ITFI20100076A1 - ROBOTIC SYSTEM FOR MINIMUM INVASIVE SURGERY INTERVENTIONS - Google Patents

Description

ROBOTIC APPARATUS FOR MINIMALLY SURGERY

INVASIVE

DESCRIPTION

Sector of the invention

The present invention refers to a robotic apparatus for minimally invasive surgery (hereinafter referred to as minimally invasive simplicity), in particular for laparoscopy.

State of the art

In traditional or open surgery procedures, the surgeon makes a generally very large incision. Once this is done, the surgeon intervenes on the part of interest manually or using manually operated tools. There are therefore the following advantages for the surgeon:

stereoscopic vision - and therefore perception of relative distances - thanks to the direct vision between the eyes of the surgeon himself and the operating scenario;

- return of natural force and tactile sensation, since the surgeon uses his hands to exert forces on the tissue directly or at the most mediated by a single instrument.

The most significant negative aspect of traditional surgery is linked to the high invasiveness of the procedure, which implies long hospital stays.

In abdominal surgery, a significant improvement in terms of less invasiveness has been achieved with the introduction of laparoscopic techniques. In this case, three to five small incisions (typically 3 mm or 5 mm, sometimes 8 mm) are made in the patient's body and, after having insufflated the abdominal cavity, the surgery is carried out. Typically, one incision is used for the passage of the camera, while the others enter operating or assistance tools. The surgical instruments for laparoscopy are passed through a tubular support body inserted transcutaneously into the incision and called trocar, which creates a so-called abdominal "door".

From the surgeon's point of view, the laparoscopic procedure is much more complex than traditional surgery for the following reasons:

the field of view and the quality of vision are reduced, as a two-dimensional camera is generally used and therefore stereoscopy and the relative perception of distance, typical of traditional surgery, are lost; the movement of the surgical instrument is reversed with respect to the surgeon's hand, due to the fulcrum effect typical of laparoscopic instruments;

force feedback is distorted by the presence of the trocar;

- the dexterity of the instrument is severely limited to a few degrees of freedom. On the other hand, thanks to the reduced invasiveness of laparoscopic procedures, hospitalization time is greatly reduced.

Some of the aforementioned disadvantages of laparoscopy are overcome by the so-called "Da Vinci" system (H. Palep: Robotic axis sted mini mally invasive surgery, in Journal of Minimal Access Surgery, vol. 5, issue 1, 2009), the only example available on robotic platform market for laparoscopic surgery. This platform consists of two main parts, namely a "master" control console, where the surgeon has the possibility to see the operating scenario on a three-dimensional display and to tele-operate four robotic arms, and a "slave" robotic system , consisting of the aforementioned robotic arms (three of 8 mm in diameter for laparoscopic instruments and one of 12 mm in diameter for the stereoscopic vision system). To the four holes for the aforementioned instruments, an additional hole must be added for the passage of support instruments to the surgical procedure (for example sponges, needle and suture thread, hemostatic tweezers, etc.).

The main advantages introduced by the Da Vinci system over traditional laparoscopic procedures are:

stereoscopic vision, therefore better perception of distances; intuitive control, as thanks to the robotic approach the fulcrum effect typical of laparoscopic instruments is compensated;

- scaling of the workspace, thanks to which a large movement of the surgeon's hand on the master equals a small but highly precise movement of the robotic instrument;

dexterity comparable to the surgeon's hand, thanks to the seven degrees of freedom typical of each operating arm of the Da Vinci.

It is also true that the Da Vinci still has several limitations that make it suitable only for highly selected and particular procedures. Among these limits we remember:

expensive;

long preparation times;

overall dimensions of the external robotic arms;

increased invasiveness compared to laparoscopy procedures (total of five holes, with a 12 mm hole, three 8 mm holes and a 5 mm hole);

- lack of force feedback (which cannot be obtained from the information of the current in the motors since, due to the external cable actuation, it cannot be considered proportional to the force exerted by the end effector).

A very promising alternative approach seems to be that of the so-called Robotic NOTES (Naturai Orifice Transluminal Surgery). This approach is currently active only at the research level (D. Oleynikov, M. Rentschler, A. Hadzialic, J. Dumpert, S.R. Platt, S. Farrito: Miniature robots can assist in laparoscopie cholecystectomy, Surg Endosc., Vol. 19 , pp. 473-476, DOI: 10.1007 / s00464-004-8918-6, 2005). In this case, a "self-sufficient" mini-robot is introduced into the patient's body through a natural orifice (or a single abdominal door) and locked inside by magnetic or needle systems. In this case, invasiveness is reduced to a minimum, as there may be no transcutaneous holes in the patient's body, eliminating the risk of infection and scarring.

The main limitations of this approach are:

dexterity, for the moment, still very limited;

- reduced power, due to the fact that all the actuators are placed on board the robot.

Regarding the latter aspect, given that the robot must pass through natural lights or through a single access door, its dimensions must necessarily be minimal and therefore motors of precisely reduced dimensions and consequently of low power must be used. Therefore, the NOTES approach is not able to guarantee the performance of the Da Vinci system in terms of instrument motion speed and traction force. This last aspect is also linked to the lack of a stable rigid support of the operating arms that allows for the exerting of forces of significant magnitude in manipulation for surgical tasks.

In summary, therefore, the current solutions for minimally invasive surgery procedures based on robotic arms operated from the outside provide for bulky units and still require more invasive incisions than traditional laparoscopy techniques (now well rooted in modern surgical practice). On the other hand, the solution based on robots that navigate the body is still in an embryonic state and seems to fail to guarantee the stability, dexterity and power necessary for surgery in the abdominal cavity.

Therefore, known systems do not obtain an optimal compromise between dexterity, power and degrees of freedom on the one hand and minimally invasive (even with the possibility of a single access door) on the other. In particular, as mentioned above, the systems that allow to operate in conditions of minimal invasiveness, with a single access door or through a natural orifice, do not allow to obtain the stability and power necessary in abdominal surgery.

Summary of the invention

The technical problem posed and solved by the present invention is therefore that of providing a robotic apparatus for minimally invasive surgery which allows to obviate the aforementioned drawbacks with reference to the known art.

This problem is solved by a robotic apparatus according to claim 1.

Preferred features of the present invention are present in the dependent claims thereof.

The present invention provides some relevant advantages. The main advantage consists in the fact that it allows to obtain a stable support for the operating arms while operating through a single lumen (for example the navel) or access door. This mechanical stability during surgery is a necessary condition for its accuracy. Furthermore, by virtue of said stability, the robotic arms can exert forces of significant magnitude and therefore be able to perform any manipulatory task necessary for surgical purposes.

Furthermore, by operating through arms that can still be implemented from the outside, the apparatus of the invention can exercise important powers and obtain satisfactory dexterity.

Finally, by virtue of said stable support for the arms, the apparatus still obtains an effective two-handedness while being able to operate through a single light or access door.

Other advantages, characteristics and methods of use of the present invention will become evident from the following detailed description of some embodiments, presented by way of non-limiting example.

Brief description of the figures

Reference will be made to the figures of the attached drawings, in which:

Figure 1 shows a schematic perspective view of a preferred embodiment of a robotic apparatus according to the invention, in an exemplary configuration with two arms (bimanual), each of which has a serial structure, i.e. with a serial arrangement of relative rotary joints;

<■> Figures 2A to 2I each show a perspective view of the apparatus of Figure 1 in a step of insertion of a relative arm through an introducer body which acts as a laparoscopic access door;

<■> Figure 3 shows a rear perspective view of part of the robotic apparatus of Figure 1 which highlights the relative locking means of the arms on the introducer body according to a first variant embodiment;

<■> Figures 4A, 4B and 4C each show a front perspective view of the robotic apparatus of Figure 3 in a respective phase of the locking procedure of the related arms on the introducer body;

<■> Figures 5A and 5B each show a respective front view of the robotic apparatus of Figure 3 which corresponds respectively to the phases of Figure 4A, 4B and 4C;

<■> Figure 6 shows a front view of a second embodiment variant of the means for locking the arms of the robotic apparatus of Figure 1;

<■> Figure 7 shows a side perspective view of a first preferred embodiment of a robotic arm of the apparatus of Figure 1;

<■> Figures 8A and 8B refer to the robotic arm of Figure 7, showing respectively a perspective view and a longitudinal section taken along the line A-A of the latter figure and highlighting the realization of means for transmitting motion from external actuators at the first two joints of the arm;

<■> Figure 9 shows a perspective view of the robotic apparatus of Figure 1, which highlights a variant embodiment for the relative arrangement of the two arms;

<■> Figures 10A and 10B each show a perspective view of the robotic apparatus of Figure 9 in a respective step of introducing an arm thereof into the introducer body;

Figure 11 shows a perspective view of a variant embodiment of motion transmission means from external actuators to the first two joints of the arm of Figure 7;

Figure 12 shows a perspective view of a transverse section of the robotic arm of Figure 7, which highlights a further variant embodiment of motion transmission means from external actuators to the first three joints of the arm itself;

Figure 13 shows a partially cut-away side perspective view of the arm of Figure 12 showing an internal cable transmission mechanism;

Figure 14 shows an exploded view of a pre-tensioning device of the arm of Figure 12;

<■> Figure 15 shows a schematic front perspective view of the robotic apparatus of Figure 1 which incorporates the cable transmission means of Figure 12;

<■> Figure 16 shows a partially exploded side perspective view of a preferred embodiment of a distal part of the robotic arm of the apparatus of Figure 1, compatible with the embodiment variants of the previous figures;

Figures 17A, 17B and 17C refer to a transmission mechanism of the arm portion of Figure 16, showing a perspective view, a plan view and a side view respectively;

Figures 18A, 18B and 18C refer to a preferred embodiment of an intermediate joint of a robotic arm of the apparatus of Figure 1, showing respectively a partially cut-away perspective view, a front sectional view and a side sectional view;

Figures 19A and 19B show respective perspective views - that of Figure 19B as an enlargement of a detail - of a preferred embodiment of a robotic arm compatible with the apparatus of Figure 1 and which provides a parallel hybrid arrangement / serial of relative rotary joints;

Figures 20 and 21 refer to a mechanism for actuating proximal joints of the robotic arm of Figures 19A, 19B, showing respectively a perspective view of the mechanism and a side view of a detail thereof;

Figures 22A, 22B and 22C each show a perspective view relating to a variant of an introduction system;

Figures 22D and 22E each show a perspective view of the same enlarged detail of the introducer body of Fig. 22A;

Figures 23A, 23B, 23C and 24 each show a perspective view of the robotic arm of Figure 19A, 19B and of the introducer body of Figure 22A-22E in a respective step of inserting the first into the second;

Figure 25 shows a perspective view of two robotic arms made according to Figure 19A, 19B inserted in the introducer body of Figure 22A;

Figures 26A and 26B each show a perspective view of a variant embodiment of an introducer body, respectively in a configuration of minimum bulk and in an unfolded configuration;

Figure 27 shows a schematic perspective view of the robotic apparatus of Figure 1 in another configuration which incorporates two parallel / serial robotic arms similar to that of Figure 19A, 19B and a serial arm similar to that of Figure 7 .

Detailed description of preferred embodiments

General structure of the robotic apparatus

With reference initially to Figure 1, a robotic apparatus for minimally invasive surgery according to a preferred embodiment of the invention is generally denoted with 100.

In this figure, the apparatus 100 is represented in an exemplary configuration which provides a first and a second robotic arm, respectively denoted by 101 and 102, each having a plurality of articulated joints arranged longitudinally along the arm itself according to a serial structure. In particular, each arm 101, 102 has six degrees of freedom. The distal end portion (with respect to the surgeon) of each robotic arm 101, 102 can be equipped with surgical instruments, such as for example forceps 109, or with sensors, such as video cameras or biometric sensors.

Alternative configurations of the apparatus 100 will be described later with reference for example to Figure 27, in which the apparatus itself includes a serial arm 101 and two parallel / serial hybrid structure arms denoted respectively with 201 and 202.

Returning therefore to Figure 1, the apparatus 100 also includes a support body 103, or introducer, presenting a tubular structure with a cylindrical geometry as a whole similar to and compatible with that of a trocar. The support body 103 has a longitudinal axis of symmetry denoted by X in Figure 1.

The support body 103 is adapted to act as an introducer of the arms 101 and 102 into the patient's body, allowing both to pass through it. The apparatus 100 also comprises a stereoscopic vision system 104, schematically represented in Figure 1. This vision system 104 can be associated with one of the arms 101 or 102 or introduced through the support body 103 by other means.

Exemplary mode of inserting the serial robotic arms through the introducer body

As mentioned above, the introducer body 103 is designed to allow the introduction of the robotic arms of the apparatus 100 into the patient's body.

A preferred entry method involves inserting one robotic arm at a time. Figures 2A to 2I show precisely, schematically and in sequence, how each of the robotic arms 101 and 102 is inserted, during a minimally invasive surgery, through the introducer body 103.

In particular, as shown in Figures 2A and 2B, during insertion the first arm 101 is arranged longitudinally within the introducer body 103 in a rectilinear alignment configuration of its joints.

During this insertion, arm 101 and body 103 are slidingly coupled by respective complementary engagement means, better visible in Figure 3. In the present example, these engagement means comprise a longitudinal rib 112 protruding from a first proximal base portion 110 of the arm 101 and able to slide in a respective groove 113 made in the internal wall of the support body 103.

With reference now to Figures 2C, 2D, 2E and 2F, once a second proximal portion 111 of the arm 101 has emerged from the introducer body 103 into the abdominal cavity or other body district, the proximal joints of the arm 101 are implemented (according to modality which will be described later) in such a way as to allow a rotation of substantially 90 degrees of the most proximal joint towards the outside with respect to the longitudinal axis of the introducer body 103.

With reference to Figures 2G, 2H and 2I, the second arm 102 is then introduced, according to methods similar to those described above for the first arm.

Once brought into the configuration introduced in Figure 2I, the arms 101 and 102 are locked onto the introducer body 103 in a manner which will be described shortly.

First way of locking the robotic arms on the introducer body

With reference to Figure 3, as mentioned above, each robotic arm 101, 102 has a first proximal base portion 110 suitable for slidingly coupling with the internal wall of the introducer body 103.

Furthermore, again as already mentioned, each robotic arm 101, 102 has a second proximal portion 111, disposed distally with respect to the first proximal portion and associated with the aforementioned plurality of articulated joints and in turn articulated to the base portion 110 in such a way as to be able to rotate approximately 90 degrees with respect to this, that is with respect to the longitudinal axis X of the introducer body 103. This "bending" of the arm can be passive or externally implemented, for example by means of cable drive systems or other mechanical transmission means of the type per se known.

In the present example, at its proximal end the second portion 111 of each arm bears a locking seat 117, better visible in Figure 5A and whose role will be clarified shortly.

As shown again in Figure 3 and as illustrated above, the overall structure of the apparatus 100 is such that both arms 101 and 102 can be inserted simultaneously through the introducer body 103 and housed, during use, within this in correspondence with their own proximal base portion 110.

Still in Figure 3, by way of example only, transmission cables 108 have been shown, intended to transmit motion to the most proximal joints (shoulder) of the arms 101 and 102 and whose role we will return to later.

In the present embodiment, the apparatus 100 also comprises a locking element 114, or pin, which is adapted to be inserted longitudinally through the introducer body 103 centrally between the two arms 101 and 102 to lock the latter on the introducer body itself. The locking element 114 has, in correspondence with its longitudinal end disposed distally during use, two transversal shaped appendages, denoted respectively by 115 and 116, arranged on diametrically opposite sides and each able to be inserted in a respective locking seat 117 of a respective arm 101, 102.

Preferably, the locking element 114 has a tubular structure, ie an internal longitudinal lumen, denoted by 118 in Figure 5A.

The methods of locking the robotic arms 101 and 102 on the introducer body 103 are described below.

Once the robotic arms are in the configuration introduced in Figure 2I, the locking element 114 is introduced between the two arms, in an arrangement in which the appendages 115, 116 are orthogonal to the direction of transverse extension of the second proximal portions 111. As shown in the sequence of Figures 4A-4C and 5A-5B, the locking element 114, once completely introduced through the body 103, is rotated so as to engage said appendages 115, 116 within the respective seats 117, where they are retained by interlocking, snapping or by other similar retaining means. In this way, by making the locking element 114 integral with the introducer body 103, the most proximal part of each arm 101, 102 is firmly locked on the introducer body 103.

For the purposes of the aforementioned insertion and rotation movement, the locking element 114 can be connected to an external rigid support, for example a motor that makes it slide and rotate 90 °.

It will be appreciated that the locking means just described allow the arms to be securely locked in position after their introduction, providing them with considerable mechanical stability. In fact, the arms, once positioned within the abdomen, form a single body with the introducer body 103. Furthermore, the central locking element 114 contributes to stiffen the whole.

Furthermore, the hollow construction of the locking element 114 ensures that an internal lumen 118 remains available, even after locking the arms, for the introduction of operating or auxiliary instruments. Figures 5A and 5B also show how, once the locking is completed, two lateral lumens 119 and 120 are also available within the introducer body 103.

Furthermore, the arrangement described ensures safety in the removal of the block. In fact, since the locking element 114 has a rigid construction and can be maneuvered from the outside, the risks associated with the impossibility of folding the arms at the end of the operation are minimal.

Figure 6 shows a variant embodiment of the locking means just described, in which the overall construction - and in particular the arrangement of the appendages 115, 116 and of the relative seats 117 - is non-axisymmetrical. In this variant, the overall arrangement is such that, once locked on the introducer body 103, the second proximal portions 111 of the two arms 101 and 102 have longitudinal axes incident according to an acute angle a, which is also the relative angle according to which the two appendages 115, 116 and of course the respective seats 117 are arranged.

General structure of a serial robotic arm

Hereinafter, some preferred embodiments will be described for the distal part of the serial structure arms 101 and 102, and in particular for the articulated joints of these. This description will refer to a single arm, in particular to the first arm 101, but is applicable as such to the second arm 102.

With reference to Figure 7, the serial structure arm 101, as already mentioned, has six degrees of freedom, associated with as many rotational joints and preferably distributed as follows:

a first degree of torsional freedom (rotation around the longitudinal axis Y) associated with a first joint 1;

a second degree of flexural freedom (rotation around the transverse axis J) associated with a second joint 2;

- a third degree of flexural freedom (rotation around the transverse axis K) associated with a third joint 3;

a fourth degree of torsional freedom (rotation around the longitudinal axis Z) associated with a fourth joint 4;

a fifth degree of flexural freedom (rotation around a transverse axis W) associated with a fifth joint 5; And

- a sixth degree of torsional freedom (rotation around the longitudinal axis U) associated with a sixth joint 6.

Therefore, the mobility and the final dexterity of the arm 101 are obtained with an alternation of torsional and flexural joints arranged in a longitudinal sequence along the arm itself.

A further degree of freedom in opening / closing can then be obtained at the level of the distal instrument 109, as shown schematically with an arrow in Figure 7.

For simplicity, we will define the first two joints 1, 2 as “proximal” and the other four joints 3-6 as “distal”.

Following an anthropomorphic analogy, the first two joints 1 and 2 can be understood as associated with the degrees of freedom of a shoulder, the third joint 3 understood as associated with a degree of freedom for the bending of an elbow and the last three joints 4- 6 intended as associated with the three degrees of freedom of a spherical wrist placed in correspondence with a "forearm".

First variant of realization for the transmission of motion from external actuators to the proximal joints of the serial robotic arm and variant of realization of the locking system of the robotic arms on the introducer body

In the present embodiment and as described in greater detail below, the first two proximal joints 1-2 are implemented from the outside by means of special transmission means, while the other four joints are implemented by local motor means.

Figures 8A and 8B refer precisely to a preferred embodiment of means for transmitting motion from external actuators 80 and 90 (schematically represented in Figure 8A and per se known) to the proximal joints 1 and 2. In this form of embodiment, the transmission means are based on a combiner gear with bevel wheels.

Going into greater detail, the two external actuators 80 and 90 are each connected to a respective first or second rotating drive shaft 8, 9 located at the beginning of the kinematic chain of the arm.

Each drive shaft 8, 9 is housed in a respective first or second sleeve 11, 12, in turn made integral with the introducer body 103 after insertion into the latter. This fixing of the sleeves 11, 12 to the introducer body 103 can be achieved by means of known clamping means applied between the motor body 80, 90 and the introducer body 103 itself.

Each drive shaft 8, 9 also passes through a portion of the outer casing of the arm 101, denoted by 10 and associated with the two joints 1 and 2, and is removably coupled thereto by means of rolling bearings or equivalent connection means.

The casing portion 10 is also integral with the two sleeves 11 and 12. In this way, the base of the robotic arm 101, in the operating position, is rigidly and firmly anchored to the introducer body 103. Therefore, in this embodiment a locking other than that described with reference to Figures 3 and 4A-6.

The transmission means described here then comprise a first and a second bevel gear, 13 and 15 respectively, each integral with a respective drive shaft 8, 9.

The first bevel gear 13 transmits motion to a shaft 14 which extends along the longitudinal axis Y and which, by means of a further distal bevel gear 16 which is coupled with a corresponding further component of the joint 2, carries out the motion in correspondence with this 'last.

The second bevel gear 15 transmits motion to a hollow shaft 151 which carries out movement to the joint 1. In particular, the longitudinal shaft 14 extends coaxially within the hollow shaft 151 and rotates within the hollow shaft 151. Therefore, the movement of the second driving shaft 9 also causes the movement of the second joint 2. It is however possible to obtain an independent movement of the first and second joints 1 and 2 by means of an appropriate combination of the movements of the driving shafts 8 and 9, here not further described in as to the reach of a person skilled in the art.

In a nutshell, the proposed transmission device (which could be subject to separate and independent protection) is based on a pair of drive shafts 8, 9 each coupled by bevel gears 13, 15 or equivalent means to a further shaft 14, 151 substantially orthogonal thereto, the shafts of this second pair being substantially orthogonal to the respective drive shafts 8, 9 and being coaxial to each other.

It will be appreciated that the embodiment just described allows the two proximal joints to be implemented with a mechanism of extremely reduced dimensions.

As already mentioned, the structure just described requires a way of inserting and locking the robotic arms through the introducer body different from that of Figures 2A-2I and shown in Figures 9 and 10A, 10B.

Figure 9 shows the apparatus 100, highlighting the relative arrangement of the two arms 101 and 102, particularly as regards the portions of the first two proximal joints 1 and 2 and according to the preferred embodiment of the latter described with reference to Figures 8A and 8B.

To obtain the configuration of Figure 9 and with reference also to Figures 10A and 10B, the two arms 101 and 102 can be inserted into the introducer body 103 one at a time. During insertion, each arm is supported by two cables 61 and 62, each connected to a respective sleeve 11, 12. Once the arms 101 and 102 have been inserted, the hollow shafts 11 and 12 are also introduced through the introducer body 103 and the two cables 61 and 62 connected to each arm are pulled from the outside, together with the whole arm, so as to allow the sleeves 11 and 12 to enter their seats inside the casing 10.

Also in this embodiment, therefore, the robotic arm 101, 102 provides a first and a second proximal portion, the latter denoted here with 121 and which is arranged, in use, substantially orthogonal to the longitudinal axis X of the introducer body 103 .

Second variant of construction for the transmission of motion from external actuators to the proximal joints of the serial robotic arm

Based on a variant of construction with respect to the arrangement of Figures 8A and 8B, the external implementation of the "shoulder" joints 1 and 2 involves the use of respective shafts in translation instead of rotation, as shown in Figure 11.

In particular, in the embodiment considered here, the transmission of motion to each of the joints 1 and 2 is carried out by means of a respective worm-toothed wheel mechanism. The transmission means therefore comprise, for each joint, a translating motor shaft 800 which passes through the casing 10 of the arm 101 and which has, at its distal end, a helical thread 27. The latter is mechanically coupled to a wheel toothed 28 housed within the casing 10 and in turn adapted to transmit motion to the corresponding degree of freedom.

The transmission means considered here also include an idle wheel 29, arranged on the opposite side of the translating shaft 800 with respect to the toothed wheel 28. This idle wheel 29 allows to support the radial stresses on the motor shaft 800 due to the worm screw coupling - toothed wheel, which can be especially critical given the small size of the mechanism.

The insertion of the drive shaft 800 through the casing 10 and between the wheels 28 and 29 can be carried out by means of an initial rotation thereof associated with an advancement equal to the pitch of the helix of the thread 27. In this way it will be possible to introduce the tree without implementing the corresponding degree of freedom. Subsequently, the translational movement of the shaft 800 will allow you to control the desired rotation of joints 1 and 2.

Still in Figure 11, the described transmission mechanism is shown coupled to an internal motion transmission made by means of cables 30, where a respective driving pulley 31 of each of these is integral with the respective toothed wheel 28.

Also with the transmission means with translating shafts just described it is possible to obtain a configuration of the system like the one illustrated in Figure 9, by means of an insertion and locking system similar to that described for the actuating mechanism with rotating shafts and illustrated in Figure 10A and 10B.

In a nutshell, the proposed solution (which could also be subject to separate and independent protection) is based on the use of a translating shaft for each joint, coupled with the joint itself by means of a gear transmission mechanism or equivalent and associated cable elements or equivalent.

It will be appreciated that the solution with translating shafts just described allows to reduce the diameter of the shafts, subjected in this case to traction / compression instead of torsion, and to have more free space in the introducer channel of the body 103 compared to the actuation with rotating shafts of Figure 8A, 8B.

Third embodiment variant for the transmission of motion from external actuators to the first three proximal joints of the serial robotic arm

A variant embodiment of the means for transmitting motion from external actuators to the first three proximal joints 1, 2 and 3 of the arm 101, 102 based on a cable transmission mechanism will now be described,

With reference to Figures 12 and 13, the aforementioned cable transmission means provide for a particular arrangement of idle pulleys within the casing of the arm in order to allow the actuation cables of the joints 2 and 3 to go beyond the first torsional joint 1. In in particular, these idle pulleys are positioned radially at a different distance from the axis of the torsional joint 1.

In the present embodiment, the joints 2 and 3 are implemented by means of four total cables, two for each of them, that is, for each degree of freedom. As mentioned above, all four of these cables must pass through the first joint 1 and two of them also through the second joint 2.

Following the path of one of the four cables that actuate joints 2 and 3, a first cable 17 is made to pass through a first idle pulley 18 - or first return - positioned on a fixed shaft 19 (i.e. not rotatable with joint 1) coaxial with the arm envelope - which arm envelope / main body is in this case denoted by 22 - and therefore with the Y axis of the arm. The first pulley 18 is arranged with its own transverse rotation axis and therefore orthogonal to the Y axis of the fixed shaft 19.

Subsequently, the cable 17 passes through a second idle pulley 20 - or second return - positioned on the fixed shaft 19 coaxially to it.

From here the path of the cable 17 proceeds towards a third idle pulley 21 or third return - also arranged with a transverse axis orthogonal to the fixed shaft 19 and integral with the rotating outer casing 22 of the arm.

The cable then arrives on the joint 2. The passage of the cables beyond the joint 2 and for the implementation of the joint 3 is then obtained by means of a transmission mechanism similar to the one just described and evidently housed in the portion of the arm interposed between the joints 2 and 3.

Figures 12 and 13 show further pulleys in addition to those described, which are suitable for the passage of the other three cables through the joint according to methods similar to those already described.

It will be appreciated that the proposed transmission mechanism can also be associated with the variant of construction with rotating shafts for the actuation of the first two joints and used for a transmission of motion to the subsequent joints and also with the embodiment with translating shafts also for the transmission. of motion at the first joints.

It will be appreciated that the mechanism just described achieves the following advantages:

an effective and reliable passage of the transmission cables through the proximal joints 1 and 2 and in an extremely limited space;

- in general terms, the passage through a torsional joint in a compact arrangement, allowing a wide rotation of the torsional joint itself and with transmission efficiency independent of the angular position of the torsional joint itself;

the absence of cable torsion present in some prior art solutions.

Again in general terms, the described mechanism allows the cable actuation of a multitude of joints downstream of a joint placed with the axis parallel to the initial longitudinal development of the cables and in a small space, since the idle pulleys are placed with radial axis with respect to the aforementioned joint.

A transmission system such as the one just described, which in its more general definition is based on a plurality of idle pulleys arranged in sequence and in which each pulley has an axis orthogonal to that of the adjacent pulley, can in fact also find application in sectors other than the one considered here. In particular, the arrangement described is applicable in any actuator device - even different from the portion of the articulated arm considered here - provided with a degree of torsional freedom and a degree of flexural freedom. In its most general definition, this actuator device includes:

a main body (equivalent to the arm portion considered) equipped with a degree of torsional freedom according to a longitudinal rotation axis (the Y axis considered above);

a joint (the joint 2 in the arrangement described above) arranged at one end of this main body;

means for transmitting the bending motion to said joint through the main body, which transmission means comprise a plurality of idle pulleys adapted to be engaged by at least one transmission cable, which idle pulleys are arranged at a variable radial distance with respect to said longitudinal axis,

With reference now to Figure 14, in the present embodiment there is also provided a device for pre-tensioning the cables, which allows the latter to be always under tension even before the actual operating phase.

The aforementioned pre-tensioning device is adapted to be housed in a small space such as the inside of the proximal part of the arm (ie the aforementioned "shoulder").

For each transmission cable, the pre-tensioning device involves the use of two pulleys coupled to each other through a mechanism that allows unidirectional rotation between the two pulleys.

In particular, for each cable in Figure 14 there is provided a first tensioning pulley 23 which is mechanically integral with a shaft 25 and a second tensioning pulley 24 free to rotate on the same shaft 25. A first and a second splined wheel are also provided. 26 and 27, each arranged inside a respective pulley 23, 24 and integral with it. The two grooved wheels 26 and 27 are shaped to form a mechanical coupling with the shaft 25 which opposes the rotation in one direction of the respective pulley, while leaving free rotation in the other direction.

In particular, the first wheel 26 has an external saw-tooth profile, which engages in a corresponding internal stepped profile of the second wheel 27, allowing jerky rotation in one direction (with the teeth sliding on the crests of the steps). and preventing that in the opposite direction because the teeth meet in the shoulders of the steps. In this way, it is possible to pre-tension the cable by rotating the pulleys in the direction of free rotation, until a desired preload is obtained. The counter-rotation of the pulleys is hampered precisely by the coupling between the splined wheels 26 and 27.

It will be appreciated that the cable construction of the transmission means allows to increase the free space inside the introducer body.

In a variant of the same system, only the first two joints 1 and 2 are actuated by cables, while the joint 3 is actuated by an internal motor, thus simplifying the overall mechanism.

The two or more arms partially actuated with cables can be arranged as in Figure 15 in accordance with the general architecture of the apparatus of Figure 1 and with the first locking method of the arms described above.

Implementation of the distal joints of the serial robotic arm

With reference now to Figures 16 and 17A-17C, as previously mentioned, the distal joints 4-6 of each robotic arm 101, 102 of the apparatus 100 of Figure 1 are moved by on-board actuation means. This on-board actuation is obtained by preferably electric miniaturized motors, in the present example brushless DC motors.

As regards joints 5 and 6, the proposed solution consists of a particular differential mechanism that allows to reduce the space occupied by the complex of the two joints 5, 6 and allows the motors to be housed along the axis of the aforementioned "forearm" . This differential mechanism comprises a first and a second assembly of three preferably bevel gear wheels, each assembly denoted by 340 and 350 respectively, which are coupled to form the differential through the use of a train of three further gear wheels, preferably with straight teeth arranged in transverse sequence and denoted respectively by 34 and 35 for the two side wheels and by 36 for the central wheel.

In particular, the first assembly of bevel gears 340 comprises three wheels coupled to substantially form a "C" -shaped structure, and in particular a first and a second wheel 341 and 343 which have incident axes of rotation. The wheel 341 has an axis of rotation parallel to the longitudinal axis of the forearm, while the axis of the wheel 343 rotates around the W axis of a shaft 360 realizing the degree of freedom 5 of figure 7. A third bevel wheel 342 it is interposed between the first two to couple them and is arranged with an axis of rotation substantially orthogonal to that of the wheel 341. A specular arrangement is provided for the second assembly 350.

The intermediate bevel gears 342 and 352 of the two assemblies are idle on the intermediate shaft 360 of axis W.

The two side wheels 34 and 35 of the aforementioned train of wheels are respectively integral with the first bevel wheel 343 of the first assembly 340 and with a similar first bevel wheel 353 of the second assembly 350.

The central wheel 36 is instead integral with the distal end, denoted by 37, of the robotic arm.

The bevel wheel 341 of the first assembly 340 is instead integral with a driving axis of motor means 38 and similarly a bevel wheel 351 of the second assembly 350 is integral with other motor means 39.

The end of the robotic arm therefore has a degree of rotation so-called pitch (pitch, rotation around the W axis) and roll (roll, rotation around the U axis) depending on whether the motor means 38 and 39 rotate in the same direction. rotation (pitch) or in the opposite direction (roll). Therefore, by means of a suitable combination of the motor means 38 and 39, a desired combination of roll and pitch can be obtained.

As regards the implementation of the torsional joint 4, further motor means 40 are provided, always placed inside the forearm with axis parallel to it and associated with transmission means 400 preferably with straight tooth gears.

In the example considered here, joints 4, 5 and 6 have incident axes in this way.

Preferably, in the assembly 340 the reduction ratio between the wheels 341 and 342 is greater than 1 and is equal to the reduction ratio between the wheels 343 and 342. This allows a rotation around the axis w of the shaft 360 greater than 90 ° without wheel 343 hitting wheel 341.

It will be appreciated that the solution proposed for the implementation of distal joints 4-6 also allows for a high level of miniaturization, while allowing adequate power values.

It will be understood that an implementation of serial joints such as the one just described can be provided as a distal part of an overall hybrid arm 201, 202 such as those of Figure 27.

Finally, it will be understood that the differential mechanism just proposed also lends itself to autonomous protection, i.e. independent from application to a robotic arm.

In its most general definition, this differential mechanism is suitable for the transmission of motion in any system that receives or is able to receive means for actuating a fissional joint and a torsional joint arranged in series, being able to be interposed between these actuation means. and said joints.

In this general definition, the transmission means comprise a first and a second assembly of three toothed wheels, preferably conical, and a train of three further toothed wheels, preferably with straight teeth, which couple said first and second together to form a differential mechanism. . Preferably, the toothed wheels of each of the first and second assemblies are arranged to form an overall "C" -shaped structure, adjacent wheels having mutually orthogonal axes of rotation, in which two wheels have an axis of rotation substantially parallel to the axis of the torsional joint and the third intermediate wheel has an axis of rotation substantially parallel or coincident with the axis of the flexural joint.

Implementation of the third joint of the serial robotic arm

With reference now to Figures 18A-18C and on the basis of a preferred embodiment variant, the joint 3 of the so-called "elbow" - which rotates a distal part 41 of the arm (ie the forearm) with respect to a proximal part 410 - provides that a rotation shaft 42 extending along the transversal axis K already introduced is made in two distinct longitudinal portions 421 and 422. The motion is transmitted by a local drive wheel 43 to the axis K of the joint through a coupling of bevel wheels 430 at right angles associated with the aforesaid two parts 421 and 422 of the shaft 42.

It will be appreciated that the proposed solution for joint 3 allows for a wide rotation, in particular an overall rotation of more than 90 degrees and up to 130 degrees, with a compact gear train.

General structure of a serial / parallel hybrid robotic arm

With reference now to Figures 19A and 19B, as previously mentioned, the structure of the apparatus of Figure 1 is also compatible with the construction of one or more of its arms according to a parallel / serial hybrid arrangement of relative rotary joints.

In particular, in each of the parallel / serial arms 201, 202 the proximal joints 1-3 of the serial embodiment described above are replaced by a parallel structure 44 which allows a distal part 45 of the arm to have three translational degrees of freedom.

Going into more detail of the present embodiment, there are three proximal points of articulation implemented by respective motors (for example brushless DC motors) positioned externally to the apparatus 100, as will be illustrated in greater detail shortly. These proximal points of articulation are made by means of three respective hinges, one of which is denoted by way of example with 46. The latter allow the rotation of as many corresponding proximal segments 471 with respect to a base 450 of the parallel structure from which each of the proximal segments 471 branches off. themselves.

As mentioned above, due to the combined movement of the three hinges 46 at the base 450, the distal portion 45 translates along three axes orthogonal to each other.

Each of the proximal segments 471 is then in turn articulated, at its own distal end, to a respective distal segment 472, the latter articulated, at the other end, to the aforementioned distal portion 45.

The distal portion 45 also has three other rotational degrees of freedom positioned orthogonally to each other, in addition to the translational ones mentioned above.

The implementation of the aforementioned three rotational degrees of freedom (and possibly the implementation of an additional degree of freedom at the level of the tool 109) can take place either with motors placed directly on the distal segments themselves or with as many motors placed externally. In the case of motors positioned externally, the power is transmitted to the segments by means of an actuation with cables that run along the axes of the parallel structure.

The implementation of the tool 109 can be transmitted along the arm by means of a cable and a sheath 48, represented by way of example in the figures considered here.

The combination of all six degrees of freedom still allows the tool 109 positioned at the tip to reach the areas affected by the surgeon, both in terms of position and angle.

Figures 20 and 21 show in greater detail the implementation of the articulation points 46 of the present embodiment, in the operating configuration of the robotic arm. As already said, this actuation takes place by means of motors external to the patient's body and an associated cable transmission. In particular, the external motors actuate driving pulleys 49 by means of respective axes, which pulleys through cables 50 control the degrees of freedom. These cables 50 are channeled into the introducer body 103. Inside the robotic arm a series of idle pulleys and returns 51 guide the cables 50 towards the opening and coupling mechanisms of the arm and towards the respective joints to be implemented.

Also in this embodiment the robotic arm 201 provides a first and a second proximal portion, the latter denoted here by 131 and which is arranged, in use, substantially orthogonal to the longitudinal axis X of an introducer body 603 which will be described here right away.

Exemplary mode of inserting the hybrid robotic arms through the introducer body

With reference to Figures 22A to 25, preferred ways of introducing the hybrid robotic arms described above into the patient's body will now be described.

In the embodiment variant considered here, an introducer body 603 modified with respect to the one described above with reference to the serial structure of the arms is used. This introducer body 603 is inserted into the abdominal cavity of the patient, exemplified by a curved line L in Figures 22A and 22B.

The introducer body 603 naturally has an operating channel which allows the surgical arms and auxiliary instruments to pass through. Guides can be obtained on the walls of this operative channel to facilitate the insertion of the surgical arms themselves.

In the variant embodiment shown in Figures 22A-22C, the introducer body 603 described above can be associated, and in particular removably inserted, a front scoring means 620, whose function is to create an opening for the insertion of the introducer body 603 o facilitate its insertion if the opening is already present. Once the insertion of the introducer body 603 is finished, the engraver can open to allow the insertion of the arms or can be directly removed, as shown in Figure 22C.

The introducer body also has locking means, intended for the reference and rigid positioning of the arms, which are generally denoted with 608 and better visible in Figure 22D. As shown in the latter figure, these locking means 608 comprise a plurality of oblong elements, typically in the form of a rod denoted by 609, housed in correspondence with the internal walls of the introducer body 603 and extending longitudinally parallel to the latter and therefore to the longitudinal axis X of the introducer body itself. Each rod 609 has, at its own distal end, a lateral attachment element or appendage 610, such that a substantially "L" shape of the rod itself results. In the present embodiment, six rods 609 are provided, two by two close to each other to lock the same robotic arm, and distributed on the circumference of the introducer body 603.

The rods 609 slide along and rotate around their own longitudinal axis substantially parallel to the longitudinal axis X of the introducer body, so that the hooking elements 610 can be translated and rotated towards the outside of the introducer body 603 and not hinder inserting the arms through it.

With reference to Figure 22E, once the insertion of an arm has been performed, the coupling elements 610 of the corresponding pair can be rotated and retracted again so as to bring them into engagement in special seats 611 obtained on the proximal portion 131 of the arm , firmly binding it to the introducer body 603 itself. The rods 609 involved are then locked onto the introducer body 603 once the corresponding arm has been hooked, so as to complete the retention of the arm itself on the introducer body 603.

The introducer body 603 can then be constrained to an external structure capable of orienting and maintaining it in a desired position.

Going into more detail of the modalities for inserting the arms, once the introducer body 603 has been positioned and the hooking elements 610 have been rotated in the aforementioned way towards the outside of the introducer body 603 itself, it is possible to proceed with the insertion of one arm 201, 202 at a time, as shown in Figures 23A and 23B. The arm 201 during insertion has a particular alignment configuration of the relative joints designed to reduce its size and consequently facilitate its insertion into the introducer body 603, shown in these figures. The guides possibly present on the walls of the introducer body facilitate this insertion.

As shown in Figures 23C and 24, once the correct position has been reached, the arm is opened and rotated in correspondence with the proximal portion 131 (and in particular of the joint 1 and a proximal joint 1 'of this) in order to be hooked to the introducer. 603 by means of elements 610. Once the robotic arm has been positioned, the lumen of the introducer body is again free for the insertion of the other arms following the same procedure, as shown in Figure 25.

It will be appreciated that the substantial difference between the device 103 of Figure 1 and the device 603 considered here lies in the fact that the introducer 103 has a common coupling system for all robotic arms. This means that to replace a robotic arm it is necessary to disengage all of them. However, it has the advantage of constructive simplicity and consequently a higher cost and practicality.

The introducer 603 can replace each arm without necessarily having to release the other arms (which can therefore continue to operate without being affected by the gearbox). This is because each robotic arm has its own anchoring system, independent of the others.

As shown again in Figure 25, in addition to the two arms in hybrid configuration, a third arm is inserted which includes a vision system 104.

The arm dedicated to the vision system presents fewer problems in terms of forces to be transmitted and accuracy of movements and moreover it can have a lower number of degrees of freedom than the robotic arms expressly designed to perform the surgical operation.

After the procedure for inserting all the arms, inside the introducer 603 there is a free operating channel to possibly allow the use of complementary surgical instruments.

The configuration described above allows you to replace the arms (eg to change the characteristics of the tool) regardless of the presence or absence of other components of the apparatus.

In the variant of Figures 26A and 26B, the introducer body, again denoted by 603, also comprises, at its distal end, a substantially flower-like deployable structure, i.e. three appendages 605 rotatably connected on the base body along the circumference of this and selectively operable to make the introducer body 603 pass from a configuration of minimum bulk, shown in Figure 26A and in which these appendages are closed on the base body, to an unfolded configuration, shown in Figure 26B and in which the appendages are rotated towards the 'external. This second configuration is designed to allow the introduction of one or more hybrid arms into the abdominal cavity.

The parallel / serial hybrid solution for the robotic arm structure has the advantage of greater system rigidity, a reduction in mechanical play and the possibility of being able to more easily implement a cable actuation. In particular, compared to a totally serial kinematics, the hybrid solution makes it easier to create an actuation system in which one or more motors are positioned externally to the robot and to the patient. This is because in order to bring the power from the motors to the distal degrees of freedom, fewer joints in the robot's kinematic chain must be traversed.

Some further possible variants of realization

In the embodiments and variants described above, the robotic arms are actuated by mechanical transmission means such as for example cables, axes in rotation or translation as described above. A particular technical solution may also include the use of pipes with pressurized fluids for the implementation of particular movements, such as the opening and closing of pliers or other tools.

It will therefore be better appreciated at this point as the robotic system of the invention, particularly in the embodiments described above:

<■> can be effectively equipped with at least two arms, performing bimanual surgical operations with single arm dexterity comparable to the Da Vinci system in terms of technical specifications;

<■> manages to achieve similar performance to the Da Vinci system in terms of dexterity, speed of operation and strength on the end-effector, while reducing the invasiveness of the procedure thanks to the single access door approach;

<■> allows, with the presence of a lumen (0-30 mm) inside the introducer body, the passage of additional instruments, such as needle and suture thread, hemostatic sponge, sensors, etc., avoiding further incisions in the patient's body ;

<■> allows you to implement, thanks to the implementation of the distal degrees of freedom on board the arm, a force feedback by reading the current absorbed by the motors (not present in current surgical robotics platforms);

<■> makes it possible, thanks to the mechanical solutions proposed for the anthropomorphic serial arm (for example the star references for the shoulder cable actuation, the linear translational actuation for the proximal degrees of freedom, the pre-tensioning mechanism of the cables in reduced spaces, the division of the elbow axis into two parts, the differential mechanism allocated in the wrist), that the total dimensions of the arm can guarantee its insertion through a single hole, while guaranteeing the desired performance specifications;

<■> is able to guarantee, with the hybrid solution of the parallel / serial arm, greater stiffness, greater precision and fluidity of movement, greater ease of construction for the cable actuation;

<■> guarantees, with the coupling mechanism a rigid support for the arms, that these can be introduced sequentially using the entire internal lumen (exploiting the entire internal diameter ensures that each arm maximizes the space available for the mechanisms and actuators);

<■> again thanks to the coupling mechanism proposed, it allows to fix more than two arms at a time, to replace one or more of them if necessary (surgical instrument replacement), and to choose the most advantageous arrangements and spatial arrangements (in terms of work and triangulation of instruments) to complete the specific surgical operation;

<■> according to the invention, the robotic arms find, by fixing to the introducer body and the presence of the locking element, an effective support on which to discharge the forces of their end effectors, thus achieving a high operational reliability.

Another important aspect is that in this case there is a truly bimanual behavior of the system.

The apparatus of the invention finds a preferential application in abdominal surgery procedures. A possible specific application of the proposed system consists of bariatric surgery procedures to treat morbid obesity.

It will be understood that, on the basis of a further aspect of the invention, this refers to a method for carrying out minimally invasive surgery by means of one or more articulated arms, each provided with a plurality of degrees of freedom and able to perform manipulative tasks in the surgical field, which method provides that a proximal part of said arm or arms is made integral with an introducer body as defined above and / or as defined in the following claims, preferably by locking said proximal part in correspondence with or proximity to the section exit of the longitudinal lumen of the introducer body.

Preferably, this method is carried out according to the same preferred characteristics of the apparatus described so far.

The present invention has been described up to now with reference to preferred embodiments. It is to be understood that there may be other embodiments that pertain to the same inventive core, as defined by the scope of the claims set out below.

Claims (36)

CLAIMS 1. Robotic apparatus for minimally invasive surgery (100), in particular laparoscopy, comprising: at least one articulated arm (101; 201) equipped with a plurality of degrees of freedom and able to perform manipulative tasks in the surgical field; an introducer body (103; 603), adapted to be inserted through the patient's skin to create an access door to the operating site, which introducer body (103; 603) has an internal longitudinal lumen, which internal lumen has a section of proximal inlet and a distal outlet section and is adapted to allow the passage of said articulated arm (101; 201) through the introducer body (103; 603); And locking means (115, 117; 608), adapted to make a proximal part (111; 121; 131) of said articulated arm (101; 201) integral with said introducer body (103; 603). Apparatus (100) according to claim 1, wherein the overall arrangement is such that said locking means operate at or near said outlet section of said lumen. Apparatus (100) according to claim 1 or 2, wherein said locking means (115, 117; 608) are of the interlocking and / or snap type. Apparatus (100) according to any one of the preceding claims, wherein said locking means comprise a locking element (114; 609) which can be inserted in said longitudinal lumen of said introducer body (103; 603), which locking element ( 114; 609) is adapted to be made integral with said introducer body (103; 603) and with a proximal part (111; 131) of said arm (101). 5. Apparatus (100) according to the preceding claim, wherein said locking element (114; 609) has an oblong shape. Apparatus (100) according to claim 4 or 5, wherein said locking element (114; 609) has at least one lateral appendage (115; 610) and said articulated arm (101; 201) has a corresponding seat (117; 611) adapted to receive said lateral appendix (115; 609). Apparatus (100) according to the preceding claim, wherein said lateral appendage is a hooking tooth (610). Apparatus (100) according to any one of claims 4 to 7, wherein said locking element (114) has a through longitudinal lumen (118). Apparatus (100) according to any one of claims 4 to 8, wherein the overall arrangement is such that, when said locking element (114) is inserted in said introducer body (103), within the latter they remain defined, externally to said locking element (114), two lateral longitudinal passages (119, 120). Apparatus (100) according to any one of claims 4 to 9, comprising means for actuating said locking element (114; 609) according to a linear and / or rotary movement, arranged, in use, externally to said introducer body ( 103; 603). Apparatus (100) according to any one of the preceding claims, comprising at least one pair of articulated arms (101, 102; 201, 202), each provided with a plurality of degrees of freedom and able to perform manipulative tasks in the surgical field. Apparatus (100) according to the preceding claim, wherein said introducer body (103; 603) is able to simultaneously receive said pair of arms (101, 102; 201, 202), simultaneously housing respective proximal parts (110) of these last. Apparatus (100) according to the preceding claim when dependent on claim 4, in which the overall arrangement is such that said locking element (114; 609) is positioned, in use, within said introducer body (103; 603). Apparatus (100) according to the preceding claim, in which the overall arrangement is such that said locking element (114) is positioned, in use, interposed between the arms of said pair (101, 102). Apparatus (100) according to any one of claims 11 to 14 when dependent on claim 4, wherein said locking element (114) carries a pair of lateral appendages (115, 116) and said articulated arms (101, 102) each have a corresponding seat (117) adapted to receive a respective lateral appendage (115, 116), the arrangement of said appendages (and seats) being substantially axial symmetrical, said appendages (and seats) being substantially aligned transversely. Apparatus (100) according to any one of claims 11 to 14 when dependent on claim 4, wherein said locking element (114) carries a pair of lateral appendages (115, 116) and said articulated arms (101, 102) each have a corresponding seat (117) adapted to receive a respective lateral appendage (115, 116), the arrangement of said appendages (and seats) being substantially non-axisymmetrical. Apparatus (100) according to any one of the preceding claims, wherein said locking means (608) comprise a pair of longitudinal locking rods (609) for said or each articulated arm (201, 202). Apparatus (100) according to the preceding claim, wherein said rods (609) are longitudinally parallel along the periphery of said introducer body (603). 19. Apparatus (100) according to any one of the preceding claims, in which said introducer body (103) and said or each articulated arm (101) have mutual engagement means (112, 113), suitable for allowing a sliding coupling between them . 20. Apparatus (100) according to the preceding claim, wherein said mutual engagement means comprise at least one longitudinal seat (113) and at least one rib (112) which can be slidably coupled with said longitudinal seat (113). 21. Apparatus (100) according to any one of the preceding claims, wherein said or each articulated arm (101, 102; 201, 202) has a first (110) and a second (111; 121; 131) proximal portion longitudinally side by side and rotatably connected to each other. 22. Apparatus (100) according to any one of the preceding claims, wherein said or each articulated arm (101, 102; 201, 202) has a first (110) and a second (111; 121; 131) proximal portion adapted to be arranged substantially at right angles to each other. 23. Apparatus (100) according to any one of the preceding claims, comprising motion transmission means of the cable type, suitable for allowing motion transmission from external actuators to one or more proximal degrees of freedom of said articulated arm (101; 102 ). Apparatus (100) according to the preceding claim, wherein said articulated arm (101) is equipped with a degree of torsional freedom according to a longitudinal rotation axis (Y) and said cable motion transmission means comprise a plurality of pulleys idlers (18, 20, 21) able to be engaged by at least one transmission cable (17), which idle pulleys (18, 20, 21) are arranged at a different radial distance with respect to said longitudinal axis (Y). 25. Apparatus (100) according to the preceding claim, in which the idle pulleys of said plurality are arranged in such a way that pulleys (19-20; 20-21) engaged by the cable (17) in sequence have substantially orthogonal axes of rotation. 26. Apparatus (100) according to any one of claims 23 to 25, wherein said articulated arm has a torsional joint (1) and a flexural joint (2, 3) disposed distally with respect to said torsional joint, and in which said means transmission cables are adapted to transmit the flexural motion to said distal joint through said torsional joint. 27. Apparatus (100) according to any one of claims 23 to 26, comprising means for pre-tensioning the transmission cables (23-26). 28. Apparatus (100) according to the preceding claim, wherein said pre-tensioning means comprise a pair of pulleys (23, 24) rotatable relative to each other and contrast means (26, 27) suitable for preventing reciprocal rotation of the pulleys (23, 24) of said pair in a given direction. 29. Apparatus (100) according to the preceding claim, in which said contrast means comprise a pair of mutually associated toothed elements (26, 27), each integral with a respective pulley (23, 24) of said pair. 30. Apparatus (100) according to any one of the preceding claims, comprising motion transmission means of the type with rotating or translating shafts, suitable for allowing motion transmission from external actuators to one or more proximal degrees of freedom of said articulated arm ( 101; 102). 31. Apparatus (100) according to the preceding claim, wherein said shaft transmission means comprise: - a first pair of drive shafts (8, 9), each associated with a respective external actuator; a second pair of coaxial shafts (14, 151), each adapted to receive motion from a respective drive shaft (8, 9); And coupling means (13, 15) between said pairs of shafts, wherein the shafts of said second pair (14, 151) are each connected to a respective proximal joint (1, 2) of said articulated arm (101, 102). 32. Apparatus (100) according to the preceding claim, wherein the shafts of said first pair (8, 9) are arranged substantially orthogonal to the respective shafts of said second pair (14, 151). 33. Apparatus (100) according to claim 31 or 32, wherein said coupling means comprise bevel gears (13, 15). 34. Apparatus (100) according to any one of claims 31 to 33, wherein said drive shafts (8, 9) are each housed in a respective sleeve (11, 12), said sleeves (11, 12) being integral or suitable to be made integral with said proximal part (111) of said articulated arm (101; 201) and with said introducer body (103). Apparatus (100) according to claim 30, wherein said shaft transmission means comprises: a translating shaft (800) for the or each proximal degree of freedom of said articulated arm (101, 102); and a transmission mechanism, preferably of the type comprising one or more gears (28, 29), interposed between a joint corresponding to said degree of freedom and said shaft (800). 36. Apparatus (100) according to any one of the preceding claims, comprising a front scoring means (620) inserted or removably insertable within said introducer body (603) and adapted to facilitate the insertion of the latter in the patient.