Systems and methods for a tendon-driven continuum robot device

Abstract

Apparatus and associated methods relate to a continuum manipulator including: at least 3 tendon cables configured to bend the continuum manipulator to a predetermined flexion range extending across 2 degrees of freedom; a plurality of sliding joints extending along the continuum manipulator, each sliding joint including: an outer ring comprising at least 3 tendon cable holes configured to receive the tendon cables to interconnect the plurality of sliding joints; and, an inner ellipsoid protrusion ring, enclosing at least one central aperture, extending from the outer ring having an inner ellipsoid protrusion ring cross-sectional surface area less than the diameter of the outer ring. Some embodiments may, for example, be used when a surgical instrument needs to be flexible and maneuverable around anatomical objects. The continuum manipulator may be used in Twin-to-Twin Transfusion Syndrome surgical operations.

Description

DESCRIPTIONSYSTEMS AND METHODS FOR A TENDON-DRIVEN CONTINUUM ROBOT DEVICECROSS REFERENCE TO RELATED APPLICATIONS

[0001] This application claims priority to U.S. Patent Application No. 63 / 689,246, titled “BIO-INSPIRED TENDON-DRIVEN CONTINUUM ROBOT SYSTEM”, filed by Ann Majewicz Fey, et al., on August 30, 2024, which is incorporated herein by reference in its entiretyFIELD OF THE DISCLOSURE

[0002] The present disclosure relates generally to the fields of medicine, surgery, and surgical devices. In some aspects, the present disclosure relates to a tendon driven continuum manipulator comprising one or more sliding or rolling joints.BACKGROUND

[0003] Twin-to-Twin Transfusion Syndrome (TTTS) occurs about in 3 per 10,000 deliveries. Twin-to-Twin Transfusion Syndrome (TTTS) is a life-threatening condition that occurs in monochorionic twin pregnancies, where one twin receives more blood flow from the shared placenta, while the other twin receives less. This imbalance can lead to cardiac failure, and in severe cases, even death of one or both twins. TTTS is treatable by a modified fetoscopic laser photocoagulation (FLP) of placental anastomoses. However, this procedure is challenging with conventional rigid instruments, especially for accessing the anterior placenta. These instruments have limited degrees of freedom hindering their ability to navigate the expansive uterine cavity and increasing movement around the amniotic membrane which could lead to Premature Rupture of Membranes (PROM) before labor begins.

[0004] Flexible and continuum robotics offer a promising pathway which could enable fetal surgeons to perform intricate surgical techniques with reduced risks to the pregnancy and the fetus. In fact, a few robotic systems have started to be developed to address the challenges of the TTTS procedure. These manipulators include a pneumatically actuated handheld device, as well as non-handheld systems that use concentric tubes, magnets, and tendons for actuation.14911-3852-9884, v 2

[0005] For instance, Ahmad et al. [6] developed a pneumatically handheld robotic device using active artificial muscle to achieve flexion which is a considerable advancement over current systems that require two-handed operation. However, while this system is compact and has benefits of being simple and handheld, it does not have any capabilities to mitigate hand tremors during delicate procedures and is susceptible to slow response time due to air compression -air is a compressible fluid and acts as a spring.

[0006] Looking at non-handheld examples, Dwyer et al. [7] designed a concentric tube robot capable of reaching the posterior and anterior placenta, though the system has a limitation of the potential for tube snapping due to the accumulation of torsional energy as the tube’s distal ends are rotated further, presenting a safety risk in fetal surgery.

[0007] In a more recent work, Lussi et al. [8] presents a magnetically actuated steerable catheter which demonstrates the potential for precise navigation and a very small diameter scope; however, the generation of magnetic fields may pose potentially harmful effects to the fetus [9] -

[0011] , and magnetic artifacts can interfere with ultrasound imaging

[0012] , which is a critical ancillary component during TTTS operations.SUMMARY

[0008] Apparatus and associated methods relate to a continuum manipulator. In an illustrative example, the continuum manipulator extends from an end effector to a housing end, the continuum manipulator including: at least 3 tendon cables configured such that the at least 3 tendon cables are manipulatable to bend the continuum manipulator to a predetermined flexion range extending across 2 degrees of freedom; a plurality of sliding joints extending along the continuum manipulator, each sliding joint including: an outer ring comprising at least 3 tendon cable holes configured to receive the tendon cables to interconnect the plurality of ellipsoid contact joints; and, an inner ellipsoid protrusion ring enclosing at least one central aperture extending from the outer ring having an inner ellipsoid protrusion ring cross-sectional surface area less than the diameter of the outer ring configured such that in a midsection of the plurality of ellipsoid contact joints, the inner ellipsoid protrusion ring contacts a rear outer ring of a subsequent sliding joint forming a contact region between the inner ellipsoid protrusion ring and subsequent outer ring.

[0009] Some embodiments, may, for example, include a tendon-driven continuum robot device including: a continuum manipulator including: at least 3 tendon cables configured 24911-3852-9884, v 2such that the at least 3 tendon cables are manipulatable to bend the continuum manipulator to a predetermined flexion range extending across 2 degrees of freedom; a plurality of sliding joints extending along the continuum manipulator, each sliding joint including: an outer ring including at least 3 tendon cable holes configured to receive the tendon cables to interconnect the plurality of ellipsoid contact joints; and, an inner ellipsoid protrusion ring enclosing at least one central aperture extending from the outer ring having an inner ellipsoid protrusion ring cross-sectional surface area less than the diameter of the outer ring configured such that in a midsection of the plurality of ellipsoid contact joints, the inner ellipsoid protrusion ring contacts a rear outer ring of a subsequent sliding joint forming a contact region between the inner ellipsoid protrusion ring and subsequent outer ring; and, a housing receiving the housing end of the continuum manipulator, the housing comprising: a tendon routing and stability region wherein the at least 3 tendon cables extending to a corresponding series of elastic actuators guided by a series of pulleys coupling the at least 3 tendon cables to at least 3 housing tendon cables; an actuation and force sensing region connected by the at least 3 housing tendon cables rotatably coupled to rotation pulleys to at least 3 corresponding bending actuation motors configured to rotate to engage the corresponding at least 3 tendon cables to bend the continuum manipulator to the predetermined flexion range, the actuation and force sensing region further including at least 3 force sensors coupled to the corresponding at least 3 housing tendon cables guided on force sensor rails; and, a control region including: at least one motor controller configured to control the at least 3 bending actuation motors; and, at least one controller to monitor the individual tension in the at least 3 housing tendon cables from a receiving force sensor signal received from the at least 3 force sensors.

[0010] Some embodiments may, for example, include a device including a continuum manipulator. The continuum manipulator includes a plurality of sliding joints extending along the continuum manipulator, each sliding joint of the plurality of joints. The plurality of joints includes an outer ring comprising at least 2 tendon cable holes configured to receive the tendon cables to interconnect the plurality of sliding joints. The plurality of joints includes an inner ellipsoid protrusion ring, enclosing at least one central aperture, extending from the outer ring having an inner ellipsoid protrusion ring cross- sectional surface area less than the diameter of the outer ring configured such that in a midsection of the plurality of ellipsoid contact joints, the inner ellipsoid protrusion ring34911-3852-9884, v 2contacts a rear outer ring of a subsequent sliding joint forming a contact region between the inner ellipsoid protrusion ring and subsequent outer ring. The continuum manipulator includes at least 2 tendon cables configured such that the at least 2 tendon cables are manipulatable to bend the continuum manipulator to a predetermined flexion range extending across one degree of freedom.

[0011] Some embodiments may, for example, further include an input module configured to receive user command inputs to modify the predetermined flexion range.

[0012] Some embodiments may, for example, further include a visual monitor depicting the current predetermined flexion range.

[0013] Some embodiments may, for example, be configured such that the plurality of sliding joints comprises at least one inner ellipsoid protrusion ring that is oval shaped.

[0014] Some embodiments may, for example, be configured such that the continuum manipulator is configured to bend to the predetermined flexion range extending to a range up to 230 degrees across 2 degrees of freedom.

[0015] Some embodiments may, for example, be configured such that the continuum manipulator is configured to omnidirectional bending.

[0016] Some embodiments may, for example, be configured such that the continuum manipulator is configured to fit a 10 Fr trocar.

[0017] Some embodiments may, for example, be configured such that the continuum manipulator is configured to fit a 3.3 mm trocar.

[0018] Some embodiments may, for example, be configured such that the continuum manipulator extends 35 cm.

[0019] Some embodiments may, for example, be configured to further comprise a hollow tube extending through the at least one central aperture of the plurality of sliding joints configured to receive an instrument through the hollow tube. Some embodiments may, for example, be configured such that the instrument comprises a fiber optic configured to conduct imaging.

[0020] Some embodiments may, for example, be configured such that the instrument comprises a laser fiber optic configured to conduct ablation.

[0021] Some embodiments may, for example, be configured such that further comprising one or more cameras coupled to the continuum manipulator.4911-3852-9884, v 2

[0022] Some embodiments may, for example, be configured such that the control region receives commands to actuate the continuum manipulator commands from a remote operator.

[0023] Some embodiments may, for example, be configured such that wherein the continuum manipulator is operated to treat a patient during a twin-to-twin transfusion syndrome operation.

[0024] Some embodiments may, for example, be configured such that the continuum manipulator is operated to treat at least one fetus during a twin-to-twin transfusion syndrome operation.

[0025] Some embodiments may, for example, be configured such that the continuum manipulator is configured to withstand external forces created by a fetus grabbing the continuum manipulator during a twin-to-twin transfusion syndrome operation.

[0026] Some embodiments may, for example, be used in connection with a medical procedure for treating twin-to-twin transfusion syndrome. The medical procedure for treating twin-to-twin transfusion syndrome includes performing an ultrasound examination to determine an insertion site for a fetoscope into an amniotic cavity of a predetermined twin.

[0027] The medical procedure for treating twin-to-twin transfusion syndrome includes providing a diagnostic scope and an operative scope, each scope comprising a continuum manipulator comprising: at least 3 tendon cables configured such that the at least 3 tendon cables are manipulatable to bend the continuum manipulator to a predetermined flexion range extending across 2 degrees of freedom; a plurality of sliding joints extending along the continuum manipulator, each sliding joint comprising: an outer ring comprising at least 3 tendon cable holes configured to receive the tendon cables to interconnect the plurality of ellipsoid contact joints; and, an inner ellipsoid protrusion ring enclosing at least one central aperture extending from the outer ring having an inner ellipsoid protrusion ring cross-sectional surface area less than the diameter of the outer ring configured such that in a midsection of the plurality of ellipsoid contact joints, the inner ellipsoid protrusion ring contacts a rear outer ring of a subsequent sliding joint forming a contact region between the inner ellipsoid protrusion ring and subsequent outer ring.

[0028] The medical procedure for treating twin-to-twin transfusion syndrome includes mapping the placenta by inserting the diagnostic scope to map the anastomoses a placenta.54911-3852-9884, v 2

[0029] The medical procedure for treating twin-to-twin transfusion syndrome includes removing the diagnostic scope after mapping the placenta.

[0030] The medical procedure for treating twin-to-twin transfusion syndrome includes inserting an operating scope comprising an end effector configured to deliver laser energy from laser fiber enclosed by the continuum manipulator to create an avascular plane between a circulation of the twins to decouple the circulation between the twins stopping unidirectional flow of blood of a donor twin to a recipient twin.

[0031] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, include a housing coupled to the continuum manipulator, the housing comprising: a tendon routing and stability region wherein the at least 3 tendon cables extending to a corresponding series of elastic actuators guided by a series of pulleys coupling the at least 3 tendon cables to at least 3 housing tendon cables; an actuation and force sensing region connected by the at least 3 housing tendon cables rotatably coupled to rotation pulleys to at least 3 corresponding bending actuation motors configured to rotate to engage the corresponding at least 3 tendon cables to bend the continuum manipulator to the predetermined flexion range, the actuation and force sensing region further comprising at least 3 force sensors coupled to the corresponding at least 3 housing tendon cables guided on force sensor rails; and, a control region comprising: at least one motor controller configured to control the at least 3 bending actuation motors; and, at least one controller to monitor the individual tension in the at least 3 housing tendon cables from a receiving force sensor signal received from the at least 3 force sensors.

[0032] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator further comprises an input module configured to receive user command inputs to modify the predetermined flexion range.

[0033] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator further comprises a visual monitor depicting the current predetermined flexion range.

[0034] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the plurality of sliding joints comprises at least one inner ellipsoid protrusion ring that is oval shaped.64911-3852-9884, v 2

[0035] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator is configured to bend to the predetermined flexion range extending to a range up to 230 degrees across 2 degrees of freedom.

[0036] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that continuum manipulator is configured to omnidirectional bending.

[0037] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator is configured to fit a 10 Fr trocar.

[0038] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator is configured to fit a 3.3 mm trocar.

[0039] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator extends 35 cm.

[0040] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator further comprises a hollow tube extending through at least one central aperture of the plurality of sliding joints configured to receive an instrument through the hollow tube. The instrument may, for example, include an endoscope. The instrument may, for example, include a fiber optic configured to conduct imaging. The instrument may, for example, include an endoscope a laser fiber optic configured to conduct ablation. The instrument may, for example, include one or more cameras coupled to the continuum manipulator.

[0041] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the control region receives commands to actuate the continuum manipulator commands from a remote operator.

[0042] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator is operated to treat a patient during a twin-to-twin transfusion syndrome operation.

[0043] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator is operated to treat at least one fetus during a twin-to-twin transfusion syndrome operation.74911-3852-9884, v 2

[0044] Some embodiments of the medical procedure for treating twin-to-twin transfusion syndrome may, for example, be configured such that the continuum manipulator is configured to withstand external forces created by a fetus grabbing the continuum manipulator during a twin-to-twin transfusion syndrome operation.

[0045] The minimalization of the minimization of “torsion” or twist deformation may, for example, be attributed to the continuum manipulator oval-geometric kinematic constraint.

[0046] Some embodiments may, for example, be used in the preparation of a medical device comprising one or more tendon wire driven by one or more motors through one or more sliding or rolling joints. In some embodiments, these sliding or rolling joints are ellipsoidal or oval in shape. In some embodiments, the device further comprises one or more hollow instrument channels.

[0047] In some embodiments, the medical device is continuum manipulator. In some embodiments, the medical device comprises one or more sliding joints.

[0048] In some embodiments, the medical device comprises one or more sliding joints that are oval or ellipsoidal in nature.

[0049] In some embodiments, the medical device further comprises one or more hollow tubes.

[0050] In some embodiments, the hollow tube is sufficient to allow an instrument to pass through the hollow tube.

[0051] In some embodiments, the medical device further comprises one or more cameras. In some embodiments, the camera is used for control. In some embodiments, the medical device is configured for remote operation.

[0052] In other aspects, the present disclosure provides methods of using the medical device described herein to operate on a patient. In some embodiments, the patient is a human. In some embodiments, the human is a fetus.

[0053] In some embodiments, the joints in the medical device with an ellipsoidal or oval shape provides useful in the device as the shape of the device may impart one or more advantages such as the ellipsoidal or oval shape allows movement in all angular motions, in two planes such as movement having 2 degrees of freedom bending (up and down, y axis & left and right, x axis) with more than 180 degrees of movement / freedom with a maximum movement of 230 degrees.84911-3852-9884, v 2

[0054] Furthermore, the geometry of these joints may form a ring geometry that creates a kinematic constraint against torsion when a force is applied that tries to rotate the joint along the z axis thus that the joints or device do not twist or deform.

[0055] In the present disclosure, the term “coupled” is defined as connected, although not necessarily directly, and not necessarily mechanically.

[0056] The use of the word “a” or “an” when used in conjunction with the term “comprising” in the claims and / or the specification may mean “one,” but it is also consistent with the meaning of “one or more” or “at least one.” The terms “approximately, “about” or “substantially” mean, in general, the stated value plus or minus 5 %. The use of the term “or” in the claims is used to mean “and / or” unless explicitly indicated to refer to alternatives only or the alternative are mutually exclusive, although the disclosure supports a definition that refers to only alternatives and “and / or.”

[0057] The terms “comprise” (and any form of comprise, such as “comprises” and “comprising”), “have” (and any form of have, such as “has” and “having”), “include” (and any form of include, such as “includes” and “including”) and “contain” (and any form of contain, such as “contains” and “containing”) are open-ended linking verbs. As a result, a method or device that “comprises,” “has,” “includes” or “contains” one or more steps or elements, possesses those one or more steps or elements, but is not limited to possessing only those one or more elements. Likewise, a step of a method or an element of a device that “comprises,” “has,” “includes” or “contains” one or more features, possesses those one or more features, but is not limited to possessing only those one or more features. Furthermore, a device or structure that is configured in a certain way is configured in at least that way, but may also be configured in ways that are not listed.

[0058] Other objects, features and advantages of the present invention will become apparent from the following detailed description. It should be understood, however, that the detailed description and the specific examples, while indicating specific embodiments of the invention, are given by way of illustration only, since various changes and modifications within the spirit and scope of the invention will be apparent to those skilled in the art from this detailed description, and from the claims.4911-3852-9884, v 2BRIEF DESCRIPTION OF THE DRAWINGS

[0059] The following drawings form part of the present specification and are included to further demonstrate certain aspects of the present invention. The invention may be better understood by reference to one or more of these drawings in combination with the detailed description of specific embodiments presented herein.

[0060] FIG. 1 depicts an illustrative use-case scenario of a tendon-driven continuum robot for treatment of twin-to-twin transfusion syndrome (TTTS) in the posterior placenta view.

[0061] FIG. 2 depicts the illustrative use-case scenario of the tendon-driven continuum robot for treatment of twin-to-twin transfusion syndrome (TTTS) depicted in FIG. 1 in the anterior placenta view.

[0062] FIG. 3 depicts an illustration of a condyloid hand joints.

[0063] FIG. 4 depicts an illustration of an ellipsoid joint mechanism.

[0064] FIG. 5 depicts an illustration of a continuum manipulator with oval-shaped rings and joints.

[0065] FIG. 6 depicts a segment view between two ellipsoid joint rings.

[0066] FIG. 7 depicts a top view of an ellipsoid joint ring.

[0067] FIG. 8 depicts a computer aided design (CAD) model of a flexible robotic system embodiment.

[0068] FIG. 9 depicts a top view of the CAD model of the flexible robotic system.

[0069] FIG. 10 depicts an experimental setup to track manipulator movement and bending in an abdomen model embodiment using an EM tracker.

[0070] FIG. 11 depicts a bending experiment of ellipsoidal manipulator with each tendon pulled separately to achieve 90°, 180°, and the maximum bending angle (e.g., an angle greater than 180°).100711 FIG. 12 depicts a 2D planar view of tracked trajectory along the X-Z plane.

[0072] FIG. 13 depicts a 2D planar view of tracked trajectory along the X-Y plane.

[0073] FIG. 14 depicts a 2D planar view of tracked trajectory along the Y-Z plane.

[0074] FIG. 15 depicts a 3D isometric view of robot volume workspace.

[0075] FIG. 16 depicts a system diagram of an exemplary a tendon-driven continuum robot device.

[0076] FIG. 17 depicts an exemplary method of treatment for twin-to-twin transfusion syndrome using a diagnostic and operating tendon-driven continuum manipulator.

[0077] FIG. 18 depicts an exemplary continuum manipulator joint segment.104911-3852-9884, v 2

[0078] Like reference symbols in the various drawings indicate like elements.DETAILED DESCRIPTION

[0079] Systems and methods for a tendon-driven continuum robot device relate to a continuum manipulator inspired by human condyloid joints. The continuum manipulator provides several advantages, including but not limited to: (1) a flexion range of up to 230°, (2) capability for omnidirectional bending, (3) torsion prevention with its ellipsoidal ring shape, and (4) a higher bending resolution and compliance compared to other rolling joint manipulators. The manipulator designed is a scaled- up prototype intended for miniaturization to fit a 10 French (e.g., 3.3 mm outer diameter) trocar.

[0080] Some embodiments may, for example, be used in connection with medical devices for navigating large anatomical cavities. The large anatomical cavities may, for example, include the abdomen and the uterine cavity during pregnancy. The large anatomical cavities may, for example, include body lumens.

[0081] Some embodiments may, for example, be used in surgical situations where rigid straight-stick scope instruments are not advantageous and requires a surgical instrument that is flexible and can be maneuverable around anatomical objects. Fetoscopes, for example, which may be used to perform in-utero fetal surgery or other medical procedures, may need to navigate around the fetus toward the placenta or to specific sites on the fetus, this is very difficult to achieve with current straight-stick instrumentation.

[0082] FIG. 1 depicts an illustration of a tendon-driven continuum robot 100 used in the treatment of twin-to-twin transfusion syndrome (TTTS) in the posterior placenta view. Tendon-driven continuum robot 100 is being inserted to provide treatment to a placenta 105. Tendon-driven continuum robot 100 is being inserted through an abdomen 110. Tendon-driven continuum robot 100 is being inserted into a uterus 1 15. Tendon-driven continuum robot 100 is inserted into uterus 115 through abdomen 110 through a fulcrum 120 (e.g., a trocar).

[0083] The trocar may, for example, be defined to create an aperture for the insertion of medical devices through the abdomen into the uterus. The trocar may, for example, be configured to operate with a 3.3 mm outer diameter.

[0084] In some embodiments, the bio-inspired tendon-driven continuum robot is flexible and its geometry is designed to protect the tendons in the event the fetus grabs the instrument and applies twisting force.114911-3852-9884, v 2

[0085] The tendon-driven continuum robot, in some embodiments, is hollow to allow instruments (e.g., such as a gripper, laser fiber, camera sensor, fiber imaging bundle, a shape sensor, etc.) to be passed through the fetoscope.

[0086] The tendon-driven continuum may, for example, not rely on anatomical walls such as airways in the lungs to be steerable. The tendon-drive continuum body may, for example, be actuated via tendons. The tendon-drive continuum body may, for example, fetoscope may, for example, bend based on its segmentation, allowing it to bend entirely compared to bending to a small section such as only the tip. The tendon-driven continuum body segmentation may, for example, enable a fetoscope to be in bodily cavities and lumens.

[0087] Tendon-driven continuum robot 100 includes a continuum manipulator 500.Continuum manipulator 500 is actuated by main housing module 810. The main housing module 810 may, for example, be enclosed in a robotic arm. The continuum manipulator in this illustrative use-case scenario includes a robotic fetoscope. The fetoscope may, for example, in some embodiments extend its length to 26 cm. The fetoscope may, for example, extend its length to 35 cm in some embodiments. The fetoscope may, for example, in some embodiments extend its length to adequately reach the posterior.

[0088] For motivational context, approximately 10-15% of monochorionic twins are affected by twin-to-twin transfusion syndrome (TTTS) [1]. In this often fatal pregnancy condition, a shared placenta circulation in the womb results in one twin receiving an excess of blood leading to cardiac failure while the co-twin receives less blood leading to decreased urine production. Untreated, the condition progresses leading to the death of one or both twins in over 90% of cases.

[0089] Currently the Fetoscopic laser photocoagulation (FLP) of the placental anastomoses between the twin circulations followed by the “Solomon technique” to connect the anastomotic sites is the standard of care for the treatment of TTTS. In this minimally invasive procedure, a perinatal sonographer first performs an ultrasound examination to find the best insertion site for the fetoscope into the amniotic cavity of one twin. A diagnostic scope is then inserted to allow the surgeon to mentally map the anastomoses of the placenta. After the surgeon has mapped the placenta, the diagnostic scope is taken out and using the same cannula, an operating scope is inserted. The diagnostic scope has a larger lens diameter to provide a broad view while the operative scope has a smaller view due to its working channel for the Fiber used to deliver the laser energy. The ablation of multiple connection points between the twins’ placental vasculature is then performed followed by the124911-3852-9884, v 2Solomon technique in an effort to create an avascular plane between the twins’ circulations. [2]. This ensures decoupling of the twins’ vasculature stopping the unidirectional flow of blood between the “donor” and “recipient” twin. This approach is critical as FLP with incomplete ablation of the entire anastomotic region of the placenta has been associated with TTTS recurrence [3].

[0090] Unfortunately, straight-stick instrumentation remains a significant challenge for fetal surgeons engaged in TTTS interventions. The intricate nature of TTTS surgeries necessitates a level of reach beyond the capabilities of rigid scopes. It becomes a challenge when the anastomotic region on the placenta is on the anterior surface of the uterus, making it arduous to maintain the optimal laser fiber angle during ablation. Surgeons handling these instruments contend with constrained degrees of freedom, impeding their ability to navigate the vast uterine cavity, whether dealing with posterior or anterior placenta scenarios. Furthermore, the risk of skill-related errors, such as intraoperative fetal bums from the laser [4] or premature rupture of membranes (PROM) due to prolonged operative times [5], underscores the pressing need to enhance operative efficiency and safety.

[0091] Prior to the previous works, the earliest proposed TTTS robot is a 2.4 mm diameter tendon-driven continuum robot capable of two degrees of freedom (2-DOF) bending, located at the instrument tip

[0013] . However, their system relies on a long rigid shaft with the flexible manipulator at the tip, and does not prevent the ring’s torsion. This can cause tendon shearing, wear, and damage, especially when miniaturizing the manipulator. The fetus, in particular, can grab the instrument during the surgery and cause the shearing forces on the tendons.

[0092] Continuum manipulator 500 with oval-shaped rings and joints and the ellipsoid joint mechanism improves on this by geometrically constraining the shearing force and using fewer links to achieve the desired range of motion. Continuum manipulator 500 may, for example, have no rigid component, making the entire body of the manipulator adaptable to reaching the placenta and interacting with the fetus.

[0093] Some embodiments of the ellipsoidal manipulator design may, for example, include a type of rolling joint continuum robot, capable of bending up to 230° and 2-DOF. Rolling joint manipulators offer numerous benefits, including low friction and robust force transmission capabilities, all while maintaining a hollow core suitable for internal channels

[0014] —

[0017] .134911-3852-9884, v 2

[0094] For context, rolling joint manipulators present certain challenges. For instance, achieving 2-DOF requires a greater number of links; one ring link pair bends along the x-axis, while another link pair bends along the y-axis. To facilitate 2-DOF, multiple types of pairs must be stacked alternately. Moreover, these manipulators are not typically designed to endure external forces, such as those exerted by a fetus grabbing the device, which could lead to breakage due to its miniature size.

[0095] Conventional rolling joints suffer from a critical flaw of two curved components potentially slipping. Such slippage can lead to control inaccuracies or, worse, a dislocated joint. The rolling joint mechanism is susceptible to three types of slippage: a lateral-slip, which occurs when the upper rolling part overshoots and falls off the lower one, leading to a dislocated joint; a longitudinal- slip, which can happen if lateral forces are applied to the joint, resulting in dislocation; and a rolling-slip, which arises when the two surfaces skid against each other, causing an uncontrolled rolling motion and control inaccuracies

[0018] .

[0096] FIG. 2 depicts the illustration of a tendon-driven continuum robot for treatment of twin-to-twin transfusion syndrome (TTTS) depicted in FIG. 1 in the anterior placenta view 200. Anterior placenta view 200 depicts a recipient 205. Anterior placenta view 200 depicts a donor 210.

[0097] FIG. 3 depicts an illustration of a condyloid hand joints 300. For example, condyloid hand joints 300 include metacarpophalangeal joints 305. For example, condyloid hand joints 300 include radiocarpal joints 310.

[0098] FIG. 4 depicts an illustration of an ellipsoid joint mechanism 400. Ellipsoid joint mechanism 400 includes an oval or an ellipsoidal shaped joint 405. Ellipsoidal joint mechanism 400 includes an oval or ellipsoidal shaped socket 410.

[0099] FIG. 5 depicts an illustration of a continuum manipulator 500 with oval-shaped rings (e.g., ellipsoidal rings) and joints according to embodiments of the present disclosure. In the embodiment shown, continuum manipulator 500 includes a manipulator receiving end 505. Manipulator receiving end 505 may, for example, receive tendons (e.g., cables) through the continuum manipulator receiving end 505 to manipulate continuum manipulator 500 based on actuation of the motors. Manipulator receiving end 505 may, for example, receive sensors that are threaded through the plurality of holes of continuum manipulator 500.144911-3852-9884, v 2

[0100] Continuum manipulator 500 includes a tendon wire 510. Continuum manipulator 500 includes an ellipsoid contact joint 515. Continuum 500 manipulator includes a tendonrouting guide 520 (e.g., an outer ring including at least three spaced holes). The length of continuum manipulator 500 depicted may, for example, be 257 mm. In some embodiments continuum manipulator 500 may, for example, extend longer to 360 mm. The diameter of the continuum manipulator 500 depicted is 14 mm. The diameter of continuum manipulator 500 in some embodiments may, for example, be miniaturized. For example, the diameter of continuum manipulator 500 in some embodiments may, for example, be miniaturized to fit through a 10 FR tocar (e.g., 3.3 mm outer diameter), as depicted in FIG. 1.

[0101] Some embodiments of the sliding joint tendon-driven continuum manipulator include an oval-shaped ring and hollow instrument channel. In certain embodiments, the sliding joint tendon-driven continuum manipulator includes an oval- shaped ring and hollow instrument channel and may, for example, model condyloid joints in the human hands as depicted in FIGS. 3 and 4.

[0102] Some embodiments of the ellipsoid joint mechanism may, for example, enable flexion greater than 180° flexion in any direction. The ellipsoid joint mechanism may, for example, enable 2-DOF bending. The ellipsoid joint mechanism may, for example, enable minimal torsion in case the fetus grabs and twists the instrument.

[0103] The ellipsoid joint mechanism of the continuum manipulator may, for example, be based on a finger joint design. The ellipsoid joint mechanism may, for example, overcome rolling joint slippage limitations as the diameter of the ellipsoidal contact joint is smaller than the diameter of the connecting component. The size difference may, for example, enable the joint to maintain a secure fit within the assembly, preventing any slippage. Moreover, constraining torsion and enabling each link to slide and bend along both the x-axis and y-axis; thus, increasing the resolution of bending and compliance. This dual-axis movement capability provides a higher degree of adaptability than current rolling joint designs that require alternating links to achieve two-axis motion.

[0104] In some embodiments, the robotic fetoscope may, for example, may be analyzed through workspace analysis of bending experiments. Analysis conducted with the robotic fetoscope may, for example, show that the robotic fetoscope may, for example, achieve a large range of motion and high dexterity suitable for TTTS surgeries.154911-3852-9884, v 2

[0105] FIG. 6 depicts a segment view between two ellipsoid joint rings 600 according to exemplary embodiments of the present disclosure. The segment view between two ellipsoid joint rings 600 includes an outer ring length L. The outer ring length L depicted is 14 mm. In some embodiments, the outer ring length L may, for example, be miniaturized. For example, the outer ring length L may, for example, be miniaturized to fit through a 10 FR tocar (e.g., 3.3 mm outer diameter).

[0106] Segment view between two ellipsoid joint rings 600 includes an outer ring width W. In the illustrated embodiment, the outer ring width W depicted is 12 mm. In some embodiments, the outer ring length W may, for example, be miniaturized. For example, the outer ring width W may, for example, be miniaturized to fit through a 10 FR tocar (e.g., 3.3 mm outer diameter).

[0107] Segment view between two ellipsoid joint rings 600 includes an outer ring height H. In the illustrated embodiment, the outer ring width H depicted is 4.5 mm. In some embodiments, the outer ring height H may, for example, be miniaturized.

[0108] Segment view between two ellipsoid joint rings 600 includes an ellipsoid contact joint height E. In the illustrated embodiment, the ellipsoid contact joint height E depicted is 3 mm. In some embodiments, the ellipsoid contact joint height E may, for example, be miniaturized. For example, the ellipsoid contact joint height E may, for example, be miniaturized to fit through a 10 FR tocar (e.g., 3.3 mm outer diameter).

[0109] Segment view between two ellipsoid joint rings 600 includes an outer ring thickness T. In the illustrated embodiment, the outer ring thickness T depicted is 2.5 mm. In some embodiments, the outer ring thickness T may, for example, be miniaturized. The outer ring thickness T may, for example, be miniaturized to fit through a 10 FR tocar (e.g., 3.3 mm outer diameter).

[0110] Segment view between two ellipsoid joint rings 600 includes a tendon hole diameter S. In the illustrated embodiment, the tendon hole diameter S depicted is 1.25 mm. In some embodiments, the tendon hole diameter S may, for example, be miniaturized. The tendon hole diameter S may, for example, be miniaturized to fit through a 10 FR tocar (e.g., 3.3 mm outer diameter).

[0111] Segment view between two ellipsoid joint rings 600 includes an ellipsoid to outer ring contact distance C. The ellipsoid to outer ring contact distance C depicted is 2 mm. In some embodiments, ellipsoid to outer ring contact distance C may, for example, be164911-3852-9884, v 2miniaturized. The ellipsoid to outer ring contact distance C may, for example, be miniaturized to fit through a 10 FR tocar (e.g., 3.3 mm outer diameter).

[0112] Segment view between two ellipsoid joint rings 600 includes an ellipsoid inner length 1. In the illustrated embodiment, the ellipsoid inner length 1 depicted is 6.5 mm. The ellipsoid inner length 1 may, for example, be miniaturized. The ellipsoid inner length 1 may, for example, be miniaturized to fit through a 10 FR tocar (e.g., 3.3 mm outer diameter).

[0113] Segment view between two ellipsoid joint rings 600 includes an ellipsoid inner width w. In the illustrated embodiment, the ellipsoid inner width w depicted is 6.5 mm. The ellipsoid inner width w may, for example, be miniaturized. The ellipsoid inner width w may, for example, be miniaturized to fit through a 10 FR tocar (e.g., 3.3 mm outer diameter).

[0114] Some embodiments may, for example, be miniaturized by scaling. Some embodiments, may, for example, be miniaturized by non-homogeneous scaling. For example, in some embodiments, the length, width, and thickness of the outer ring may, for example, may not be scaled linearly. Some embodiments may, for example, scale the length, width, and thickness of the outer ring linearly.

[0115] In some embodiments, the ellipsoidal joint end-effector manipulator may, for example, be configured to meet the needs of surgeons. The ellipsoidal joint end-effector manipulator may, for example, effectively create a solution for the treatment of TTTS.

[0116] In some embodiments, the ellipsoidal joint end-effector manipulator may, for example, provide 180° flexion to reach the anterior placenta and navigate around the fetus to reach the posterior placenta.

[0117] In some embodiments, the ellipsoidal joint end-effector manipulator may, for example, provide 2-DOF bending along the x-axis and y-axis to improve dexterity for laser ablation across various placental regions.

[0118] In some embodiments, the ellipsoidal joint end-effector manipulator may, for example, minimize torsion along the manipulator’s axis to avoid the shearing of tendons that drive the bending motion.

[0119] In some embodiments, the ellipsoidal joint manipulator may, for example, include less parts.174911-3852-9884, v 2

[0120] In some embodiments, the ellipsoidal joint end-effector manipulator may, for example, provide compliance to adjust manipulator shape and stiffness according to contact forces in the fluidic environment.

[0121] For context, the condylar joint, also known as the condyloid or ellipsoid joint, is a type of synovial joint that allows movement in two planes, such as flexion, extension, abduction, adduction, and circumduction

[0019] . The wrist and knuckle joints from the human hand are examples of condylar joints and inspired by the human hand.

[0122] The tendon-driven continuum manipulator with ellipsoidal joints for TTTS surgery may, for example, include ellipsoidal tendon-routing rings that allow for sliding joint motion. The dimensions for the ellipsoidal joints as depicted in FIG. 5 are depicted in FIG. 6.

[0123] For context, researchers have previously designed various mechanisms mimicking human joints to create robotic prostheses

[0020] , however, condylar joints have not been applied or suggested to be applied to a continuum robotic manipulator before. Advantageously, the continuum robotic manipulator may, for example, achieve high flexion range. Advantageously, the continuum robotic manipulator may, for example, achieve 2-DOF bending. Advantageously, the continuum robotic manipulator may, for example, achieve minimal torsion.

[0124] In the illustrated embodiment, the ellipsoidal ring depicted is manufactured with stereolithography (SLA) clear resin with a SLA printer. The SLA printer may, for example, include a Form 3+® printer (available from Form Labs, Somerville Massachusetts).

[0125] The ellipsoidal ring, for example, may be shaped as an oval with a different length and width rather than equal measurements found in a circle or sphere, introduces a kinematic constraint designed to minimize twisting in the manipulator. The length- width difference creates a geometric constraint that prevents the ring from rotating along its axis, as it would impact the bending direction of the manipulator and decrease accuracy in movement and laser ablation.

[0126] The length- width difference may, for example, prevent manipulator damage from fetal interference. For example, during TTTS surgery, the fetus may inadvertently grasp the instrument, applying shearing forces to the tendons and compromise the manipulator’s integrity. The design of the continuum robotic manipulator may, for184911-3852-9884, v 2example, be dexterous manipulator, because it was inspired by finger joint anatomy. The continuum robotic manipulator may, for example, limit the risk of tendon breakage.

[0127] FIG. 7 depicts a top view of an ellipsoid joint ring 700. Ellipsoid joint ring 700 includes tendon holes 705. Ellipsoid joint ring includes a central protrusion 710. Ellipsoid joint ring 700 includes an outer ring 715. Ellipsoid joint ring 700 encloses a central aperture 720.

[0128] FIG. 8 depicts a computer aided design (CAD) model of a flexible robotic system 800 according to an embodiment of the present disclosure. In certain embodiments, flexible robotic system 800 may, including continuum manipulator 500. In the embodiment shown, continuum manipulator 500. includes an X-Axis and a Y-axis. Continuum manipulator 500 is actuated by main housing module 810 in the illustrated embodiment.

[0129] Main housing module 810 depicted is 12 cm height. Main housing module 810 depicted is 19 cm width. Main housing module 810 depicted has a 60 cm length. Some embodiments may, for example, include different dimensions. Some embodiments may, for example, include different shapes. The length, width, and height, or shape, may, for example, be modified.

[0130] In the illustrated embodiment, flexible robotic system 800 actuation system for the continuum manipulator is based on three tendons 830 that run through the ellipsoidal rings of continuum manipulator 500 and are actuated from main housing module 810.

[0131] In the illustrated embodiment, tendons 830 are coupled to three bending actuation motors 845 (e.g., DC motors) with series elastic actuators (SEAs) at the front of main housing module 810 before the tendons go through the manipulator.

[0132] In the illustrated embodiment, the SEAs comprise three extension springs 820. The tendons may, for example, be nylon coated stainless steel wire rope and have a pretension to ensure stability and stiffness of the manipulator. The motors are controlled by a PID controller that regulates the tendon length and tension according to the desired motor angle. The actuation system allows the manipulator to achieve a flexion range of more than 180° in any direction.

[0133] Main housing module 810 includes cable translation DOF 815 for tendons. The cable translation DOF 815 may, for example, be facilitated by the extension springs 820. The extension springs 820 are located between idler pulleys 825. A first set of idler pulleys may, for example, be set at an exterior of the housing proximal to the flexible manipulator. A second set of idler pulleys may, for example, be positioned at a mid-194911-3852-9884, v 2housing position distal to the flexible manipulator. The idler pulleys may, for example, guide the tendons from the flexible manipulator to the extension spring where on an opposing end of the extension spring a tendon is coupled and guided by the idler pulleys into the housing to be actuated by the bending actuation motors.

[0134] Main housing module 810 includes force sensors 835. Force sensors 835 measure the force exerted to each tendon cable along force sensor rails 850. The force sensors may, for example, measure force from the tendons that are coupled to a series of rotation pulleys 840. The rotation pulleys 840 are coupled to the bending actuation motors 845.

[0135] FIG. 9 depicts a top view of the CAD model of a flexible robotic system 900. CAD model of the flexible robotic system 900 includes continuum manipulator 500. Continuum manipulator 500 is coupled with the main housing module 810 to a tendon routing stability region 910. The tendon routing stability region transitions to the actuation and force sensing region 915. The tendon routing stability region 910 includes the area of transition of the tendon from the manipulator to the extension spring to the tendon coupled to the opposing end of the spring. The left and right tendon may, for example, be guided by the idler pulleys. The central tendon may, for example, directly connect to the actuation / force sensing region in some embodiments. The actuation and force sensing region 915 is controlled by the control region 920. The control region may, for example, be situated behind the actuation and force sensing region in some embodiments.

[0136] The control system may, for example, include an Arduino Mega (available from Arduino) with a PID controller to drive the DC motors through a motor driver. The control system may, for example, include an Arduino Micro (available from Arduino). The Arduino Micro may, for example, be used to monitor the cable tension using force sensors mounted on the rails, which are in turn connected to both the motors and the tendons, enabling cable transmission throughout the system.

[0137] FIG. 10 depicts an experimental setup 1000 to track manipulator movement and bending in an abdomen model embodiment using an EM tracker. The experimental setup 1000 includes a robotic system 1005. The experimental setup 10005, as depicted, may, for example, be used to assess the performance of our manipulator design in terms of flexion range and workspace volume. The robotic system 1005 includes an electromagnetic (EM) sensor 1020. The experimental process began with inserting the204911-3852-9884, v 2EM sensor 1020 through the inner diameter of the manipulator, ensuring it was positioned accurately at the tip.

[0138] The robotic system 1005 was then placed within an abdomen model 1010 (e.g., the da Vinci surgical abdomen model, available at Intuitive Surgical, Sunnyvale, California). The abdomen model may, for example, provide a reasonable simulator of a twin pregnancy abdomen for the purposes of this experimental process.

[0139] The robotics system includes an EM field generator 1015. The robotics system includes an EM Tracker 1030. The EM tracker 1030 includes a computer interface 1025. After placing the robotic system 1005, the EM tracker 1030 and field generator 1015 may, for example, be activated, initiating the data collection process. The robot, upon being commanded to bend in all directions of the abdomen model, had its manipulator’s tip position and orientation continuously recorded by the EM tracker throughout the bending process.

[0140] FIG. 11 depicts a bending experiment 1100 of an ellipsoidal manipulator 1105 with each tendon pulled separately to achieve 90°, 180°, and the maximum bending angle (e.g., an angle greater than 180°).

[0141] In the bending experiment 1100, the motors may, for example, be individually actuated to pull each tendon, increasing the robot’s bending angle to 90° in step 1110. The tendon bending angle may, for example, be increased then to 180° in step 1115. In step 1120, the tendon bending angle may, for example, be increased pushing it to its maximum bending limit in the direction of pull. This experimental process may, for example, ensure that the manipulator met its design requirement of achieving at least 180° of flexion. The results of this initial phase are captured in FIG. 11, which illustrates the manipulator’s proficiency in reaching and surpassing the targeted bending angles.

[0142] In some experimental methods, the full range of the manipulator’s workspace may, for example, be analyzed by directing it through various bending trajectories. In FIGS. 12-15, the manipulator’s versatility in bending in all directions is shown in its operational sphere. FIG. 12 depicts a 2D planar view of tracked trajectory along the X-Z plane 1200. The tracked trajectory along the X-Z plane 1200 includes a mapping of EM sensor’s trajectory 1205 of the continuum manipulator within an abdomen based on the x, z orientation as depicted

[0143] FIG. 13 depicts a 2D planar view of tracked trajectory along the X-Y plane 1300. The tracked trajectory along the X-Y plane 1300 includes a mapping of EM sensor’s214911-3852-9884, v 2trajectory 1305 of the continuum manipulator within an abdomen based on the x, y orientation as depicted.

[0144] FIG. 14 depicts a 2D planar view of tracked trajectory along the Y-Z plane 1400. The tracked trajectory along the Y-Z plane 1400 includes a mapping of EM sensor’s trajectory 1405 of the continuum manipulator within an abdomen based on the y, z orientation as depicted

[0145] FIG. 15 depicts a 3D isometric view of robot volume workspace 1500. The robot volume workspace 1500 includes a continuum manipulator 500. A mapping of EM sensor’s trajectory 1510 of the continuum manipulator within an abdomen based on the x, y, z orientation is depicted. The mapping of the maximum range 1510 is mapped within a sphere 1515.

[0146] In the workspace analysis, the EM tracker may, for example, be used to capture the position and orientation data of the EM sensor located at the robot’ s tip. The manipulator’s movements may, for example, be tracked in a reference space set by the EM field generator. The XYZ position data of the robotic tip may, for example, be recorded as a three-element vector: (x, y, z). The orientation may, for example, be recorded in quaternion format, expressed as a four-element vector: (w, x, y, z), where w is the scalar, and (x, y, z) form the vector. The workspace of the continuum manipulator may, for example, be conceptualized as a spherical volume within which the end-effector can maneuver. To quantify this workspace, the center of the sphere may, for example, correspond to the central coordinates of the robot’s continuum body. The radius of the sphere may, for example, then be computed based on the furthest reach of the manipulator from this central point. This process may, for example, be achieved by calculating the Euclidean distance between the center, C = (ex, cy, cz), and a point, P = (px, py, pz), using the distance formula (Eq. 1). The maximum distance found across all points is designated as the radius (R) of the sphere.

[0148] Using the calculated radius (R), a plot of a 3D sphere representing the boundary of the manipulator’s workspace 1515 may, for example, be generated. The EM sensor’s trajectory 1510 is plotted as points within the sphere 1515, as shown in FIG. 15, illustrating the manipulator’s reach in the abdominal model. With the radius determined,224911-3852-9884, v 2the volume (V) of the sphere is calculated using the formula for the volume of a sphere

[0150] To analyze the bending motion of the manipulator, a user of the experimental method may, for example, compute the change in angle from all recorded orientations. The equation, Eq. 7, may, for example, be used to compute pitch, or the bending angle (0), as a function of the quaternion components (qw, qx, qy, qz) and as derived from the discriminant (A)

[0021] .

[0151] ^qwqy xQz (2)

[0152] This discriminant may, for example, be used to calculate the pitch angle (x), which is the rotation around the y-axis and is analogous to the bending angle. The yawpitch ( ), and roll (i ) angles may, for example, be computed from the quaternion as well.

[0156] These equations are derived from the transformation matrices associated with a quaternion and a triplet of angles, yaw- pitch-roll. In our case, we are only interested in the pitch angle, representing the bending angle of the manipulator, thereby deriving Eq. 7 from Eq. 3 and Eq. 5 where 0 = x-

[0157] 6 = arcsin(2(qwqy- qxqz) (7)

[0158] Therefore, through the EM tracking data presented in FIGS . 12- 15 , the experimental process may, for example, demonstrate the manipulator’s bending within a defined volume, as well as ascertain its maximum bending angle, thereby calculating the precise range of motion and bending depictions in FIG. 11.

[0159] The maximum distance or radius calculated with Eq. 1 across all XYZ points from the EM data is 21.16 cm, may, for example, be used to lead to a spherical volume of 39,685.84 cm3that the current robot size may, for example, can cover.

[0160] This maximum radius may, for example, be measured from the center of the manipulator to the tip whenever it bends. The manipulator’s full length from the base to the tip, in this embodiment, is 257 mm or 25.7 cm which would be the diameter of the workspace sphere if the manipulator were to extend fully in a straight line without 234911-3852-9884, v 2bending. However, the actual workspace volume when the robot bends is based on the maximum radius of 21.16 cm, which accommodates the various positions the manipulator can achieve in different directions within its workspace.

[0161] In conjunction with this spatial analysis, computations may, for example, be calculated, using Eq. 7, reveal that the maximum bending angle achieved by the manipulator was 230°, showcasing a substantial range of motion that exceeds the capabilities of most rolling joint continuum robotic manipulators that have a maximum bending of 180°.

[0162] This flexibility may, for example, be contrasted by the minimum bending angle, which was observed to be 0°, representing the manipulator’s fully extended position. The range of bending underscores the manipulator’ s versatility, allowing the continuum manipulator to bend and operate effectively towards anterior placenta sites requiring more than 180° bending. FIGS. 11-15 provide a clear visualization of the manipulator’s volumetric workspace and its bending capacity.

[0163] FIG. 16 depicts a system diagram of an exemplary tendon-driven continuum robot device 1600 according to exemplary embodiments of the present disclosure. In the illustrated embodiment, the tendon driven robot device 1600 includes an input module 1605. The input module 1605 may, for example, be used to deliver command inputs to control the continuum manipulator. The command inputs may, for example, change the flexion bending to the command input. A user may, for example, enter command inputs to match a predetermined flexion range as decided by a user of the device or method. The user may, for example, make the decision to change to a predetermined flexion range based on their discretion. The user may, for example, make the decision to change the flexion range based on their surgical experience. The user may, for example, make the decision to change the flexion range based on their surgical knowledge. During teleoperation, the input module may, for example, be configured to receive manipulation from remote surgeons.

[0164] The input module 1605 is communicatively coupled to a control region 915. The tendon routing and stability region 910 couples to tendon cables 1610. The continuum manipulator 500 is coupled to the main housing module 810 by coupling a housing end 1615 to the main housing module. The plurality tendon cables 1610 are constrained within a plurality of ellipsoid ring sliding joints 1620 (e.g., as depicted in FIG. 6). The plurality of ellipsoid sliding joints 1620 are coupled to an end effector 1625. The end244911-3852-9884, v 2effector f 625 is coupled to an instrument 1635. The interment may, for example, include a laser. The instrument may, for example, include a camera. The instrument may, for example, include a surgical device. The instrument may, for example, include sensors. In the illustrated embodiment, the instrument is coupled to a cable 1630. The cable may, for example, include optic fiber. The cable may, for example, include laser fiber. The cable may, for example, include scopes. The cable may, for example, include a fetoscope. The cable may, for example, include an endoscope. The cable 1630 may, for example, enter via housing end 1615 of the continuum manipulator as coupled to the main housing module 810.

[0165] FIG. 17 depicts an exemplary method 1700 of treatment for twin-to-twin transfusion syndrome using diagnostic and operating continuum manipulator.. In step 1705, a surgeon may, for example, perform an ultrasound examination to determine an insertion site for a continuum manipulator into an amniotic cavity of a predetermined twin. In step 1710, the surgeon may, for example, create the insertion site for the continuum manipulator.

[0166] In step 1715, the surgeon may, for example, provide a diagnostic and operative continuum manipulator including at least 3 tendon cables configured such that the at least 3 tendon cables are manipulatable to bend the continuum manipulator to a predetermined flexion range extending across 2 degrees of freedom; a plurality of sliding joints extending along the continuum manipulator, each sliding joint comprising: an outer ring comprising at least 3 tendon cable holes configured to receive the tendon cables to interconnect the plurality of ellipsoid contact joints; and, an inner ellipsoid protrusion ring enclosing at least one central aperture extending from the outer ring having an inner ellipsoid protrusion ring cross-sectional surface area less than the diameter of the outer ring configured such that in a midsection of the plurality of ellipsoid contact joints, the inner ellipsoid protrusion ring contacts a rear outer ring of a subsequent sliding joint forming a contact region between the inner ellipsoid protrusion ring and subsequent outer ring; and, a housing receiving the housing end of the continuum manipulator including: a tendon routing and stability region wherein the at least 3 tendon cables extending to a corresponding series of elastic actuators guided by a series of pulleys coupling the at least 3 tendon cables to at least 3 housing tendon cables; an actuation and force sensing region connected by the at least 3 housing tendon cables rotablably coupled to rotation pulleys to at least 3 corresponding bending actuation motors configured to rotate to engage the corresponding at least 3 tendon cables to bend the continuum manipulator to the254911-3852-9884, v 2predetermined flexion range, the actuation and force sensing region further comprising at least 3 force sensors coupled to the corresponding at least 3 housing tendon cables guided on force sensor rails; and, a control region including: at least one motor controller configured to control the at least 3 bending actuation motors; and, at least one controller to monitor the individual tension in the at least 3 housing tendon cables from a receiving force sensor signal received from the at least 3 force sensors.10167J In step 1715, a surgeon may map the placenta by inserting the continuum manipulator scope to map the anastomoses of a placenta. In step 1720, the surgeon may, for example, begin generating the map of the placenta by inserting the diagnostic and operative continuum manipulator scope. In step 1725 the surgeon may, for example, determine whether the mapping is complete.

[0168] In step 1730, the surgeon may, for example, operate the continuum manipulator scope including an end effector configured to deliver laser energy from laser fiber enclosed by the continuum manipulator to create an avascular plane between a circulation of the twins to decouple the circulation between the twins stopping unidirectional flow of blood of a donor twin to a recipient twin.

[0169] In step 1735, the surgeon may, for example, determine whether the operation was complete. If the operation was successful, the surgeon may, for example, remove the operating probe. If additional regions may, for example, need additional laser energy, the continuum manipulator may, for example, be manipulated to complete the treatment.

[0170] FIG. 18 depicts an exemplary continuum manipulator joint segment 1800 embodiment. Continuum manipulator joint segment 1800 includes a plurality of central aperture. Continuum manipulator joint segment 1800 includes a central aperture 1805. Continuum manipulator joint segment 1800 includes an adjacent secondary central aperture 1810. Continuum manipulator joint segment 1800 includes an adjacent secondary opposing central aperture 1810a. Continuum manipulator joint segment 1800 includes four cable channels 1815, 1815a, 1815b, 1815c. Continuum manipulator joint segment 1800 includes an inner protrusion ring 1825. Continuum manipulator joint segment 1800 includes an outer ring 1820. The continuum ring may, for example, have a major radius of 3.87 m by a minor radius of 3.11 mm dimension. The three central apertures may, for example, have dimensions of 0.678 mm, 1.9 mm, and 0.565 mm. The tendon channels may, for example, have a diameter of 0.395 mm.264911-3852-9884, v 2

[0171] Although various embodiments have been described with reference to the figures, other embodiments are possible.

[0172] Some embodiments, with the goal of improving current fetal surgery practices, specifically TTTS, include a 2-DOF bending tendon-driven continuum ellipsoidal manipulator capable of up to 230° flexion and volumetric workspace of approximately 39,685.84 cm3. The design may, for example, be bio-inspired by human condyloid hand joints. The design may, for example, improve the lack of dexterity in TTTS procedures and augment surgeon performance.

[0173] In some embodiments, the continuum manipulator, the manipulator may, for example, be computer- controlled. Some embodiments of the continuum manipulator may, for example, incorporate a teleoperable interface such as a haptic device (e.g., a Geomagic Touch haptic device, available at 3D Systems Corp, Valencia, California, U.S)).

[0174] Some embodiments may, for example, use a haptic controller interface module for firing a laser and manipulating the flexible instrument during teleoperation.

[0175] Some embodiments may, for example, include a more sophisticated control strategy to enhance its precision and user-friendliness.

[0176] Some embodiments may, for example, be modified from the continuum manipulator depicted as its outer diameter measures 14mm x 12mm, which is too large for a 10 Fr trocar (3.3 mm outer diameter) commonly used in TTTS surgery. Some embodiments may, for example, miniaturize the manipulator diameter design to be able to fit through a 10 Fr trocar.

[0177] Some embodiments, may, for example, be modified from the manipulator’s length, currently shorter than the standard 26 cm fetoscopes used for TTTS procedures. The continuum manipulator was originally designed to accommodate the maximum depth of the experiment abdomen model. Accordingly, some embodiments may, for example, extend the length of the continuum manipulator beyond 26 cm, potentially up to 35 cm, to adequately reach the posterior and anterior placenta locations.

[0178] Some embodiments may, for example, use different material. The current material, SLA resin, may lead to increased friction between joints; thus, some embodiments may, for example, include more durable and smoother metal material such as stainless steel, ceramic, or other types of photosensitive resin.274911-3852-9884, v 2

[0179] Some embodiments of the continuum manipulator may, for example, be modified to replace the existing backbone, which is currently the cable of the endoscope, with a flexible outer sheath to maintain constant curvature or a dedicated backbone that incorporates channels for fiber optic imaging and a laser fiber for ablation.

[0180] Some embodiments of the continuum manipulator may, for example, be modified such that the inner diameter of the ellipsoidal contact joints is smaller than both its ovalshaped ring outer diameter and the inner diameters of other rolling joint manipulators. This may, for example, be advantageous to counteract torsion. Modifying the inner diameter of the ellipsoidal contact joints to be smaller than both its oval-shaped ring outer diameter and the inner diameters of other rolling joint manipulators may, for example, improve the manipulator’s structural integrity.

[0181] Some embodiments of the manipulator’s design may, for example, include the integration of two additional degrees of freedom. Additional degrees of freedom may, for example, enable the robot to move both forward and backward, as well as to rotate around its axis. Including additional degrees may, for example, significantly expand the operational versatility and maneuverability of the robot. These planned improvements may, for example, refine the manipulator’s performance, making it more suitable for TTTS and withstanding interactions with the fetus.

[0182] In some embodiments may, for example, the manipulator may include an ellipsoidal shape and actuation system equipped with force sensors and three DC motors for PID control, with one tendon attached to each DC motor and connected to one end of the manipulator tip.

[0183] Some embodiments of the flexible manipulator may, for example, addresses the issue of tendon damage in current continuum manipulators caused by external forces during surgery, especially for miniaturized tendon-driven manipulators with very small outer diameters (less than 2mm - 6mm).

[0184] Although exemplary systems, devices, and methods have been described with reference to FIGS. 1-18, other implementations may be deployed in other industrial, scientific, medical, commercial, or residential applications.

[0185] Some embodiments may, for example, be used in various minimally invasive procedures where rigid scopes are problematic and navigation is required without relying on organ walls for steering.284911-3852-9884, v 2

[0186] Some embodiments of the flexible manipulator may, for example, be used in endoscopy or gastrointestinal procedures. Some embodiments of the flexible manipulator may, for example, be used for navigating and treating conditions within the gastrointestinal tract.

[0187] Some embodiments of the flexible manipulator may, for example, be used in lung catheter biopsies.

[0188] Some embodiments of the flexible manipulator may, for example, be used for performing biopsies in the lungs where airways decrease in size and reaching airways located 180 degrees of the instrument insertion site.

[0189] Some embodiments of the flexible manipulator may, for example, be used in intracranial surgery.

[0190] Some embodiments of the flexible manipulator may, for example, be used in endoscopic transnasal transsphenoidal surgery. Some embodiments of the flexible manipulator may, for example, be used for accessing and treating brain lesions.

[0191] Some embodiments of the flexible manipulator may, for example, be to enter through the nose to remove tumors from the pituitary gland and skull base.

[0192] Some embodiments of the flexible manipulator may, for example, be used in fetal surgery.

[0193] Some embodiments of the flexible manipulator may, for example, be used in spina bifida treatments.

[0194] Some embodiments of the flexible manipulator may, for example, be used in fetoscopic tracheal occlusion treatments. Some embodiments of the flexible manipulator may, for example, be used in in-utero fetal brain surgery.

[0195] Some embodiments of the flexible manipulator may, for example, be used in esophageal varices surgery.

[0196] Some embodiments may, for example, be used in pediatric procedures.

[0197] Some embodiments may, for example, be used in child surgical operations, as children in some cases need smaller flexible surgical instruments than adults.

[0198] A number of implementations have been described. Nevertheless, it will be understood that various modifications may be made. For example, advantageous results may be achieved if the steps of the disclosed techniques where performed in a different sequence, or if components of the discloses systems and devices were combines in a different manner, or if the components were supplemented with other components.294911-3852-9884, v 2Accordingly, other implementations are contemplated within the scope of the following claims.304911-3852-9884, v 2REFERENCES

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[0010] D.-K. Li, H. Chen, and R. Odouli, “Maternal exposure to magnetic fields during pregnancy in relation to the risk of asthma in offspring,” Archives of pediatrics & adolescent medicine, vol. 165, no. 10, pp. 945-950, 2011.

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Claims

1. CLAIMS1. A device comprising: a continuum manipulator comprising: a plurality of sliding joints extending along the continuum manipulator, each sliding joint of the plurality of joints comprising: an outer ring comprising at least 3 tendon cable holes configured to receive the tendon cables to interconnect the plurality of sliding joints; and, an inner ellipsoid protrusion ring, enclosing at least one central aperture, extending from the outer ring having an inner ellipsoid protrusion ring cross-sectional surface area less than the diameter of the outer ring configured such that in a midsection of the plurality of ellipsoid contact joints, the inner ellipsoid protrusion ring contacts a rear outer ring of a subsequent sliding joint forming a contact region between the inner ellipsoid protrusion ring and subsequent outer ring; and at least 3 tendon cables configured such that the at least 3 tendon cables are manipulatable to bend the continuum manipulator to a predetermined flexion range extending across 2 degrees of freedom.

2. A device comprising: a continuum manipulator comprising: at least 3 tendon cables configured such that the at least 3 tendon cables are manipulatable to bend the continuum manipulator to a predetermined flexion range extending across 2 degrees of freedom; a plurality of sliding joints extending along the continuum manipulator, each sliding joint comprising: an outer ring comprising at least 3 tendon cable holes configured to receive the tendon cables to interconnect the plurality of ellipsoid contact joints; and, an inner ellipsoid protrusion ring, enclosing at least one central aperture, extending from the outer ring having an inner ellipsoid protrusion ring cross-sectional surface area less than the diameter of the outer ring configured such that in a midsection of the plurality of344911-3852-9884, v 2ellipsoid contact joints, the inner ellipsoid protrusion ring contacts a rear outer ring of a subsequent sliding joint forming a contact region between the inner ellipsoid protrusion ring and subsequent outer ring; and, a housing receiving the continuum manipulator, the housing comprising: a tendon routing and stability region wherein the at least 3 tendon cables extending to a corresponding series of elastic actuators guided by a series of pulleys coupling the at least 3 tendon cables to at least 3 housing tendon cables; an actuation and force sensing region connected by the at least 3 housing tendon cables rotatably coupled to rotation pulleys to at least 3 corresponding bending actuation motors configured to rotate to engage the corresponding at least 3 tendon cables to bend the continuum manipulator to the predetermined flexion range, the actuation and force sensing region further comprising at least 3 force sensors coupled to the corresponding at least 3 housing tendon cables guided on force sensor rails; and, a control region comprising: at least one motor controller configured to control the at least 3 bending actuation motors; and, at least one controller to monitor the individual tension in the at least 3 housing tendon cables from a receiving force sensor signal received from the at least 3 force sensors.

3. A device comprising: a continuum manipulator comprising: a plurality of sliding joints extending along the continuum manipulator, each sliding joint of the plurality of joints comprising: an outer ring comprising at least 2 tendon cable holes configured to receive the tendon cables to interconnect the plurality of sliding joints; and, an inner ellipsoid protrusion ring, enclosing at least one central aperture, extending from the outer ring having an inner ellipsoid protrusion ring cross-sectional surface area less than the diameter of the outer ring configured such that in a midsection of the plurality of354911-3852-9884, v 2ellipsoid contact joints, the inner ellipsoid protrusion ring contacts a rear outer ring of a subsequent sliding joint forming a contact region between the inner ellipsoid protrusion ring and subsequent outer ring; and at least 2 tendon cables configured such that the at least 2 tendon cables are manipulatable to bend the continuum manipulator to a predetermined flexion range extending across one degree of freedom.

4. The device of either one of claims 1-3, further comprising an input module configured to receive user command inputs to modify the predetermined flexion range.

5. The device of either one of claims 1-3, further comprising a visual monitor depicting the current predetermined flexion range.

6. The device of either one of claims 1-3, wherein the plurality of sliding joints comprises at least one inner ellipsoid protrusion ring that is oval shaped.

7. The device of either one of claims 1-3, wherein the continuum manipulator is configured to bend to the predetermined flexion range extending to a range up to 230 degrees across 2 degrees of freedom.

8. The device of either one of claims 1-3, wherein the continuum manipulator is configured to omnidirectional bending.

9. The device of either one of claims 1-3, wherein the continuum manipulator is configured to fit a 10 Fr trocar.

10. The device of either one of claims 1-3, wherein the continuum manipulator is configured to fit a 3.3 mm trocar.

11. The device of either one of claims 1-3, wherein the continuum manipulator extends 35 cm.

12. The device of either one of claims 1-3, further comprising a hollow tube extending through the central aperture of the plurality of sliding joints configured to receive an instrument through the hollow tube.

13. The device of claim 12, wherein the instrument comprises a fiber optic configured to conduct imaging.

14. The device of claim 12, wherein the instrument comprises a laser fiber optic configured to conduct ablation.

15. The device of either one of claims 1-3, further comprising one or more cameras coupled to the continuum manipulator.364911-3852-9884, v 216. The device of either one of claims 1-3, wherein the control region receives commands to actuate the continuum manipulator commands from a remote operator.

17. The device of either one of claims 1-3, wherein the continuum manipulator is operated to treat a patient during a twin-to-twin transfusion syndrome operation.

18. The device of either one of claims 1-3, wherein the continuum manipulator is operated to treat at least one fetus during a twin-to-twin transfusion syndrome operation.

19. The device of either one of claims 1-3, wherein the continuum manipulator is configured to withstand external forces created by a fetus grabbing the continuum manipulator during a twin-to-twin transfusion syndrome operation.

20. A medical procedure for treating twin-to-twin transfusion syndrome comprising: performing an ultrasound examination to determine an insertion site for a fetoscope into an amniotic cavity of a predetermined twin; providing a diagnostic and operative continuum manipulator , the diagnostic and operative continuum manipulator comprising: at least 3 tendon cables configured such that the at least 3 tendon cables are manipulatable to bend the continuum manipulator to a predetermined flexion range extending across 2 degrees of freedom; a plurality of sliding joints extending along the continuum manipulator, each sliding joint comprising: an outer ring comprising at least 3 tendon cable holes configured to receive the tendon cables to interconnect the plurality of sliding joints; and, an inner ellipsoid protrusion ring, enclosing at least one central aperture, extending from the outer ring having an inner ellipsoid protrusion ring cross-sectional surface area less than the diameter of the outer ring configured such that in a midsection of the plurality of ellipsoid contact joints, the inner ellipsoid protrusion ring contacts a rear outer ring of a subsequent sliding joint forming a contact region between the inner ellipsoid protrusion ring and subsequent outer ring; mapping the placenta by inserting the diagnostic and operative continuum manipulator scope to map the anastomoses a placenta;374911-3852-9884, v 2operating the diagnostic and operative continuum manipulator scope comprising an end effector configured to deliver laser energy from laser fiber enclosed by the continuum manipulator to create an avascular plane between a circulation of the twins to decouple the circulation between the twins stopping unidirectional flow of blood of a donor twin to a recipient twin.

21. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator further comprises housing receiving the continuum manipulator comprising, the housing comprising: a tendon routing and stability region wherein the at least 3 tendon cables extending to a corresponding series of elastic actuators guided by a series of pulleys coupling the at least 3 tendon cables to at least 3 housing tendon cables; an actuation and force sensing region connected by the at least 3 housing tendon cables rotatably coupled to rotation pulleys to at least 3 corresponding bending actuation motors configured to rotate to engage the corresponding at least 3 tendon cables to bend the continuum manipulator to the predetermined flexion range, the actuation and force sensing region further comprising at least 3 force sensors coupled to the corresponding at least 3 housing tendon cables guided on force sensor rails; and, a control region comprising: at least one motor controller configured to control the at least 3 bending actuation motors; and, at least one controller to monitor the individual tension in the at least 3 housing tendon cables from a receiving force sensor signal received from the at least 3 force sensors.

22. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator further comprises an input module configured to receive user command inputs to modify the predetermined flexion range.

23. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator further comprises a visual monitor depicting the current predetermined flexion range.384911-3852-9884, v 224. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the plurality of sliding joints comprises at least one inner ellipsoid protrusion ring that is oval shaped.

25. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator is configured to bend to the predetermined flexion range extending to a range up to 230 degrees across 2 degrees of freedom.

26. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator is configured to omnidirectional bending.

27. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator is configured to fit a 10 Fr trocar.

28. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator is configured to fit a 3.3 mm trocar.

29. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator extends 35 cm.

30. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator further comprises a hollow tube extending through the at least one central aperture of the plurality of sliding joints configured to receive an instrument through the hollow tube.

31. The medical procedure for treating twin-to-twin transfusion syndrome of claim 30, wherein the instrument comprises a fiber optic configured to conduct imaging.

32. The medical procedure for treating twin-to-twin transfusion syndrome of claim 30, wherein the instrument comprises a laser fiber optic configured to conduct ablation.

33. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, further comprising one or more cameras coupled to the continuum manipulator.

34. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the control region receives commands to actuate the continuum manipulator commands from a remote operator.

35. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator is operated to treat a patient during a twin-to-twin transfusion syndrome operation.

36. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator is operated to treat at least one fetus during a twin-to-twin transfusion syndrome operation.394911-3852-9884, v 237. The medical procedure for treating twin-to-twin transfusion syndrome of claim 20, wherein the continuum manipulator is configured to withstand external forces created by a fetus grabbing the continuum manipulator during a twin-to-twin transfusion syndrome operation.404911-3852-9884, v 2

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