedures, or the like. The controller 150 can be incorporated into, used with, or otherwise interact with other databases, systems, and components disclosed herein. In some embodiments, the controller 150 can be incorporated into the surgical robot 140 or other systems disclosed herein. In some embodiments, the controller 150 can be located at a remote location and can communicate with a surgical robot via one or more networks. For example, the controller 150 can communicate with a hospital via a network, such as a wide area network, a cellular network, one or more local networks, etc.

[0087] The controller 150 or other systems disclosed herein can collect and analyze data using one or more AI / ML techniques. AI / ML techniques can be used to develop computing systems capable of simulating aspects of human intelligence, e.g., learning, reasoning, planning, problem solving, decision making, etc. Al techniques can include, but are not limited to, case-based reasoning, rule-based systems, artificial neural networks, decision trees, support vector machines, regression analysis, Bayesian networks (e.g., naive Bayes classifiers), genetic algorithms, cellular automata, fuzzy logic systems, multi-agent systems, swarm intelligence, data mining, machine learning (e.g., supervised learning, unsupervised learning, reinforcement learning), and hybrid systems.

[0088] In some embodiments, the controller 150 analyzes data using one or more trained ML models. Various types of ML models, algorithms, and techniques are suitable- 38 -125752.8020.WO00\182882826.1for use with the present technology. In some embodiments, the ML model is initially trained on a training data set, which is a set of examples used to fit the parameters (e.g., weights of connections between “neurons” in artificial neural networks) of the model. For example, the training data set can include any of the reference data stored in the database, such as a plurality of reference procedure data sets or a selected subset thereof (e.g., a plurality of similar patient data sets). The controller 150 can analyze instrument position data, visualization data, patient data, and plans to, for example, control robotic arms, end effectors, instruments, navigation systems, or the like.

[0089] In some embodiments, the ML model (e.g., a neural network or a naive Bayes classifier) may be trained on the training data set using a supervised learning method (e.g., gradient descent or stochastic gradient descent). The training data set can include pairs of generated “input vectors” with the associated corresponding “answer vector” (commonly denoted as the target). The current model is run with the training data set and produces a result, which is then compared with the target, for each input vector in the training data set. Based on the result of the comparison and the specific learning algorithm being used, the parameters of the model are adjusted. The model fitting can include both variable selection and parameter estimation. The fitted model can be used to predict the responses for the observations in a second data set called the validation data set. The validation data set can provide an unbiased evaluation of a model fit on the training data set while tuning the model parameters. Validation data sets can be used for regularization by early stopping, e.g., by stopping training when the error on the validation data set increases, as this may be a sign of overfitting to the training data set. In some embodiments, the error of the validation data set can fluctuate during training, such that ad hoc rules may be used to decide when overfitting has truly begun. Finally, a test data set can be used to provide an unbiased evaluation of a final model fit on the training data set.

[0090] To generate one or more plans, prior patient data can be inputted into the trained ML model(s). The trained ML model(s) can then calculate whether various candidate treatment procedures, visualization steps, etc. are likely to produce a favorable outcome for the patient or meet one or more targeted outcomes. Additionally or alternatively, the trained ML model(s) can select at least one plan for the patient. In- 39 -125752.8020.WO00\182882826.1embodiments where multiple trained ML models are used, the models can be run sequentially or concurrently to compare outcomes and can be periodically updated using training data sets. The multiple trained ML models can generate preoperative plans, intraoperative plans, modifications for plans, etc.C. MULTI-PORTAL INSTRUMENT HOLDERS

[0091] Figure 6 illustrates an end effector 652 of a multi-portal robotic system with one or more twist lock instrument holders 620, 650, in accordance with one or more embodiments. The multi-portal robotic system can be, for example, the system 100 of Figure 1. Figure 7 illustrates the end effector 652 of Figure 6 holding instruments 756, 757. The instruments 756, 757 can be identical to or generally similar to the instruments 156, 157 of Figure 1 or other instruments disclosed herein, including instruments disclosed in U.S. App. No. 17 / 902,685 and U.S. App. No. 16 / 687,520. The end effector 652 can be coupled to a robotic arm 651 by a coupler 605. As described herein, the robotic arm 651 can facilitate robotic movement and / or positioning of the end effector 652, the instrument holders 620, 650, and / or the instruments 756, 757. The robotic arm 651 and the coupler 605 can be identical to or generally similar to the robotic arm 151 and the coupler 200, respectively, as described in more detail with reference to Figures 1 and 2.

[0092] Referring to Figures 6 and 7 collectively, the instrument holders 620, 650 can have a hollow cylindrical body configured to fit and / or maintain a number of the instruments 756, 757. In some embodiments, the instrument holders 620, 650 include one or more twisting locking mechanisms 630, 632 that enable a user to lock the instruments 756, 757 into the instrument holders 620, 650. The instrument holders 620, 650 can further include one or more pivots 615, 617 and one or more compressible members 640, 642, respectively. The pivots 615, 617 can allow for angular rotation of the instruments 756, 757. The instrument holders 620, 650 can rotate about the pivots 615, 617 along the path 610 (e.g., as shown in Figure 6) to angle the instruments 756, 757 toward one another within the patient 755 (e.g., as shown in Figure 7). The compressible members 640, 642 can extend from and / or line an entirety or a portion of the instrument holders 620, 650 such that the compressible members 640, 642 increase the range of motion of the instruments 756, 757, thereby increasing flexibility of positioning the- 40 -125752.8020.WO00\182882826.1instruments 756, 757 within the patient 755. In some embodiments, an entirety of the instrument holders 620, 650 is laterally translatable across a length of the body 600 of the end effector 652 to further increase flexibility of positioning the instruments 756, 757. As described herein, the end effector 652 and the instrument holders 620, 650 can include one or more robotic linkages, motors, etc. that enable the system 100 to dynamically modify the position of the instruments 756, 757. Additionally or alternatively, the end effector 652, the instrument holders 620, 650, and / or the instruments 756, 757 can be manually adjusted by one or more users throughout the surgical procedure to modify the position of the instruments 756, 757.

[0093] In some embodiments, the locking mechanisms 630, 632 enable a user to unlock one or both of the instrument holders 620, 650, remove the current instruments 756, 757, and / or replace the instrument holder(s) 620, 650 with one or more other instruments 756, 757. For example, and as described in more detail with reference to Figures 1 and 2, the instruments 756, 757 can be replaced to perform a new step in the surgical plan, to adjust one or more operating parameters (e.g., triangulation parameters, irrigation parameters), to meet a threshold outcome score, etc. Additionally or alternatively, the locking mechanisms 630, 632 can be configured to lock and / or unlock the instrument holders 620, 650 from the body 600 of the end effector 652 such that the instrument holders 620, 650 can be replaced with different instrument holders 620, 650 generally better suited to the instruments 756, 757. In some embodiments, the instrument holders 620, 650 and the body 600 of the end effector 652 have a separate locking mechanism to the locking mechanisms 630, 632 used to lock and / or unlock the instruments 756, 757 from the instrument holders 620, 650.

[0094] The end effector 652 can be a multi-portal instrument holder configured to hold multiple of the instruments 756, 757. The end effector 652 can assist with positioning of instruments by, for example, limiting movement of the instruments (e.g., movement relative to one another, movement relative to the patient, etc.) to be within a predetermined working envelope, providing robotic guided movement to perform one or more steps of a surgical plan, or the like. The twist lock instrument holders 620, 650 can also be rotatably coupled to the end effector 652 such that the twist lock instrument holders 620, 650, and thereby the instruments 756, 757, can be repositioned a plurality- 41 -125752.8020. WOOO\182882826.1of times throughout the surgical procedure. As described above and herein, the end effector 652 can include two twist lock instrument holders 620, 650 configured to hold one or more visualization instruments (e.g., endoscopes) and / or one or more working instruments to perform a visualization-assisted multi-portal surgical procedure.

[0095] Figure 8 illustrates an end effector 852 of a multi-portal robotic system with one or more clamp instrument holders 820, 850, in accordance with one or more embodiments. The multi-portal robotic system can be, for example, the system 100 of Figure 1. Figure 9 illustrates the end effector 852 of Figure 8 holding instruments 956, 957. The instruments 956, 957 can be identical to or generally similar to the instruments 156, 157 and 756, 757 of Figures 1 and 7, respectively, or other instruments disclosed herein. The end effector 852 can be coupled to a robotic arm 851 by a coupler 805 such that the robotic arm 851 can enable and / or manage robotic movement and / or positioning of the end effector 852, the instrument holders 820, 850, and / or the instruments 956, 957. The robotic arm 851 and the coupler 805 can be identical to or generally similar to the robotic arms 151 , 651 and the couplers 200, 605 as described in more detail with reference to Figures 1-2 and 6-7, respectively.

[0096] Referring to Figures 8 and 9 collectively, the clamp instrument holders 820, 850 can extend from a body 800 of the end effector 852 by one or more elongated members 815, 817. In some embodiments, the elongated members 815, 817 are linearly movable or translatable laterally along a length of the body 800 (e.g., via a track, elongated slot, etc.), increasing the flexibility for positioning the instruments 956, 957 at specified orientations relative to one another. The instrument holders 820, 850 can be spaced apart from one another via a track (not illustrated) within the body 800 that the elongated members 815, 817 can be slid along to reposition the instrument holders 820, 850 and / or the instruments 956, 957. For example, the track can be a linear slot, a serpentine slot, or a slot shaped to define an instrument holder path. In some embodiments, the elongated members 815, 817 are configured to allow the instrument holders 820, 850 to slide along a slot of the body 800 while keeping the instruments 956, 957 positioned along, for example, an imaginary plane, within a working envelope, within an acceptable range of motion, or the like. In some embodiments, the elongated members 815, 817 can be fixedly coupled to the clamp instrument holders 820, 850 such that when- 42 -125752.8020. WOOO\182882826.1the instrument holders 820, 850 are replaced, so are the elongated members 815, 817. Additionally or alternatively, the end effector 852 can omit the track described above an / or the elongated members 815, 817, and the body 800 can be configured to directly couple the clamp instrument holders 820, 850. In some embodiments, the slot can include a pivoter configured to allow rotation of the elongated members 815, 817, the instrument holders 820, 850, and / or the instruments 956, 957.

[0097] The clamp instrument holders 820, 850 can further include a first jaw portion 840, 844 and a second jaw portion 842, 846 coupled together by a joint 830, 832, respectively. Although not explicitly illustrated, one or more portions of the first jaw portions 840, 844 and the second jaw portions 842, 846 can include one or more retention members in the form of, for example, one or more teeth, compressible members, serrated portions, or the like, such that when the clamp instrument holders 820, 850 are moved to a closed configuration (Figure 9), the instruments 956, 957 can be held in place. In some embodiments, the clamp instrument holders 820, 850 can be rotatably coupled to the end effector 852 such that the angular orientation of the instruments 956, 957 can be adjusted by repositioning the instrument holders 820, 850. For example, one or both of the first jaw portions 840, 844 and the second jaw portions 842, 846 can be rotatable about the joints 830, 832. Figures 8 and 9 show the clamp instrument holders 820, 850 movable (indicated by arrows 810 in Figure 8) between an open configuration for receiving instruments and a closed configuration (shown in Figure 9) for holding the instruments 956, 957 toward one another within a patient 955.

[0098] In some embodiments, the end effector 852 can include one or more locking mechanisms configured to lock the elongated members 815, 817, the instrument holders 820, 850, and / or the instruments 956, 957 at, for example, a position, an angular orientation, or the like. The configuration of the body 800, the elongated members 815, 817, and / or the instrument holders 820, 850 can be selected based on the procedure to be performed. In some embodiments, the elongated members 815, 817 and the body 800 of the end effector 852 have a locking mechanism separate from the locking mechanism used to lock and / or unlock the instrument holders 820, 850 to and from the elongated members 815, 817 and / or the instruments 956, 957 to and from the instrument holders 820, 850.- 43 -125752.8020. WOOO\182882826.1

[0099] In some embodiments, the system 100 can dynamically lock and / or unlock the elongated members 815, 817 and the instrument holders 820, 850, remove the current instruments 956, 957, and / or replace the instrument holder(s) 820, 850 with one or more new instruments and / or instrument holders. Additionally or alternatively, a user can manually lock and / or unlock the elongated members 815, 817 and the instrument holders 820, 850, remove the current instruments 956, 957, and / or replace the instrument holder(s) 820, 850 with one or more new instruments and / or instrument holders. In some embodiments, one or more of the components of the end effector 852 (e.g., the elongated members 815, 817, the instrument holders 820, 850, etc.) can be replaced to perform a new step in the surgical plan, to adjust one or more operating parameters (e.g., triangulation parameters, irrigation parameters), to meet a threshold outcome score, etc.

[0100] As described above and herein, one or more components of the end effector 852 and the instrument holders 820, 850 can include one or more robotic linkages, motors, etc. that enable the system 100 to dynamically modify the position of the instruments 956, 957. Additionally or alternatively, the end effector 852, the instrument holders 820, 850, and / or the instruments 956, 957 can be manually adjusted by one or more users throughout the surgical procedure to modify the position of the instruments 956, 957 within the patient 955.D. ADDITIONAL MULTI-PORTAL ROBOTIC SYSTEMS AND TECHNIQUES

[0101] Figure 10 illustrates a top plan view of a multi-portal robotic system surgical kit 1000 (“surgical kit 1000”), in accordance with one or more embodiments. The surgical kit 1000 can include components discussed in connection with Figures 1 -9. The surgical kit 1000 can include, among other components, one or more multi-portal instrument holders 1050, 1052, 1055, one or more split cannulas 1060, 1062, 1064, a set of tubular closed cannulas 1003, a set of ports 1011 , and implants 1038. The configuration and components of the surgical kit 1000 can be selected based on the multi-portal surgical procedure to be performed. Moreover, one or more of the kit’s components can be disposable and can be made from metal, polymer, ceramic, composite, or other biocompatible and sterilizable material. The surgical kit 1000 can further include a- 44 -125752.8020. WOOO\182882826.1container 1017 for holding the components. The container 1017 can be a reusable or disposable box.

[0102] In some embodiments, one or more cannulas 1003, 1060, 1062, 1064 are used to perform one or more steps of the multi-portal surgical procedure. The system and / or a physician can select appropriate cannulas based on the multi-portal surgical procedure, the instruments called for in the surgical plan, the configuration of components in the system (e.g., the surgical robot), etc. In the illustrative embodiment, the one or more split cannulas 1060, 1062, 1064 include three cannulas; however, a higher or lower number of cannulas can be provided and the cannulas can be of the same or different sizes. For example, the split cannulas 1060, 1062, 1064 can have different lengths to provide flexibility to access internal sites. In some embodiments, portions of two or more of the cannulas 1003, 1060, 1062, 1064 can be geometrically congruent. This allows for consistent usage of different instruments. For example, split shafts of cannulas can be geometrically congruent to provide for similar interaction of instruments. In some procedures, both tubular closed cannulas and split cannulas can be utilized. The split cannula can allow the instrument to be moved laterally out of the cannula into a large working space in the patient. As such, instruments can be positioned in relatively large working spaces relative to an access port or incision in the skin (i.e., the incision can be significantly smaller than the size of the working space within the patient). In some embodiments, the cannulas are not used, or are used for only a portion of the surgical procedure. Instead, the one or more multi-portal instrument holders 1050, 1052, 1055 can directly contact, move, and / or position the one or more instruments throughout the surgical procedure.

[0103] The surgical kit 1000 can further include a plurality of decompression instruments. In the illustrated embodiment, the surgical kit 1000 includes a debulking instrument 1020 and a reamer 1022. If the decompression instruments are utilized, the system and / or a physician can select at least one of the ports from the set of ports 1011 configured to fit the decompression instruments. The surgical kit 1000 can also include scalpels, dilators, rongeurs, and / or other working instruments. Additionally or alternatively, the surgical kit 1000 can include one or more visualization tools, such as a set of visualization instruments 1040, 1042 that aid in, for example, positioning one or- 45 -125752.8020.WO00\182882826.1more working instruments for delivery or deployment of the implants 1038. The multiportal instrument holders 1050, 1052, 1055 can be configured to couple cannulas (e.g., cannulas 1060, 1062, 1064), instruments (e.g., working instruments 1020, 1022 or visualization instruments 1040, 1042), or the like. For example, the surgical kit 1000 can include the multi-portal instrument holders 1050, 1052, 1055 discussed herein with reference to the end effectors 152, 652, and 852 in Figures 1 , 2, and 6-9. As described herein, the end effectors, the instrument holders associated with the end effectors, and / or the instruments can be removed and replaced a plurality of times throughout the surgical procedure depending on the instruments (e.g., visualization instrument(s) and / or working instrument(s)) suggested for one or more steps of the surgical plan.

[0104] In operation, the system or a user can select tools based on the location of the working space, predetermined working envelopes, target outcome scores, and / or the like. In some procedures, instruments of different configurations (e.g., lengths, widths, etc.) can be used to sequentially access, remove, and / or view tissue at the working site. The instrument configurations can be selected based on the location (e.g., depth) of the tissue, anatomical structures surrounding access paths and / or targeted tissue, etc.

[0105] Systems, components, and instruments disclosed herein can be disposable or reusable. For example, components of the surgical kit 1000 can be disposable to prevent cross-contamination. As used herein, the term “disposable” when applied to a system or component (or combination of components), such as an instrument holder, cannula, port, dispenser, instrument, tool, or a distal tip or a head (e.g., a reamer head, a rongeur, etc.), is a broad term and generally means, without limitation, that the system or component in question is used a finite number of times and is then discarded. Some disposable components are used only once and are then discarded. In other embodiments, the components and instruments are non-disposable and can be used any number of times. The instrument holders, cannulas, visualization instruments, working instruments, and other kit components can be reusable or disposable and configured to be used with one another.

[0106] Figure 11 illustrates a surgical robot 1140 with multiple moveable robotic arms 1151 , 1153, in accordance with one or more embodiments. The surgical robot 1140- 46 -125752.8020.WO00\182882826.1can be a part of a multi-portal robotic system, for example, the system 100 of Figure 1. Additionally or alternatively, the surgical robot 1140 can be identical to or generally similar to the surgical robot 140 of Figure 1 or any of the other surgical robots described herein. In the illustrative embodiment, the surgical robot 1140 includes two robotic arms (e.g., the robotic arms 1151 , 1153) that can move independent of one another, thereby enabling independent movement of instruments 1156, 1157. Each of the robotic arms 1151 , 1153 can include an end effector 1152, 1154 coupled to instruments 1156, 1157, respectively. In some embodiments, at least one of the robotic arms 1151 , 1153 is configured to hold one or more visualization instruments and the other one of the robotic arms 1151 , 1153 is configured to hold one or more working instruments to perform a visualization-assisted multi-portal surgical procedure, as described herein.

[0107] In the illustrative embodiment, each of the robotic arms 1151 , 1153 is coupled to one of the end effectors 1152, 1154 configured to hold, move, and / or position one of the instruments 1156, 1157 within a patient 1155. However, it is worth noting that each of the robotic arms 1151 , 1153 can be coupled to a multi-portal end effector (e.g., the end effectors 152, 652, 852 of Figures 1 , 2, and 6-9) or any one of the multi-portal end effectors or multi-portal instrument holders described herein. For example, one of the robotic arms 1151 , 1153 can be coupled to a multi-portal end effector whereas the other one of the robotic arms 1151 , 1153 can be coupled to an end effector configured to hold only one instrument.

[0108] In some embodiments, a user 1118 can select one or more of the robotic arms 1151 , 1153 to perform one of the surgical steps in the surgical plan while the surgical robot 1140 autonomously controls one or more of the other robotic arms 1151 , 1153 to concurrently perform another one of the surgical steps. In another example, the system 100 can perform one or more steps of the multi-portal surgical procedure according to the surgical plan. For example, the surgical plan can include one or more robotic arm control plans that coordinate one or more steps of the surgical plan between the robotic arms 1151 , 1153, the end effectors 1152, 1154, and / or the instruments 1156, 1157 without user input. In some embodiments, the use of multiple robotic arms 1151 , 1153 enables the surgical robot 1140 to perform generally more complicated multi-portal surgical procedures. Although Figure 11 illustrates a surgical robot 1140 including two robotic- 47 -125752.8020. WOOO\182882826.1arms 1151 , 1153, three or more robotic arms can also be included. For example, the surgical robot 1140 can perform surgical procedures involving three, four, or five surgical arms, each with one or more end effectors 1152, 1154 and / or multi-portal end effectors.

[0109] Figure 12 illustrates a surgical robot 1240 with a multi-modality imaging system 1263, in accordance with one or more embodiments. The surgical robot 1240 can be a part of a multi-portal robotic system, for example, the system 100 of Figure 1. Additionally or alternatively, the surgical robot 1240 can be identical to or generally similar to the surgical robots 140, 1140 of Figures 1 and 11 , respectively, or any of the other surgical robots described herein. In the illustrative embodiment, the surgical robot 1240 includes a robotic arm 1251 that enables movement of a multi-portal end effector 1252 (“end effector 1252”). The end effector 1252 can couple one or more instruments 1256, 1257 as described in more detail with reference to the end effectors 152, 652, 852, 1152, 1154 of Figures 1 , 2, 6-9, and 11 . In some embodiments, at least one of the instruments 1256, 1257 is a visualization instrument (e.g., an endoscope) and the other one of the instruments 1256, 1257 is a working instrument.

[0110] The multi-modality imaging system 1263 can have one or more imaging devices 1264a, 1264b (collectively “imaging devices 1264”). The imaging devices 1264 can be, for example, positron-emission tomography (PET) scanners, ultrasound imagers, magnetic resonance imaging (MRI) imagers, computed tomography (CT) scanners, cameras (e.g., camera imager hardware, digital cameras, etc.), infrared imagers, etc. In some embodiments, the surgical robot 1240 retrieves / receives images from stand-alone X-ray machines, MRI machines, CT scanners, etc. The number, imaging capabilities, and configurations of the imaging devices 1264 can be selected based on the multi-portal surgical procedure, the surgical plan, and / or the imaging to be performed. In some embodiments, the surgical robot 1240 can control both a visualization instrument for direct visualization and the multi-modality imaging system 1263 (e.g., one or more of the imaging devices 1264) for continuous visualization throughout the surgical procedure. For example, at least one of the instruments 1256, 1257 can be a visualization instrument used in combination or substituted with other visualization techniques, such as one or more of fluoroscopy, MRI imaging, CT imaging, etc. In some procedures, the- 48 -125752.8020.WO00\182882826.1intraoperative imaging can be displayed via one or more digital screens (e.g., endoscopic imaging and fluoroscopy on different screens) in the operating room.

[0111] The system 100 can perform multi-modality imaging preoperatively, intraoperatively, and / or post-operatively. Preoperative images can be used to generate preoperative surgical plans that can be dynamically updated throughout the surgical procedure according to visualization obtained from, for example, a visualization instrument and / or the multi-modality imaging system 1263. In some embodiments, the end effector 1252 can be periodically reconfigured throughout the procedure depending on the surgical step being performed and / or the results of intraoperative imaging. For example, if the instruments 1256, 1257 need to be repositioned for installation of a spinal implant in the intervertebral space, the surgical robot 1240 can automatically adjust the position of one or more of the instruments 1256, 1257 in a patient 1255 using the end effector 1252. Additionally or alternatively, a user 1218 can manually modify, remove, and / or reattach one or more of the instruments 1256, 1257 from the end effector 1252 to set the instruments 1256, 1257 at a distance that is preferred for installation of the implant. In some embodiments, at least one of the instruments 1256, 1257 is an endoscope positioned to view at least a portion of an intervertebral disc, vertebral bodies, and / or the distal portion of the other one of the instruments 1256, 1257. Fluoroscopy, MRI imaging, CT imaging, direct visualization, or other visualization techniques can also be used in addition to or in lieu of the endoscopic viewing.

[0112] In some embodiments, the system 100 performs one or more multi-modality analyses in which the multi-modality imaging system 1263 performs (sequentially or concurrently) multiple scans / tests, such as CT scans, radiation tests, sound tests, optical tests, acoustic tests, photoacoustic tests, combinations thereof, or the like. In some embodiments, a multi-modality image can simultaneously image a working site and / or target area to capture images with matching perspectives relative to the working site and / or target area such that features from one image can be overlayed onto another, features from multiple images can be stitched together to form a composite image, and / or cross-image features identification can be performed.- 49 -125752.8020.WO00\182882826.1

[0113] In some embodiments, imaging from the multi-modality imaging system 1263 can be analyzed preoperatively and / or as the surgical procedure is being performed. For example, the multi-modality imaging system 1263 can take one or more scans of the target region that the system 100 can use to perform one or more analysis tests. In a single scan test, the system 100 can concurrently perform multiple tests while moving along the patient’s spine. In multiple scan tests, the system 100 can sequentially perform tests during corresponding scans and / or concurrently perform multiple tests during each scan. The system 100 can perform different testing, imaging, and / or scanning protocols based on the analysis to be performed. In some embodiments, the system 100 performs analysis using additional tests to calculate the position of one or more of the instruments 1256, 1257, calculate the triangulation parameters of the instruments 1256, 1257 relative to one another or a target area, confirm or compare visualization of the working site, create three-dimensional models, and / or the like.

[0114] Further, the system 100 can combine the results from the multi-modality imaging system 1263 with visualization from a visualization instrument to provide generally more information on a target region, working site, or combinations thereof. For example, the system 100 can combine the results from the multi-modality imaging system 1263 with image data from a visualization instrument to determine whether visualization at a working site in the form of an intraoperative simulation, model, etc., substantially matches predicted visualization for the surgical step and / or portion of the multi-portal surgical procedure. The system 100 can analyze the combination of results to, for example, determine whether to modify the surgical plan, modify one or more positions of the instruments 1256, 1257, modify one or more irrigation parameters, and / or replace one or more of the instruments 1256, 1257, instrument holders, and / or end effector 1252.

[0115] The multi-modality imaging system 1263 can include any number or configuration of the imaging devices 1264 capable of collecting data which can be used to create an image, or a representation of a physical structure or phenomena. The imaging devices 1264 may include any devices capable of detecting sound or electromagnetic waves and assembling a visual representation of the detected waves. The imaging devices 1264 may collect waves from any part of the electromagnetic spectrum or sounds at any range of frequencies, often as a matrix of independently- 50 -125752.8020.WO00\182882826.1acquired measurements which each represent a pixel of a two- or three-dimensional image. These measurements may be taken simultaneously or in series via a scanning process or a combination of methods. Some pixels of an image produced by an imaging device can be interpolated from direct measurements representing adjacent pixels in order to increase the resolution of a generated image.

[0116] The multi-modality imaging system 1263 can include an algorithm or software module capable of determining qualitative or quantitative data from medical images. The algorithm can be a deep learning algorithm trained on a data set of medical images. The multi-modality imaging system 1263 may further refer to a system used to acquire medical imagery by any means including MRI, CT, X-ray, PET, ultrasound, arthrography, fluoroscopy, or myelography.

[0117] The multi-modality imaging system 1263 can acquire images that can be annotated with, for example, target areas, non-target areas, patient information, procedure information, and / or the like. The patient information can include, without limitation, three-dimensional models of the patient’s spine labeled with target intervertebral bodies, non-target tissue and nerves, etc. The procedure information can include, for example, completed surgical steps, planned future surgical steps, triangulation parameters, working envelope ranges, irrigation parameters, implant sites, instrument orientation information, and other information discussed in connection with Figures 1-9, and other information disclosed herein.

[0118] Figure 13 is a flow diagram illustrating an example process 1300 for using a multi-portal robotic system, in accordance with one or more embodiments. The multiportal robotic system can be, for example, the system 100 of Figure 1. One or more of the steps described herein can be initiated and / or executed by one or more of a user (e.g., the users 119, 121 of Figure 1 ), a controller (e.g., the controller 150 of Figures 1 and 5), or any other computing device in a network of the system 100 (e.g., the network 104 of Figure 1 ). As described below, the process 1300 is initiated and executed by a controller with user interaction at one or more steps of the process 1300. However, one skilled in the art will appreciate that, for this process and other processes and methods disclosed herein, the functions performed in the processes and methods may be- 51 -125752.8020.WO00\182882826.1performed entirely by the controller, or another computing device, and / or in a differing order. Furthermore, the outlined steps and operations are only provided as examples, and some of the steps and operations may be optional, combined into fewer steps and operations, or expanded into additional steps and operations without detracting from the essence of the disclosed embodiments.

[0119] Initially, at step 1302, a controller can obtain images of a patient. The images obtained can include one or more images stored in a patient module of the controller and associated with the patient’s patient ID. Additionally or alternatively, the controller can initiate one or more external imaging devices to obtain the images. At step 1304, the controller can generate a preoperative model of a surgical site using the images obtained. The preoperative model can include an entirety of a patient, for example, a three- dimensional twin of the patient, and / or the preoperative model can be limited to just the working site of the patient (e.g., the patient’s spine, etc.). At step 1306, the controller identifies one or more target area(s) and non-target areas in the preoperative model. The one or more target areas and non-target areas can be identified using historical data (e.g., data from previous procedures, previous patient data, physician preferences, etc.). The system can also access one or more databases (e.g., triangulation databases, procedural databases, patient databases, etc.) to identify targeted tissue, non-targeted tissue, working envelopes, surgical procedure parameters, and / or target patient outcomes. Additionally or alternatively, a physician can manually identify and / or adjust targeted tissue, non-targeted tissue, working envelopes, surgical procedure parameters, and / or target patient outcomes using a user interface. The non-target areas can include, for example, one or more healthy discs, vertebrae, spinal cord / nerves, and / or other spinal structures.

[0120] In some embodiments, the user performs one or more virtual simulations on the preoperative model to identify target areas and non-target areas and / or to plan one or more steps of the surgical procedure. For example, the user can simulate one or more steps of a multi-portal surgical procedure, selecting one or more surgical robotic end effectors, instrument holders, cannulas, working instruments, visualization instruments, and / or irrigation flow rates to perform each of the one or more steps. The virtual simulations can be used to identify and plan visualization of the target area throughout- 52 -125752.8020.WO00\182882826.1the surgical procedure. In some embodiments, visualization planning can further include use of multi-modality imaging such as both endoscopic imaging and external imaging. A user can select the type of imaging, overlaying of images, annotating of images, and other data sources for performing virtual simulations. The system can predict triangulation parameters, working envelopes for positioning instruments, irrigation parameters, and / or the like for reaching the simulated visualization. The simulations can predict the types of images the physician will see at the surgical site throughout the procedure based on the instruments and parameters selected. For example, the controller can save the one or more simulations, images, models, etc. for intraoperative monitoring throughout the surgical procedure and / or to modify one or more instrument and / or procedural parameters to reach a threshold outcome score, as described herein. The system can score one or more of the steps the user performs virtually, including identifying target areas, avoiding non-target areas, etc., such that a surgical plan with the highest threshold outcome score can be generated.

[0121] At step 1308, a user selects a navigation program, via the user interface, for performing a multi-portal surgical procedure. The navigation program can be associated with endoscopic fusion procedures, decompression procedures, a number of levels, surgical approaches (e.g., ALIF, TLIF), etc. For example, each navigation program can be associated with a different set of end effectors, instruments, working / triangulation envelope parameters, etc. used for visualization planning and generating a surgical plan specific to the patient and the type of procedure being performed. The navigation program can further be associated with one or more historical surgical procedures that can be used for planning procedural visualization and / or generating a surgical plan specific to the type of procedure being performed. In some embodiments, a multi-portal endoscopic visualization plan is synchronized with one or more steps of the surgical plan to provide viewing of each step.

[0122] At step 1310, the controller generates a surgical plan for the multi-portal surgical procedure to meet a threshold outcome score. The threshold outcome score can be representative of the success of the surgical procedure (e.g., the likelihood of successfully delivering the implants to the target area, etc ). The surgical plan can be generated, at least in part, by identifying one or more steps performed virtually by the- 53 -125752.8020.WO00\182882826.1user on the preoperative model of the patient. In some embodiments, a user’s surgical maneuvers on the preoperative model can be recognized and recorded as part of the surgical plan. Each of the one or more surgical maneuvers can be linked to at least one working instrument and / or at least one visualization instrument. Additionally or alternatively, the surgical plan can be identified using historical surgical plans associated with the surgical procedure to be performed. For example, the controller can reference past procedures that are similar to the multi-portal surgical procedure to be performed. A combination of steps performed by the user in the surgical simulation and steps from historical surgical plans can be used to generate a surgical plan with the highest outcome score.

[0123] At step 1312, the controller can predict the visualization instruments, working instruments, instrument holders, and / or end effectors needed to perform the multi-portal surgical procedure according to the surgical plan generated and to meet the threshold outcome score. Additionally or alternatively, the controller can predict endoscopes and / or multi-modality imaging instruments needed for intraoperative monitoring of surgical sites, instrument operation parameters, instrument positioning (e.g., triangulation / working envelopes), and irrigation parameters.

[0124] At step 1314, the user inputs the materials required for performing a step in the surgical plan. The user can select the one or more end effectors, instrument holders, instruments, etc. associated with the surgical plan and set up a surgical robot (e.g., the surgical robot 140 of Figure 1 ) for performing at least one step of the surgical plan. At step 1316, the system can perform one or more steps of the surgical plan with the surgical robot. The surgical robot can be programmed to execute these steps on the patient according to the surgical plan. The system can, for example, confirm positioning using external imaging via one or more cameras, stored positioning information (e.g., preoperative images, simulations, parameters, etc.), and / or the like. The system can further determine positioning using the user’s feedback, via the user interface or console, and / or using intraoperative images available from the one or more imaging sources, including fluoroscopy and endoscopic cameras. The system can automatically determine and / or perform any adjustments to the instrument and / or patient (e.g., repositioning of the patient) before performing or while performing the surgical step.- 54 -125752.8020.WO00\182882826.1

[0125] At step 1318, the controller can obtain images of the surgical site from, for example, a visualization instrument being used and / or one or more external imaging devices. In some embodiments, the system automatically requests images of the surgical site after completion of at least one of the surgical steps is determined. Additionally or alternatively, the user can notify the system of completion of the surgical step and / or request intraoperative images. The surgical plan can be modified during the operation based on the images obtained from, for example, one or more of the instruments or imaging devices within or at the working site. For instance, the position of a working instrument can be adjusted based on endoscopic viewing to ensure a minimum outcome score is maintained.

[0126] At step 1320, the controller can generate an intraoperative model of the surgical site using the intraoperative images obtained. The intraoperative images and / or intraoperative model can be overlayed with preoperative images, models, and / or simulations to determine whether the surgical site generally matches the expected visualization corresponding to the one or more surgical steps performed. At step 1322, the controller calculates a confidence score using the intraoperative simulations / models. The confidence score can be representative of the success of the surgical procedure based on real-time images and / or sensor data (e.g., patient vitals, flow rates coming from instruments, etc.). Additionally or alternatively, the confidence score can be a score indicative of whether the intraoperative model substantially matches the preoperative model, images, or simulation expected at this point in the surgical plan.

[0127] At step 1324, the controller determines whether the confidence score calculated is below a threshold outcome score. In response to a determination that the confidence score at least meets the threshold outcome score, the controller continues performing the multi-portal surgical procedure according to the surgical plan at step 1314.

[0128] In response to a determination that the confidence score is below the threshold outcome score, the controller can dynamically modify the surgical plan to meet the threshold outcome score, at step 1326. For example, in some embodiments, the intraoperative model can be used to simulate one or more of the next steps in the surgical plan, determine a positioning plan for triangulation to reach the preplanned visualization- 55 -125752.8020.WO00\182882826.1or a user-inputted visualization, compare threshold outcome scores of automated versus user-controlled steps, and / or the like. The controller or user can initiate the surgical robot modifying instrument positions and / or irrigation parameters to improve visualization and / or to meet a threshold outcome score. Additionally or alternatively, the controller can notify a user to replace one or more of the end effectors, instrument holders, and / or instruments based on the modified surgical plan.

[0129] Figure 14 is a flow diagram illustrating an example process 1400 for using a multi-portal robotic system, in accordance with one or more embodiments. The multiportal robotic system can be, for example, the system 100 of Figure 1. As described above, one or more of the steps described herein can be initiated and / or executed by one or more of a user (e.g., the users 119, 121 of Figure 1 ), a controller (e.g., the controller 150 of Figures 1 and 5), or any other computing device in a network of the system 100 (e.g., the network 104 of Figure 1). The process 1400 can be performed in combination with one or more steps of the process 1300 described in Figure 13 and any of the other processes or methods described herein.

[0130] At step 1402, a controller can perform one or more steps of the surgical plan with, for example, a surgical robot (e.g., the surgical robot 140 of Figure 1 ) and as described in more detail with reference to step 1316 of Figure 13. At step 1404, the controller can obtain intraoperative images of a surgical site using, for example, one or more visualization instruments or external imaging devices positioned within and / or near the patient. For example, an endoscope can be one of the instruments at the surgical site, and one or more endoscopic views or images of the surgical site can be used to identify the position of a working instrument relative to the endoscope and / or the target area. Additionally or alternatively, other imaging modalities (e.g., fluoroscopy, X-ray, MRI scans, CT scans, etc.) can be used to determine intraoperative conditions at the surgical site. In some embodiments, one or both of the instruments can include one or more sensors that can be used to track positioning of the instruments relative to one another and / or the target area. The process of obtaining intraoperative images can be performed as described in more detail with reference to step 1318 of Figure 13.- 56 -125752.8020.WO00\182882826.1

[0131] At step 1406, the controller can generate an intraoperative model of the surgical site using the intraoperative images obtained to, for example, determine and visualize positioning of one or more instruments relative to one another and / or the target area. At step 1408, the controller can identify one or more target area(s) and non-target areas in the intraoperative model. The processes for generating an intraoperative model and identifying one or more target areas and / or non-target areas are described in more detail with reference to steps 1320 and 1306, respectively, of Figure 13. In some embodiments, the intraoperative model can display current conditions at the surgical site, for example, visualization of a target vertebral body, removal of tissue, deployment of a vertebral implant, etc. The intraoperative model can be overlayed with one or more images, models, or simulations taken preoperatively and / or at previous steps of the surgical procedure. For example, each of the steps of the surgical procedure can be associated with a stored expected visualization of the surgical site at that point in the surgical procedure. The expected visualization can include one or more expected positions for the instruments at the surgical site, such as triangulation parameters associated with the instruments. The expected positions can be compared to intraoperative positions of the instruments, as described herein.

[0132] At step 1410, the controller determines the positions of a visualization instrument and a working instrument in the intraoperative model. As described above, the instruments can include one or more sensors that can detect the positions of the instruments in the intraoperative model. Additionally or alternatively, the controller can perform image analysis to determine positions of the instruments in the intraoperative model. At step 1412, the controller can use the determined positions of the instruments in the intraoperative model to calculate one or more triangulation parameters representative of the position of the instruments relative to the target area(s) identified, non-target areas identified, one another, etc. For example, the triangulation parameters can include an angular orientation, a trajectory, a depth, a distance, etc. It is worth noting that although the triangulation parameters discussed herein primarily relate to the positions of the instruments, one or more of the instrument holders, end effectors, and / or other components of the system can have triangulation parameters associated with their position relative to other instruments or components at the surgical site throughout the- 57 -125752.8020.WO00\182882826.1surgical procedure. Accordingly, one or more of the instrument holders, end effectors, and / or other components of the system can include sensors to track position and / or can be a part of the intraoperative model.

[0133] At step 1414, the controller determines whether the triangulation parameter is below a threshold triangulation parameter. The threshold triangulation parameter can be associated with the one or more steps of the surgical plan performed (e.g., at step 1402) and / or can be associated with a threshold outcome score representative of the surgical procedure being performed successfully. In response to a determination that the triangulation parameter at least meets the threshold triangulation parameter, the controller continues performing the surgical procedure according to the current surgical plan at step 1402. In response to a determination that the triangulation parameter is below the threshold triangulation parameter, the controller can determine whether one or more of the positions of the instruments, instrument holders, and / or end effectors, and / or one or more parameters (e.g., irrigation parameters) can be modified to meet or be within the threshold triangulation parameter at step 1416. If one or both of the visualization instrument and / or the working instrument can be modified to meet or be within the threshold triangulation parameter, then at step 1418, the controller can cause, for example, the surgical robot to dynamically modify one or more of the positions of the working instrument and / or the visualization instrument while avoiding the identified nontarget areas. In some embodiments, the modifications can include parameter modifications, such as increasing or decreasing the flow of fluid from an irrigation device at the surgical site to increase visualization of a distal end of one or both of the instruments.

[0134] In response to a determination that the visualization instrument position and / or the working instrument position are not modifiable to maintain the threshold triangulation parameter, then at step 1420, the controller can notify the user to replace at least one of the visualization instrument, the working instrument, the instrument holder(s), and / or the end effector(s). In some embodiments, modifying a position of the instruments and / or replacing one or more components of the system can allow the system to maintain visualization of a distal end of the working instrument relative to the target area while avoiding non-target areas. Additionally or alternatively, modifying a position of the- 58 -125752.8020.WO00\182882826.1instruments and / or replacing one or more components of the system can allow the instruments to remain within a predetermined working envelope associated with the surgical procedure. As described herein, one or more component(s) modifications and / or replacements can increase the likelihood of successfully performing the multi-portal surgical procedure.

[0135] The present technology is illustrated, for example, according to various aspects described below as numbered examples (1 , 2, 3, etc.) for convenience. These are provided as examples and do not limit the present technology. It is noted that any of the dependent examples may be combined in any combination, and placed into a respective independent example. The other examples can be presented in a similar manner.1. A computer-implemented method for performing a multi-portal robotic surgical procedure, comprising: endoscopically viewing, using a visualization instrument positioned in a first port along a patient, a plurality of working instruments positioned in a second port along the patient according to a multi-portal endoscopic visualization plan, wherein the second port is spaced apart from the first port; and performing, using a surgical robot, at least a portion of the multi-portal robotic surgical procedure on the patient using the plurality of working instruments according to a surgical plan based on the endoscopic viewing.2. The computer-implemented method of example 1 , wherein one or more steps of the surgical plan are associated with at least one of an instrument holder, a working instrument of the plurality of working instruments, or the visualization instrument, the method further comprising determining a triangulated positional relationship between the visualization instrument and the working instrument for endoscopically viewing a working site while performing the one or more steps using the working instrument.- 59 -125752.8020.WO00\182882826.13. The computer-implemented method of example 1 or example 2, further comprising performing a preoperative simulation for generating the multi-portal endoscopic visualization plan.4. The computer-implemented method of any of examples 1-3, further comprising: performing an intraoperative simulation of visualization of a working site in the patient; and modifying the multi-portal endoscopic visualization plan based on the intraoperative simulation.5. The computer-implemented method of example 4, further comprising: determining a visualization score based on the intraoperative simulation; and determining one or more modifications to at least one of the surgical plan or the multi-portal endoscopic visualization plan based on the visualization score being below a target score.6. The computer-implemented method of any of examples 1-5, wherein the surgical plan includes steps for installing working instruments in the surgical robot.7. The computer-implemented method of any of examples 1-6, wherein the surgical robot is programmed to position the visualization instrument to view a working site in the patient based on a surgical step to be performed.8. The computer-implemented method of any of examples 1-7, further comprising performing, using the surgical robot, the at least the portion of the multi-portal robotic surgical procedure on the patient based on at least one of: one or more images from a camera; one or more fluoroscopic images; or computer vision.- 60 -125752.8020.WO00\182882826.19. The computer-implemented method of any of examples 1-8, wherein the multi-portal endoscopic visualization plan is synchronized with one or more steps of the surgical plan.10. The computer-implemented method of any of examples 1-9, further comprising modifying the multi-portal endoscopic visualization plan based on output from edge computing performed by the surgical robot using one or more images from the visualization instrument.11 . The computer-implemented method of any of examples 1-10, wherein the multi-portal endoscopic visualization plan is part of the surgical plan, and wherein the working instruments are sequentially positioned in the second port.12. A multi-portal robotic system for performing a multi-portal surgical procedure, comprising: one or more processors; and a non-transitory computer-readable storage medium storing computer instructions, which when executed by the one or more processors cause a surgical robot to perform a method of examples 1-11.13. A computer-implemented method for performing a multi-portal robotic surgical procedure, comprising: obtaining one or more images of a patient; generating a preoperative model of a working site in the patient using the one or more images; generating a surgical plan for the multi-portal robotic surgical procedure, wherein each step of the surgical plan is associated with at least one of an instrument holder, a working instrument, or a visualization instrument configured for endoscopic viewing;- 61 -125752.8020.WO00\182882826.1simulating endoscopic visualization of one or more steps of the surgical plan on the preoperative model according to a multi-portal endoscopic visualization plan; and determining whether the endoscopic visualization meets a visualization score.14. The computer-implemented method of example 13, further comprising: in response to a determination that the endoscopic visualization meets the visualization score, storing at least a portion of the endoscopic visualization for reference during the multi-portal robotic surgical procedure.15. The computer-implemented method of example 13 or example 14, further comprising: in response to a determination that the endoscopic visualization does not meet the visualization score, modifying the surgical plan.16. The computer-implemented method of any of examples 13-15, wherein the surgical plan includes the multi-portal endoscopic visualization plan, wherein one or more of the steps are surgical steps, and wherein the multi-portal endoscopic visualization plan includes at least one target position for the endoscopic visualization instrument to view the surgical steps.17. The computer-implemented method of example 15, wherein modifying the surgical plan includes changing one or more triangulation parameters that correspond to a position of the working instrument relative to the visualization instrument.18. The computer-implemented method of claim 15, wherein modifying the surgical plan includes changing one or more triangulation parameters that correspond to a position of an instrument relative to a target area.19. The computer-implemented method of any of examples 13-18, wherein the visualization score indicates that the visualization instrument is positioned in a working- 62 -125752.8020.WO00\182882826.1envelope, which is determined by one or more triangulation parameters, and wherein the one or more triangulation parameters correspond to at least one of a distance, an orientation, a trajectory, a spinal reference frame, or a depth of one or more instruments.20. The computer-implemented method of example 15, wherein modifying the surgical plan includes changing one or more irrigation parameters associated with a flow rate of a fluid at the working site.21. The computer-implemented method of example 15, wherein modifying the surgical plan includes replacing at least one of the instrument holder, the working instrument, or the visualization instrument corresponding to at least one step of the surgical plan.22. The computer-implemented method of any of examples 13-21 , further comprising referencing the endoscopic visualization while performing the multi-portal robotic surgical procedure to monitor adherence to the surgical plan.23. The computer-implemented method of any of examples 13-22, wherein the endoscopic visualization represents an expected visualization image at the working site after performing at least one step of the surgical plan on the patient.24. The computer-implemented method of example 23, further comprising: comparing the expected visualization image to an intraoperative image taken after performing the at least one step of the surgical plan on the patient; in response to a determination that the expected visualization image substantially matches the intraoperative image, continuing to perform the multi-portal robotic surgical procedure according to the surgical plan; and in response to a determination that the expected visualization image does not substantially match the intraoperative image, modifying the surgical plan.- 63 -125752.8020.WO00\182882826.125. The computer-implemented method of any of examples 13-24, further comprising identifying one or more target areas and one or more non-target areas in the preoperative model, wherein the one or more non-target areas include nerve tissue.26. The computer-implemented method of any of examples 13-25, further comprising: storing the preoperative model for reference throughout the multi-portal robotic surgical procedure.27. The computer-implemented method of any of examples 13-26, further comprising selecting one of a plurality of navigation programs for the multi-portal robotic surgical procedure, and wherein each of the plurality of navigation programs is associated with a set of instrument holders, working instruments, visualization instruments, triangulation parameters, irrigation parameters, and / or historical surgical data.28. The computer-implemented method of any of examples 13-27, wherein the surgical plan is generated by identifying one or more actions performed by a user on the preoperative model.29. The computer-implemented method of any of examples 13-28, wherein the surgical plan is generated by: identifying one or more surgical actions performed by a user on the preoperative model; and comparing the one or more surgical actions performed by the user to historical surgical data from surgical procedures similar to the multi-portal robotic surgical procedure to be performed.30. A multi-portal robotic system for performing a multi-portal surgical procedure by a surgical robot, comprising: one or more computer processors; and- 64 -125752.8020.WO00\182882826.1a non-transitory computer-readable storage medium storing computer instructions, which when executed by the one or more computer processors cause the surgical robot to: obtain one or more images of a patient; generate a preoperative model of a working site in the patient using the one or more images; display the preoperative model, via an electronic display, for viewing by a user; generate a surgical plan for the multi-portal surgical procedure, wherein each step of the surgical plan is associated with at least one of an instrument holder, a working instrument, or a visualization instrument configured for endoscopic viewing; simulate endoscopic visualization of one or more steps of the surgical plan on the preoperative model according to a multi-portal endoscopic visualization plan; and determine whether the endoscopic visualization meets a visualization score.31. The multi-portal robotic system of example 30, wherein the computer instructions cause the robotic system to, in response to a determination that the endoscopic visualization meets the visualization score, store at least a portion of the endoscopic visualization for reference during the multi-portal surgical procedure.32. The multi-portal robotic system of example 30 or example 31 , wherein the computer instructions cause the robotic system to, in response to a determination that the endoscopic visualization does not meet the visualization score, modify the surgical plan.33. The multi-portal robotic system of any of examples 30-32, wherein the surgical plan includes the multi-portal endoscopic visualization plan, wherein one or more of the steps are surgical steps, and wherein the multi-portal endoscopic visualization plan- 65 -125752.8020.WO00\182882826.1includes at least one target position for the endoscopic visualization instrument to view the surgical steps.34. The multi-portal robotic system of any of examples 30-33, wherein the computer instructions cause the robotic system to: identify one or more surgical actions performed by the user on the preoperative model; and generate the surgical plan based on the one or more surgical actions identified.35. The multi-portal robotic system of any of examples 30-34, wherein the computer instructions cause the robotic system to: identify one or more surgical actions performed by the user on the preoperative model; generate a first surgical plan based on the one or more surgical actions identified; generate a second surgical plan based on historical surgical plans from surgical procedures similar to the multi-portal surgical procedure to be performed; compare one or more outcome scores of one or more steps corresponding to the first surgical plan to one or more outcome scores of one or more steps corresponding to the second surgical plan; and in response to a determination that the one or more outcome scores of the one or more steps corresponding to the second surgical plan exceed at least one of the one or more outcome scores of the one or more steps corresponding to the first surgical plan, modify the first surgical plan to include the one or more steps corresponding to the second surgical plan.36. The multi-portal robotic system of any of examples 30-35, wherein the computer instructions cause the robotic system to: perform one or more steps of the surgical plan on the patient; obtain one or more intraoperative images of the working site in the patient;- 66 -125752.8020.WO00\182882826.1compare the one or more intraoperative images to the endoscopic visualization corresponding to one or more steps of the multi-portal endoscopic visualization plan; in response to a determination that the one or more intraoperative images substantially match the endoscopic visualization, continue to perform the multi-portal surgical procedure according to the surgical plan; and in response to a determination that the one or more intraoperative images do not substantially match the endoscopic visualization, modify the surgical plan.37. The multi-portal robotic system of any of examples 30-36, wherein the computer instructions cause the robotic system to: perform one or more steps of the surgical plan on the patient; obtain one or more intraoperative images of the working site in the patient; generate an intraoperative model of the working site in the patient using the one or more intraoperative images; determine positions of the working instrument and the visualization instrument in the intraoperative model; calculate a triangulation parameter representative of a position of the working instrument and a position of the visualization instrument relative to one another; compare the triangulation parameter to a working envelope associated with the one or more steps of the surgical plan performed; in response to a determination that the triangulation parameter is within the working envelope, continue to perform the multi-portal surgical procedure according to the surgical plan; and in response to a determination that the triangulation parameter is not within the working envelope, modify the surgical plan.38. The multi-portal robotic system of example 37, wherein to modify the surgical plan, the computer instructions cause the robotic system to:- 67 -125752.8020.WO00\182882826.1in response to a determination that at least one of the working instrument or the visualization instrument can be repositioned to be within the working envelope, dynamically modify at least one position of the working instrument or the visualization instrument; and in response to a determination that at least one of the working instrument or the visualization instrument cannot be repositioned to be within the working envelope, notify the user to replace at least one of the instrument holder, the working instrument, or the visualization instrument.39. A computer-implemented method for performing a multi-portal robotic surgical procedure, comprising: performing one or more steps of a surgical plan on a patient; obtaining one or more intraoperative images of a working site in the patient; generating an intraoperative model of the working site using the one or more intraoperative images; determining a position of a visualization instrument and a position of a working instrument in the intraoperative model; calculating a triangulation parameter representative of the position of the working instrument and the position of the visualization instrument relative to one another; and comparing the triangulation parameter to a working envelope associated with the one or more steps performed.40. The computer-implemented method of example 39, further comprising in response to a determination that the triangulation parameter is within the working- 68 -125752.8020.WO00\182882826.1envelope, continuing to perform the multi-portal robotic surgical procedure according to the surgical plan.41. The computer-implemented method of example 39 or example 40, further comprising in response to a determination that the triangulation parameter is not within the working envelope, modifying the surgical plan.42. The computer-implemented method of example 41 , wherein modifying the surgical plan further comprises: in response to a determination that at least one of the working instrument or the visualization instrument can be repositioned to be within the working envelope, dynamically modifying at least one of the position of the working instrument or the position of the visualization instrument; and in response to a determination that at least one of the working instrument or the visualization instrument cannot be repositioned to be within the working envelope, notifying a user to replace at least one of an instrument holder, the working instrument, or the visualization instrument.43. The computer-implemented method of example 41 , wherein modifying the surgical plan further comprises: changing one or more irrigation parameters associated with a flow rate of a fluid at the working site.44. The computer-implemented method of any of examples 39-43, further comprising: determining a first position of the working instrument relative to a target area and a second position of the visualization instrument relative to the target area; and calculating a triangulation parameter representative of the first position and the second position relative to one another.- 69 -125752.8020.WO00\182882826.1

[0136] The foregoing detailed description has set forth various embodiments of the devices and / or processes via the use of block diagrams, flowcharts, and / or examples. Insofar as such block diagrams, flowcharts, and / or examples contain one or more functions and / or operations, it will be understood by those within the art that each function and / or operation within such block diagrams, flowcharts, or examples can be implemented, individually and / or collectively, by a wide range of hardware, software, firmware, or virtually any combination thereof.

[0137] The above detailed descriptions of embodiments of the technology are not intended to be exhaustive or to limit the technology to the precise form disclosed above. Although specific embodiments of, and examples for, the technology are described above for illustrative purposes, various equivalent modifications are possible within the scope of the technology, as those skilled in the relevant art will recognize. For example, while steps are presented in a given order, alternative embodiments may perform steps in a different order. Features from various systems, methods, instruments, and / or instrument holders can be combined with features disclosed in U.S. Provisional Patent Application No. 63 / 673,239; U.S. App. No. 15 / 793,950; U.S. App. No. 17 / 902,685; U.S. App. No. 18 / 988,467; U.S. App. No. 18 / 464,949; U.S. App. No. 18 / 470,140; U.S. App. No. 18 / 764,784; U.S. Pat. No. 8,632,594; U.S. Pat. No. 9,308,099; U.S. Pat. No. 10,105,238; U.S. Pat. No. 10,201 ,431 ; U.S. Pat. No. 10,898,340; U.S. Pat. No. 9,820,788; U.S. Pat. No. 10,322,009; U.S. Pat. No. 11 ,464,648; U.S. Pat. No. 11 ,950,770; U.S. App. No. 63 / 568,701 ; U.S. App. No. 18 / 335,737; PCT App. No. PCT / US20 / 49982; PCT App. No. PCT / US25 / 14790; PCT App. No. PCT / US22 / 21193; PCT App. No. PCT / US24 / 18567, which are hereby incorporated by reference and made a part of this application. Variations of the implants are contemplated. Relevant examples of instruments and methods of operation at a working space are disclosed in U.S. Patent App. No. 18 / 987,830, which is hereby incorporated by reference and made part of this application. To the extent any material incorporated herein by reference conflicts with the present disclosure, the present disclosure controls.

[0138] Systems, components, and instruments disclosed herein can be disposable or reusable. For example, the ports, instruments, or cannulas can be disposable to prevent cross-contamination. As used herein, the term “disposable” when applied to a- 70 -125752.8020.WO00\182882826.1system or component (or combination of components), such as an instrument, a tool, or a distal tip or a head, is a broad term and generally means, without limitation, that the system or component in question is used a finite number of times and is then discarded. Some disposable components are used only once and are then discarded. In other embodiments, the components and instruments are non-disposable and can be used any number of times. In some kits, all of the components can be disposable to prevent crosscontamination. In some other kits, components (e.g., all or some of the components) can be reusable.

[0139] Where the context permits, singular or plural terms may also include the plural or singular term, respectively. Moreover, unless the word “or” is expressly limited to mean only a single item exclusive from the other items in reference to a list of two or more items, then the use of “or” in such a list is to be interpreted as including (a) any single item in the list, (b) all of the items in the list, or (c) any combination of the items in the list. Additionally, the term “comprising” is used throughout to mean including at least the recited feature(s) such that any greater number of the same feature and / or additional types of other features are not precluded. It will also be appreciated that specific embodiments have been described herein for purposes of illustration, but that various modifications may be made without deviating from the technology. Further, while advantages associated with certain embodiments of the technology have been described in the context of those embodiments, other embodiments may also exhibit such advantages, and not all embodiments need necessarily exhibit such advantages to fall within the scope of the present technology. Accordingly, the disclosure and associated technology can encompass other embodiments not expressly shown or described herein.- 71 -125752.8020.WO00\182882826.1

Claims

CLAIMSWHAT IS CLAIMED IS:

1. A computer-implemented method for performing a multi-portal robotic surgical procedure, comprising: obtaining, via a surgical robotic system, a multi-portal endoscopic visualization plan and a surgical plan for a patient, wherein the surgical robotic system includes a surgical robot; endoscopically viewing, using a visualization instrument positioned in a first port along a patient by the surgical robot, a plurality of working instruments positioned in a second port along the patient according to the multi-portal endoscopic visualization plan, wherein the second port is spaced apart from the first port; and performing, using the surgical robot, at least a portion of the multi-portal robotic surgical procedure on the patient using the plurality of working instruments according to the surgical plan based on the endoscopic viewing.

2. The computer-implemented method of claim 1 , wherein one or more steps of the surgical plan are associated with at least one of an instrument holder, a working instrument of the plurality of working instruments, or the visualization instrument, the method further comprising determining a triangulated positional relationship between the visualization instrument and the working instrument for endoscopically viewing a working site while performing the one or more steps using the working instrument.

3. The computer-implemented method of claim 1 , further comprising performing a preoperative simulation for generating the multi-portal endoscopic visualization plan.

4. The computer-implemented method of claim 1 , further comprising:- 72 -125752.8020.WO00\182882826.1performing an intraoperative simulation of visualization of a working site in the patient; and modifying the multi-portal endoscopic visualization plan based on the intraoperative simulation.

5. The computer-implemented method of claim 4, further comprising: determining a visualization score based on the intraoperative simulation; and determining one or more modifications to at least one of the surgical plan or the multi-portal endoscopic visualization plan based on the visualization score being below a target score.

6. The computer-implemented method of claim 1 , wherein the surgical plan includes steps for installing working instruments in the surgical robot.

7. The computer-implemented method of claim 1 , wherein the surgical robot is programmed to position the visualization instrument to view a working site in the patient based on a surgical step to be performed.

8. The computer-implemented method of claim 1 , further comprising performing, using the surgical robot, the at least the portion of the multi-portal robotic surgical procedure on the patient based on at least one of: one or more images from a camera; one or more fluoroscopic images; or computer vision.

9. The computer-implemented method of claim 1 , wherein the multi-portal endoscopic visualization plan is synchronized with one or more steps of the surgical plan.

10. The computer-implemented method of claim 1 , further comprising modifying the multi-portal endoscopic visualization plan based on output from edge- 73 -125752.8020.WO00\182882826.1computing performed by the surgical robot using one or more images from the visualization instrument.

11. The computer-implemented method of claim 1 , wherein the multi-portal endoscopic visualization plan is part of the surgical plan, and wherein the working instruments are sequentially positioned in the second port.

12. A computer-implemented method for performing a multi-portal robotic surgical procedure, comprising: obtaining one or more images of a patient; generating a preoperative model of a working site in the patient using the one or more images; generating a surgical plan for the multi-portal robotic surgical procedure, wherein each step of the surgical plan is associated with at least one of an instrument holder, a working instrument, or a visualization instrument configured for endoscopic viewing; simulating endoscopic visualization of one or more steps of the surgical plan on the preoperative model according to a multi-portal endoscopic visualization plan; and determining whether the endoscopic visualization meets a visualization score.

13. The computer-implemented method of claim 13, further comprising: in response to a determination that the endoscopic visualization meets the visualization score, storing at least a portion of the endoscopic visualization for reference during the multi-portal robotic surgical procedure.

14. The computer-implemented method of claim 13, further comprising: in response to a determination that the endoscopic visualization does not meet the visualization score, modifying the surgical plan.- 74 -125752.8020. WOOO\182882826.

115. The computer-implemented method of claim 13, wherein the surgical plan includes the multi-portal endoscopic visualization plan, wherein one or more of the steps are surgical steps, and wherein the multi-portal endoscopic visualization plan includes at least one target position for the endoscopic visualization instrument to view the surgical steps.

16. The computer-implemented method of claim 15, wherein modifying the surgical plan includes changing one or more triangulation parameters that correspond to a position of the working instrument relative to the visualization instrument.

17. The computer-implemented method of claim 15, wherein modifying the surgical plan includes changing one or more triangulation parameters that correspond to a position of an instrument relative to a target area.

18. The computer-implemented method of claim 13, wherein the visualization score indicates that the visualization instrument is positioned in a working envelope, which is determined by one or more triangulation parameters, and wherein the one or more triangulation parameters correspond to at least one of a distance, an orientation, a trajectory, a spinal reference frame, or a depth of one or more instruments.

19. The computer-implemented method of claim 15, wherein modifying the surgical plan includes changing one or more irrigation parameters associated with a flow rate of a fluid at the working site.

20. The computer-implemented method of claim 15, wherein modifying the surgical plan includes replacing at least one of the instrument holder, the working instrument, or the visualization instrument corresponding to at least one step of the surgical plan.- 75 -125752.8020.WO00\182882826.

121. The computer-implemented method of claim 13, further comprising referencing the endoscopic visualization while performing the multi-portal robotic surgical procedure to monitor adherence to the surgical plan.

22. The computer-implemented method of claim 13, wherein the endoscopic visualization represents an expected visualization image at the working site after performing at least one step of the surgical plan on the patient.

23. The computer-implemented method of claim 23, further comprising: comparing the expected visualization image to an intraoperative image taken after performing the at least one step of the surgical plan on the patient; in response to a determination that the expected visualization image substantially matches the intraoperative image, continuing to perform the multi-portal robotic surgical procedure according to the surgical plan; and in response to a determination that the expected visualization image does not substantially match the intraoperative image, modifying the surgical plan.

24. The computer-implemented method of claim 13, further comprising identifying one or more target areas and one or more non-target areas in the preoperative model, wherein the one or more non-target areas include nerve tissue.

25. The computer-implemented method of claim 13, further comprising: storing the preoperative model for reference throughout the multi-portal robotic surgical procedure.

26. The computer-implemented method of claim 13, further comprising selecting one of a plurality of navigation programs for the multi-portal robotic surgical procedure, and wherein each of the plurality of navigation programs is associated with a set of instrument holders, working instruments, visualization instruments, triangulation parameters, irrigation parameters, and / or historical surgical data.- 76 -125752.8020.WO00\182882826.

127. The computer-implemented method of claim 13, wherein the surgical plan is generated by identifying one or more actions performed by a user on the preoperative model.

28. The computer-implemented method of claim 13, wherein the surgical plan is generated by: identifying one or more surgical actions performed by a user on the preoperative model; and comparing the one or more surgical actions performed by the user to historical surgical data from surgical procedures similar to the multi-portal robotic surgical procedure to be performed.

29. A multi-portal robotic system for performing a multi-portal surgical procedure by a surgical robot, comprising: one or more computer processors; and a non-transitory computer-readable storage medium storing computer instructions, which when executed by the one or more computer processors cause the surgical robot to: obtain one or more images of a patient; generate a preoperative model of a working site in the patient using the one or more images; display the preoperative model, via an electronic display, for viewing by a user; generate a surgical plan for the multi-portal surgical procedure, wherein each step of the surgical plan is associated with at least one of an instrument holder, a working instrument, or a visualization instrument configured for endoscopic viewing; simulate endoscopic visualization of one or more steps of the surgical plan on the preoperative model according to a multi-portal endoscopic visualization plan; and- 77 -125752.8020.WO00\182882826.1determine whether the endoscopic visualization meets a visualization score.

30. The multi-portal robotic system of claim 30, wherein the computer instructions cause the robotic system to, in response to a determination that the endoscopic visualization meets the visualization score, store at least a portion of the endoscopic visualization for reference during the multi-portal surgical procedure.

31. The multi-portal robotic system of claim 30, wherein the computer instructions cause the robotic system to, in response to a determination that the endoscopic visualization does not meet the visualization score, modify the surgical plan.

32. The multi-portal robotic system of claim 30, wherein the surgical plan includes the multi-portal endoscopic visualization plan, wherein one or more of the steps are surgical steps, and wherein the multi-portal endoscopic visualization plan includes at least one target position for the endoscopic visualization instrument to view the surgical steps.

33. The multi-portal robotic system of claim 30, wherein the computer instructions cause the robotic system to: identify one or more surgical actions performed by the user on the preoperative model; and generate the surgical plan based on the one or more surgical actions identified.

34. The multi-portal robotic system of claim 30, wherein the computer instructions cause the robotic system to: identify one or more surgical actions performed by the user on the preoperative model; generate a first surgical plan based on the one or more surgical actions identified; generate a second surgical plan based on historical surgical plans from surgical procedures similar to the multi-portal surgical procedure to be performed;- 78 -125752.8020.WO00\182882826.1compare one or more outcome scores of one or more steps corresponding to the first surgical plan to one or more outcome scores of one or more steps corresponding to the second surgical plan; and in response to a determination that the one or more outcome scores of the one or more steps corresponding to the second surgical plan exceed at least one of the one or more outcome scores of the one or more steps corresponding to the first surgical plan, modify the first surgical plan to include the one or more steps corresponding to the second surgical plan.

35. The multi-portal robotic system of claim 30, wherein the computer instructions cause the robotic system to: perform one or more steps of the surgical plan on the patient; obtain one or more intraoperative images of the working site in the patient; compare the one or more intraoperative images to the endoscopic visualization corresponding to one or more steps of the multi-portal endoscopic visualization plan; in response to a determination that the one or more intraoperative images substantially match the endoscopic visualization, continue to perform the multi-portal surgical procedure according to the surgical plan; and in response to a determination that the one or more intraoperative images do not substantially match the endoscopic visualization, modify the surgical plan.

36. The multi-portal robotic system of claim 30, wherein the computer instructions cause the robotic system to: perform one or more steps of the surgical plan on the patient; obtain one or more intraoperative images of the working site in the patient; generate an intraoperative model of the working site in the patient using the one or more intraoperative images; determine positions of the working instrument and the visualization instrument in the intraoperative model;- 79 -125752.8020.WO00\182882826.1calculate a triangulation parameter representative of a position of the working instrument and a position of the visualization instrument relative to one another; compare the triangulation parameter to a working envelope associated with the one or more steps of the surgical plan performed; in response to a determination that the triangulation parameter is within the working envelope, continue to perform the multi-portal surgical procedure according to the surgical plan; and in response to a determination that the triangulation parameter is not within the working envelope, modify the surgical plan.

37. The multi-portal robotic system of claim 37, wherein to modify the surgical plan, the computer instructions cause the robotic system to: in response to a determination that at least one of the working instrument or the visualization instrument can be repositioned to be within the working envelope, dynamically modify at least one position of the working instrument or the visualization instrument; and in response to a determination that at least one of the working instrument or the visualization instrument cannot be repositioned to be within the working envelope, notify the user to replace at least one of the instrument holder, the working instrument, or the visualization instrument.

38. A computer-implemented method for performing a multi-portal robotic surgical procedure, comprising: performing one or more steps of a surgical plan on a patient; obtaining one or more intraoperative images of a working site in the patient; generating an intraoperative model of the working site using the one or more intraoperative images; determining a position of a visualization instrument and a position of a working instrument in the intraoperative model;- 80 -125752.8020.WO00\182882826.1calculating a triangulation parameter representative of the position of the working instrument and the position of the visualization instrument relative to one another; and comparing the triangulation parameter to a working envelope associated with the one or more steps performed.

39. The computer-implemented method of claim 39, further comprising in response to a determination that the triangulation parameter is within the working envelope, continuing to perform the multi-portal robotic surgical procedure according to the surgical plan.

40. The computer-implemented method of claim 39, further comprising in response to a determination that the triangulation parameter is not within the working envelope, modifying the surgical plan.

41. The computer-implemented method of claim 41 , wherein modifying the surgical plan further comprises: in response to a determination that at least one of the working instrument or the visualization instrument can be repositioned to be within the working envelope, dynamically modifying at least one of the position of the working instrument or the position of the visualization instrument; and in response to a determination that at least one of the working instrument or the visualization instrument cannot be repositioned to be within the working envelope, notifying a user to replace at least one of an instrument holder, the working instrument, or the visualization instrument.

42. The computer-implemented method of claim 41 , wherein modifying the surgical plan further comprises: changing one or more irrigation parameters associated with a flow rate of a fluid at the working site.- 81 -125752.8020.WO00\182882826.

143. The computer-implemented method of claim 39, further comprising: determining a first position of the working instrument relative to a target area and a second position of the visualization instrument relative to the target area; and calculating a triangulation parameter representative of the first position and the second position relative to one another.- 82 -125752.8020.WO00\182882826.1

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