(12) United States Patent
`US 6,817,974 132
`(10) Patent N0.:
`(45) Date of Patent:
`Cooper et al.
`Nov. 16, 2004
`
`USOO6817974B2
`
`SURGICAL TOOL HAVING POSITIVELY
`POSITIONABLE TENDON-ACTUATED
`MULTI-DISK WRIST JOINT
`
`FOREIGN PATENT DOCUMENTS
`
`DE
`JP
`
`41388614 A1
`5—184525
`
`*
`
`5/1993
`7/1993
`
`(54)
`
`(75)
`
`Inventors: Thomas G. Cooper, Menlo Park, CA
`(US); Daniel T. Wallace, Redwood
`City, CA (US); Stacey Chang,
`Sunnyvale, CA (US); S. Christopher
`Anderson, Northampton, MA (US);
`Dustin Williams, Mountain View, CA
`(US); Scott Manzo, Shelton, CT (US)
`
`(73)
`
`Assignee:
`
`Intuitive Surgical, Inc., Sunnyvale, CA
`(US)
`
`(*)
`
`Notice:
`
`Subject to any disclaimer, the term of this
`patent is extended or adjusted under 35
`U.S.C. 154(b) by 161 days.
`
`(21)
`
`(22)
`
`(65)
`
`(60)
`
`(51)
`(52)
`(58)
`
`(56)
`
`Appl. N0.: 10/187,248
`
`Filed:
`
`Jun. 28, 2002
`Prior Publication Data
`
`US 2003/0036748 A1 Feb. 20, 2003
`
`Related US. Application Data
`Provisional application No. 60/301,967, filed on Jun. 29,
`2001, and provisional application No. 60/327,702, filed on
`Oct. 5, 2001.
`
`Int. Cl.7 .................................................. A61B 1/00
`US. Cl.
`........................................ 600/142; 606/205
`Field of Search ................................. 600/139—142,
`600/146; 606/205—208, 210, 211
`
`References Cited
`
`U.S. PATENT DOCUMENTS
`
`3,268,059 A
`3,788,303 A
`4,203,430 A
`4,483,326 A
`4,834,069 A *
`
`8/1966 Stelle
`1/1974 Hall
`5/1980 Takahashi
`11/1984 Yamaka et al.
`5/1989 Umeda ....................... 600/142
`
`OTHER PUBLICATIONS
`
`Neisius, B. et al. (1995). “Entwicklugng Eines Mainpulators
`Zur Endoskopischen Handhabung Chirurgischer Effektom,”
`Nachrichten— Forshchunszentrum.
`
`Rosheim, ME. (1995). “Chap. 5: Pitch—Yaw—Roll Wrists,”
`In Robotic WristActuators, John Wiley and Sons, Inc., New
`York.
`
`Primary Examiner—Beverly M. Flanagan
`(74) Attorney, Agent, or Firm—Townsend and Townsend
`and Crew LLP
`
`(57)
`
`ABSTRACT
`
`The present invention is directed to a tool having a wrist
`mechanism that provides pitch and yaw rotation in such a
`way that the tool has no singularity in roll, pitch, and yaw.
`A positively positionable multi-disk wrist mechanism
`includes a plurality of disks or vertebrae stacked in series.
`Each vertebra is configured to rotate in pitch or in yaw with
`respect to each neighboring vertebra. Actuation cables are
`used to manipulate and control movement of the vertebrae.
`In specific embodiments, some of the cables are distal cables
`that extend from a proximal vertebra through one or more
`intermediate vertebrae to a distal vertebra, while the remain-
`ing cables are medial cables that extend from the proximal
`vertebra to one or more of the intermediate vertebrae. The
`
`cables are actuated by a pivoted plate cable actuator mecha-
`nism.
`In specific embodiments,
`the actuator mechanism
`includes a plurality of small radius holes or grooves for
`receiving the medial cables and a plurality of large radius
`holes or grooves for receiving the distal cables. The holes or
`grooves restrain the medial cables to a small radius of
`motion and the distal cables to a large radius of motion, so
`that the medial cables to the medial vertebra move only a
`fraction of the amount as the distal cables to the distal
`
`vertebra, so as to achieve precise control and manipulation
`of the vertebrae.
`
`(List continued on next page.)
`
`45 Claims, 55 Drawing Sheets
`
`54
`
`52
`
`54
`
`IS 1007
`
`1
`
`IS 1007
`
`

`

`US 6,817,974 132
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`
`US. PATENT DOCUMENTS
`
`393229333 2
`,
`,
`5,454,827 A
`5,479,930 A
`5,755,731 A
`
`$133: ElmfletaL
`60 e 6
`10/1995 Austetal.
`1/1996 Gruner et a1.
`5/1998 Grinberg
`
`5,885,288 A
`5,916,146 A *
`6,270,453 B1 *
`69436407 B1
`.
`.
`* Clted by examlner
`
`3/1999 Aust et 211.
`6/1999 Allotta et a1. ............... 600/141
`8/2001 Sakai
`......................... 600/141
`8/2002 wang etal‘
`
`2
`
`

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`Nov. 16, 2004
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`[40
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`42
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`40\
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`50\
`54
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`52
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`
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`US 6,817,974 B2
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`1
`SURGICAL TOOL HAVING POSITIVELY
`POSITIONABLE TENDON-ACTUATED
`MULTI-DISK WRIST JOINT
`
`CROSS-REFERENCES TO RELATED
`APPLICATIONS
`
`This application is based on and claims the benefit of US.
`Provisional Patent Application No. 60/301,967, filed Jun.
`29, 2001, and No. 60/327,702, filed Oct. 5, 2001, the entire
`disclosures of which are incorporated herein by reference.
`This application is related to the following patents and
`patent applications, the full disclosures of which are incor-
`porated herein by reference:
`PCT International Application No. PCT/US98/19508,
`entitled “Robotic Apparatus”, filed on Sep. 18, 1998, and
`published as WO99/50721;
`L.S. patent application Ser. No. 09/418,726, entitled
`“Surgical Robotic Tools, Data Architecture, and Use”, filed
`on Oct. 15, 1999;
`L .S. patent application Ser. No. 60/111,711, entitled
`“Image Shifting for a Telerobotic System”, filed on Dec. 8,
`1998;
`LS. patent application Ser. No. 09/378,173, entitled
`“Stereo Imaging System for Use in Telerobotic System”,
`filed on Aug. 20, 1999;
`LS. patent application Ser. No. 09/398,507, entitled
`“Master Having Redundant Degrees of Freedom”, filed on
`Sep. 17, 1999;
`L .S. application Ser. No. 09/399,457, entitled “Coopera-
`tive Minimally Invasive Telesurgery System”, filed on Sep.
`17, 1999;
`LS. patent application Ser. No. 09/373,678, entitled
`“Camera Referenced Control in a Minimally Invasive Sur-
`gical Apparatus”, filed on Aug. 13, 1999;
`LS. patent application Ser. No. 09/398,958, entitled
`“Surgical Tools for Use in Minimally Invasive Telesurgical
`Applications”, filed on Sep. 17, 1999; and
`LS. Pat. No. 5,808,665, entitled “Endoscopic Surgical
`Instrument and Method for Use”, issued on Sep. 15, 1998.
`BACKGROUND OF THE INVENTION
`
`
`
`The present invention relates generally to surgical tools
`and, more particularly,
`to various wrist mechanisms in
`surgical tools for performing robotic surgery.
`technology
`Advances in minimally invasive surgical
`could dramatically increase the number of surgeries per-
`formed in a minimally invasive manner. Minimally invasive
`medical techniques are aimed at reducing the amount of
`extraneous tissue that
`is damaged during diagnostic or
`surgical procedures, thereby reducing patient recovery time,
`discomfort, and deleterious side effects. The average length
`of a hospital stay for a standard surgery may also be
`shortened significantly using minimally invasive surgical
`techniques. Thus, an increased adoption of minimally inva-
`sive techniques could save millions of hospital days, and
`millions of dollars annually in hospital residency costs
`alone. Patient recovery times, patient discomfort, surgical
`side effects, and time away from work may also be reduced
`with minimally invasive surgery.
`The most common form of minimally invasive surgery
`may be endoscopy. Probably the most common form of
`endoscopy is laparoscopy, which is minimally invasive
`inspection and surgery inside the abdominal cavity.
`In
`standard laparoscopic surgery, a patient’s abdomen is insuf-
`
`10
`
`15
`
`20
`
`25
`
`30
`
`35
`
`40
`
`45
`
`50
`
`55
`
`60
`
`65
`
`2
`fiated with gas, and cannula sleeves are passed through small
`(approximately 1/2 inch) incisions to provide entry ports for
`laparoscopic surgical instruments. The laparoscopic surgical
`instruments generally include a laparoscope (for Viewing the
`surgical field) and working tools. The working tools are
`similar to those used in conventional (open) surgery, except
`that the working end or end effector of each tool is separated
`from its handle by an extension tube. As used herein, the
`term “end effector” means the actual working part of the
`surgical
`instrument and can include clamps, graspers,
`scissors, staplers, and needle holders, for example. To per-
`form surgical procedures, the surgeon passes these working
`tools or instruments through the cannula sleeves to an
`internal surgical site and manipulates them from outside the
`abdomen. The surgeon monitors the procedure by means of
`a monitor that displays an image of the surgical site taken
`from the laparoscope. Similar endoscopic techniques are
`employed in, e.g., arthroscopy,
`retroperitoneoscopy,
`pelviscopy, nephroscopy, cystoscopy, cisternoscopy,
`sinoscopy, hysteroscopy, urethroscopy and the like.
`There are many disadvantages relating to current mini-
`mally invasive surgical (MIS) technology. For example,
`existing MIS instruments deny the surgeon the flexibility of
`tool placement found in open surgery. Most current laparo-
`scopic tools have rigid shafts, so that it can be difficult to
`approach the worksite through the small
`incision.
`Additionally,
`the length and construction of many endo-
`scopic instruments reduces the surgeon’s ability to feel
`forces exerted by tissues and organs on the end effector of
`the associated tool. The lack of dexterity and sensitivity of
`endoscopic tools is a major impediment to the expansion of
`minimally invasive surgery.
`Minimally invasive telesurgical robotic systems are being
`developed to increase a surgeon’s dexterity when working
`within an internal surgical site, as well as to allow a surgeon
`to operate on a patient from a remote location. In a telesur-
`gery system, the surgeon is often provided with an image of
`the surgical site at a computer workstation. While viewing a
`three-dimensional image of the surgical site on a suitable
`viewer or display, the surgeon performs the surgical proce-
`dures on the patient by manipulating master input or control
`devices of the workstation. The master controls the motion
`
`of a servomechanically operated surgical instrument. During
`the surgical procedure, the telesurgical system can provide
`mechanical actuation and control of a variety of surgical
`instruments or tools having end effectors such as, e.g., tissue
`graspers, needle drivers, or the like, that perform various
`functions for the surgeon, e.g., holding or driving a needle,
`grasping a blood vessel, or dissecting tissue, or the like, in
`response to manipulation of the master control devices.
`Some surgical tools employ a roll-pitch-yaw mechanism
`for providing three degrees of rotational movement to an end
`effector around three perpendicular axes. The pitch and yaw
`rotations are typically provided by a wrist mechanism
`coupled between a shaft of the tool and an end effector, and
`the roll rotation is typically provided by rotation of the shaft.
`At about 90° pitch, the yaw and roll rotational movements
`overlap, resulting in the loss of one degree of rotational
`movement, referred to as a singularity.
`
`BRIEF SUMMARY OF THE INVENTION
`
`The present invention is directed to alternative embodi-
`ments of a tool having a wrist mechanism that provides pitch
`and yaw rotation in such a way that
`the tool has no
`singularity in roll, pitch, and yaw.
`In one preferred
`embodiment, a wrist mechanism includes a plurality of disks
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`US 6,817,974 B2
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`3
`or vertebrae stacked or coupled in series. Typically the most
`proximal vertebrae or disk of the stack is coupled to a
`proximal end member segment, such as the working end of
`a tool or instrument shaft; and the most distal vertebrae or
`disk is coupled to a distal end member segment, such as an
`end-effector or end-effector support member. Each disk is
`configured to rotate in at least one degree of freedom or DOF
`(e.g., in pitch or in yaw) with respect to each neighboring
`disk or end member.
`
`the term disk or
`in the discussion herein,
`In general,
`vertebrae may include any proximal or distal end members,
`unless the context indicates reference to an intermediate
`
`segment disposed between the proximal and distal end
`members. Likewise, the terms disk or vertebrae will be used
`interchangeably herein to refer to the segment member or
`segment subassembly,
`it being understood that the wrist
`mechanisms having aspects of the invention may include
`segment members or segment subassemblies of alternative
`shapes and configurations, which are not necessarily disk-
`like in general appearance.
`Actuation cables or tendon elements are used to manipu-
`late and control movement of the disks, so as to effect
`movement of the wrist mechanism. The wrist mechanism
`
`resembles in some respects tendon-actuated steerable mem-
`bers such as are used in gastroscopes and similar medical
`instruments. However, multi-disk wrist mechanisms having
`aspects of the invention may include a number of novel
`aspects. For example, a wrist embodiment may be positively
`positionable, and provides that each disk rotates through a
`positively determinable angle and orientation. For this
`reason, this embodiment is called a positively positionable
`multi-disk wrist (PPMD wrist).
`In some of the exemplary embodiments having aspects of
`the invention, each disk is configured to rotate with respect
`to a neighboring disk by a nonattached contact. As used
`herein, a nonattached contact refers to a contact that is not
`attached or joined by a fastener, a pivot pin, or another
`joining member. The disks maintain contact with each other
`by, for example, the tension of the actuation cables. The
`disks are free to separate upon release of the tension of the
`actuation cables. A nonattached contact may involve rolling
`and/or sliding between the disks, and/or between a disk and
`an adjacent distal or proximal wrist portion.
`to particular
`As is described below with respect
`embodiments, shaped contact surfaces may be included such
`that nonattached rolling contact may permit pivoting of the
`adjacent disks, while balancing the amount of cable motion
`on opposite sides of the disks. In addition, the nonattached
`contact aspect of the these exemplary embodiments pro-
`motes convenient, simplified manufacturing and assembly
`processes and reduced part count, which is particularly
`useful in embodiments having a small overall wrist diam-
`eter.
`
`It is to be understood that alternative embodiments having
`aspects of the invention may have one or more adjacent
`disks pivotally attached to one another and/or to a distal or
`proximal wrist portion in the same or substantially similar
`configurations by employing one or more fastener devices
`such as pins, rivets, bushings and the like.
`Additional embodiments are described which achieve a
`
`cable-balancing configuration by inclusion of one or more
`inter-disk struts having radial plugs which engage the adja-
`cent disks (or disk and adjacent proximal or distal wrist
`portion). Alternative configurations of the intermediate strut
`and radial plugs may provide a nonattached connection or an
`attached connection.
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`In certain embodiments, some of the cables are distal
`cables that extend from a proximal disk through at least one
`intermediate disk to a terminal connection to a distal disk.
`The remaining cables are medial cables that extend from the
`proximal disk to a terminal connection to a middle disk. The
`cables are actuated by a cable actuator assembly arranged to
`move each cable so as to deflect the wrist mechanism. In one
`exemplary embodiment, the cable actuator assembly may
`include a gimbaled cable actuator plate. The actuator plate
`includes a plurality of small radius holes or grooves for
`receiving the medial cables and a plurality of large radius
`holes or grooves for receiving the distal cables. The holes or
`grooves restrain the medial cables to a small radius of
`motion (e.g., 1/2 R) and the distal cables to a large radius of
`motion (R), so that the medial cables to the medial disk
`move a smaller distance (e.g., only half as far) compared to
`the distal cables to the distal disk, for a given gimbal motion
`or rotation relative to the particular cable. Note that for
`alternative embodiments having more than one intermediate
`cable termination segment, the cable actuator may have a
`plurality of sets of holes at selected radii (e.g., R, 2/3R, and
`1/3R). The wrist embodiments described are particularly
`suitable for robotic surgical systems, although they may be
`included in manually operated endoscopic tools.
`Embodiments including a cable actuator assembly having
`aspects of the invention provide to the simultaneous actua-
`tion of a substantial plurality of cables, and provide for a
`predetermined proportionality of motion of a plurality of
`distinct cable sets. This capability is provided with a simple,
`inexpensive structure which avoids highly complex control
`mechanisms. As described further below, for a given total
`cross-sectional area in each cable set and a given overall disk
`diameter, a mechanically redundant number of cables per-
`mits the cable diameter to be smaller, permits increasing the
`moment arm or mechanical advantage of the cables, and
`permits a larger unobstructed longitudinal center lumen
`along the centerline of the disks. These advantages are
`particularly useful in wrist members built to achieve the very
`small overall diameter such as are currently used in endo-
`scopic surgery.
`In some embodiments, a grip actuation mechanism is
`provided for operating a gripping end effector. When cables
`are used to manipulate the end effector, the grip actuation
`mechanism may include a grip cable actuator disposed in a
`tool or instrument proximal base or “back end.” The path
`length of a grip actuation cable may tend to vary in length
`during bending of the wrist in the event that cable paths do
`not coincide with the neutral axis. The change in cable path
`lengths may be accounted for in the back end mechanism
`used to secure and control the cables. This may be achieved
`by including a cable tension regulating device in the grip
`actuation mechanism, so as to decouple the control of the
`end effector such as grip jaws from the bending of the wrist.
`In specific embodiments,
`the back end mechanism is
`configured to allow for the replacement of the end effector,
`the wrist, and the shaft of the surgical
`instrument with
`relative ease.
`
`In accordance with an aspect of the present invention, a
`minimally invasive surgical instrument comprises an elon-
`gate shaft having a working end, a proximal end, and a shaft
`axis between the working end and the proximal end. Awrist
`member has a proximal portion connected to the working
`end. An end effector is connected to a distal portion of the
`wrist member. The wrist member comprises at least three
`vertebrae connected in series between the working end of
`the elongate shaft and the end effector. The vertebrae include
`a proximal vertebra connected to the working end of the
`elongate shaft and a distal vertebra connected to the end
`effector.
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`US 6,817,974 B2
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`5
`Each vertebra is pivotable relative to an adjacent vertebra
`by a pivotal connection, which may employ a nonattached
`(or alternatively an attached) contact. At least one of the
`vertebrae is pivotable relative to an adjacent vertebra by a
`pitch contact around a pitch axis which is nonparallel to the
`shaft axis. At least one of the vertebrae is pivotable relative
`to an adjacent vertebra by another contact around a second
`axis which is nonparallel to the shaft axis and nonparallel to
`the pitch axis.
`In accordance with another aspect of this invention, a
`minimally invasive surgical instrument comprises an elon-
`gate shaft having a working end, a proximal end, and a shaft
`axis between the working end and the proximal end. Awrist
`member has a proximal portion or proximal end member
`connected to the working end, and a distal portion or distal
`end member connected to an end effector. The wrist member
`
`three vertebrae connected in series
`least
`comprises at
`between the working end of the elongate shaft and an end
`effector.
`
`The vertebrae include a proximal vertebra connected to
`the working end of the elongate shaft and a distal vertebra
`connected to the end effector. Each vertebra is pivotable
`relative to an adjacent vertebra by a pivotable vertebral joint.
`At least one of the vertebrae is pivotable relative to an
`adjacent vertebra by a pitch joint around a pitch axis which
`is nonparallel to the shaft axis. At least one of the vertebrae
`is pivotable relative to an adjacent vertebra by a yaw joint
`around a yaw axis which is nonparallel to the shaft axis and
`perpendicular to the pitch axis. An end effector is connected
`to a distal portion of the wrist member. Aplurality of cables
`are coupled with the vertebrae to move the vertebrae relative
`to each other. The plurality of cables include at least one
`distal cable coupled with the terminating at the distal ver-
`tebra and extending proximally to a cable actuator member,
`and at least one intermediate cable coupled with and termi-
`nating at an intermediate vertebra disposed between the
`proximal vertebra and the distal vertebra and extending to
`the cable actuator member. The cable actuator member is
`
`configured to adjust positions of the vertebrae by moving the
`distal cable by a distal displacement and the intermediate
`cable by an intermediate displacement shorter than the distal
`displacement.
`In some embodiments, a ratio of each intermediate dis-
`placement to the distal displacement is generally propor-
`tional to a ratio of a distance from the proximal vertebra to
`the intermediate vertebra to which the intermediate cable is
`connected and a distance from the proximal vertebra to the
`distal vertebra to which the distal cable is connected.
`
`In accordance with another aspect of the invention, a
`method of performing minimally invasive endoscopic sur-
`gery in a body cavity of a patient comprises introducing an
`elongate shaft having a working end into the cavity. The
`elongate shaft has a proximal end and a shaft axis between
`the working end and the proximal end. A wrist member
`comprises at
`least
`three vertebrae connected in series
`between the working end of the elongate shaft and the end
`effector. The vertebrae include a proximal vertebra con-
`nected to the working end of the elongate shaft and a distal
`vertebra connected to the end effector. Each vertebra is
`
`pivotable relative to an adjacent vertebra by a pivotal
`coupling, which may employ a nonattached contact. An end
`effector is connected to a distal portion of the wrist member.
`The end effector is positioned by rotating the wrist member
`to pivot at least one vertebra relative to an adjacent vertebra
`by a pivotal pitch coupling around a pitch axis which is
`nonparallel to the shaft axis. The end effector is repositioned
`by rotating the wrist member to pivot at least one vertebra
`
`6
`relative to an adjacent vertebra by another pivotal coupling
`around a second axis which is nonparallel to the shaft axis
`and nonparallel to the pitch axis.
`In accordance with another aspect of the present
`invention, a minimally invasive surgical instrument has an
`end effector which comprises a grip support having a left
`pivot and a right pivot. Aleft jaw is rotatable around the left
`pivot of the grip support and a right jaw is rotatable around
`the right pivot of the grip support. Aleft slider pin is attached
`to the left jaw and spaced from the left pivot pin, and a right
`slider pin is attached to the right jaw and spaced from the
`right pivot pin. A slotted member includes a left slider pin
`slot in which the left slider pin is slidable to move the left
`jaw between an open position and a closed position, and a
`right slider pin slot in which the right slider pin is slidable
`to move the right jaw between an open position and a closed
`position. A slider pin actuator is movable relative to the
`slotted member to cause the left slider pin to slide in the left
`slider pin slot and the right slider pin to slide in the right
`slider pin slot, to move the left jaw and the right jaw between
`the open position and the closed position.
`In accordance with another aspect of the present
`invention, a method of performing minimally invasive endo-
`scopic surgery in a body cavity of a patient comprises
`providing a tool comprising an elongate shaft having a
`working end coupled with an end effector, a proximal end,
`and a shaft axis between the working end and the proximal
`end. The end effector includes a grip support having a left
`pivot and a right pivot; a left jaw rotatable around the left
`pivot of the grip support and a rightjaw rotatable around the
`right pivot of the grip support, a left slider pin attached to the
`left jaw and spaced from the left pivot pin, a right slider pin
`attached to the right jaw and spaced from the right pivot pin;
`and a slotted member including a left slider pin slot in which
`the left slider pin is slidable to move the left jaw between an
`open position and a closed position, and a right slider pin slot
`in which the right slider pin is slidable to move the rightjaw
`between an open position and a closed position. The method
`further comprises introducing the end effector into a surgical
`site; and moving the left slider pin to slide in the left slider
`pin slot and the right slider pin to slide in the right slider pin
`slot, to move the left jaw and the right jaw between the open
`position and the closed position.
`According to another aspect, a medical instrument com-
`prises a base shaft having a working end, a proximal end,
`and a shaft axis between the working end and the proximal
`end. A segmented wrist member comprises a plurality of
`spaced-apart segment vertebrae disposed sequentially adja-
`cent to one another along a wrist longitudinal line. The
`plurality of vertebrae include a proximal vertebra connected
`to the shaft working end, a distal vertebra supporting an end
`effector, and at least one intermediate vertebra disposed
`between the proximal vertebra and the distal vertebra, the at
`least one intermediate vertebrae being connected to each
`adjacent vertebra by a pivotally movable segment coupling.
`Each segment coupling has a coupling axis nonparallel to
`the wrist longitudinal line. At least two of the coupling axes
`are non-parallel to one another. At least one of the interme-
`diate vertebrae is a medial vertebra. A plurality of movable
`tendon elements are disposed generally longitudinally with
`respect to the shaft and wrist member. The tendon elements
`each have a proximal portion, and have a distal portion
`connected to one of the distal vertebra and the medial
`
`vertebra so as to pivotally actuate the connected vertebra. At
`least one of the tendons is connected to the at least one
`medial vertebra and at least one of the tendons is connected
`to the distal vertebra. A tendon actuation mechanism is
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`US 6,817,974 B2
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`7
`drivingly coupled to the tendons and configured to control-
`lably move at least selected ones of the plurality of tendons
`so as to pivotally actuate the plurality of connected vertebrae
`to laterally bend the wrist member with respect to the shaft.
`Another aspect is directed to a tendon actuating assembly
`for a surgical instrument, wherein the instrument includes a
`shaft-like member having a distal working end for insertion
`into a patient’s body through an aperture, and wherein the
`working end includes at least one distal moveable member
`arranged to be actuated by at least one of a plurality of
`movable tendon element. The actuating assembly comprises
`a tendon actuator member which is configured to be mov-
`able to at least pivot in one degree of freedom, and which
`includes a plurality of tendon engagement portions. Each
`engagement portion is drivingly couplable to at least one of
`the plurality of tendons. A drive mechanism is drivingly
`coupled to the actuator member so as to controllably pivot
`the actuator member in the at least one degree of freedom,
`so as to move at least one of the tendons relative to the
`shaft-like member so as to actuate the distal moveable
`member.
`
`In another aspect, a minimally invasive surgical instru-
`ment comprises a shaft having a working end, a proximal
`end, and a shaft axis between the working end and the
`proximal end. A segmented wrist member comprises a
`plurality of spaced-apart segment vertebrae disposed
`sequentially adjacent to one another along a wrist longitu-
`dinal line. The plurality of vertebrae include a proximal
`vertebra connected to the shaft working end, a distal vertebra
`supporting an end effector, and at least one intermediate
`vertebra disposed between the proximal vertebra and the
`distal vertebra. The at least one intermediat