Versius Surgical System

0. History

The Versius Surgical System is a soft-tissue remote robotic surgical system based on a master-slave configuration. Cambridge Medical Robotics (CMR) was founded in January 2014 and entered into the fast developing field of robotic surgery, where different companies are competing with new devices. The first series of cadaveric trials with the new system were completed in June 2016 and it was officially introduced in September 2018. The first commercial introduction was at Galaxy Care Hospital in Pune, India, in October 2019, and in Europe, at Lothian and Milton Keynes University Hospital (HNS Foundation Trust), in the UK, in February 2020. In June 2022 there were over 5,000 clinical cases completed.

Although the basic concept is the same and there are very similar items (like the instruments), there are also some remarkable differences with the da Vinci Robotic Surgery System. There is no Vision Cart. Just the console and the effector modules. The console has and open design: the system works with a 3D image, but it is displayed in a monitor. Therefore the surgeon (or anyone around) needs to use polarized glasses. Additional 2D monitors might be connected to the system. There are no pedals in the surgeon´s console, so everything is controlled through the hand manipulators (we will discuss them in another chapter).

1. General design

Endoscope and instrument arms are split into individual modules. There is an endoscope module and up to three instrument modules (also to be discussed later). The weight of the console is 180kg; each module 100kg, with a footprint of 38x38cm. They do not use any motorized assistance to be transported. The system configuration is flexible, so it is possible to use just the endoscope (in the same way that other robotic endoscope holders), or one, two or three additional instrument arms. The company argues that this concept and design eases the coexistence with and a smooth transition from conventional endoscopic surgery to robotic remote surgery.

2. Modules

See other buttons at the module. “ZZZ” is of course for awakening and rest. The circular button with arrow-heads in the four directions is to align every module in the same working direction as the others. Plus (+) and minus (-) buttons modify the height of the platform. It can be raised up to 45 additional centimetres.

The connections panel at the back, down, is quite simple. Energies (monopolar and bipolar) to connect the instrument in the arm as required, and the connection to the console (“in”). There is another connection (“out”) as the modules can support a series connection.

The arm it-self has 3 joints that can be assimilated to shoulder, elbow and wrist (although there is another wrist at the tip of the instrument). The joints are free to move in every direction of the space. The neutral position of the first joint is vertical upwards, so the second joint has to be necessarily arched towards the surgical table. However, depending on the specific approach, the third joint can be arched in the same or in an inverse direction. The first option will be a “C” configuration, and the second a “Z” configuration, which are the only possible ones.

3. Endoscopes

The motto of the company is think laparoscopic, operate robotically. So some of the components used in Versius robotic surgery might be used in conventional endoscopic surgery. This is particularly true for the endoscopes.

The Versius system incorporates a conventional rigid optic endoscope sourced from a third party, Richard Wolf (Knittlingen, Germany), renowned globally for its solutions in endoscopy. The Wolf panoview 3D HD endoscope is a dual 10mm rigid instrument measuring approximately 30cm in length, offering options for 0º and 30º views. This endoscope can be used for conventional endoscopic/laparoscopic surgery and Versius surgery. However, for the latter application, the system necessitates an external light source, including a light cable, in addition to the robotic components.

The camera head is specifically designed to be held by the camera/endoscope module. It receives signals from both the right and left endoscopes and processes them into digital signals for subsequent use. With the exception of the arm tip and connections, the camera module shares a similar appearance with the instrument modules. However, it is important to note that these modules are not interchangeable.

This solution prompts several considerations. The historical shift from analog to digital image acquisition is evident and logical. For instance, earlier iterations of the da Vinci system employed optic endoscopes but transitioned to videoendoscopes, which possess a camera chip located at the endoscope’s tip, enabling direct digital image acquisition. This transition offers multiple advantages, including lighter and more durable endoscopes, as well as expanded possibilities for image processing. Another important advantage is that the endoscope can be flexible. This is not used in the da Vinci multiport system, but it is critical for the design of the da Vinci Single Port (SP). While the optic endoscope may seem like a regression compared to current robotic surgery technology, it may find relevance during the transitional period from conventional laparoscopic surgery to remote robotic surgery. Undoubtedly, it remains a valid solution for the majority of contemporary endoscopic procedures. However, when considering transoral surgery, it is worth exploring the direction set by the Medrobotics Flex vision solution.

4. Instruments

The instruments utilized in the Versius Surgical System adhere to the fundamental design established by its predecessor. It is a mechanical tool moved by a system of of pulleys and tensors. The instrument itself is at the distal end of a vastagus. They are wristed. They attach to the arm at the proximal end where both electronic and mechanical connections are built-in.

Differences. Instruments are 6.8 mm in diameter. To maintain the same degrees of freedom the decision was made to transfer rotational movement to the arm itself. Consequently, the entire disposable instrument can rotate due to the design of the arms. This innovation results in fewer cables within the vastagus and a reduced number of mechanical connections (only three) at the instrument-arm interface.

Available instruments are the usual ones. Maryland dissector, fenestrated forceps, needle holder, scissor, hook… with monopolar or bipolar energy depending on the particular instrument. Advanced-energy options are not yet available, although the company assures they are currently made, waiting for official approval.

As a remarkable difference, the system does not require a distal support in the cannula. The cannula is not attached to the arm, so it may be used or not. Actually, conventional (non-robotic) cannulas are used. While it remains essential for percutaneous approaches, it is not required for transorificial or open approaches. The virtual pivot point (referred to as the remote center in the previous system) must be manually set for each instrument.

Finally, note that the system is designed so the arm holds the instrument “aligned”. Both the da Vinci Surgical system and the new device from Medtronic (Hugo) operate in a retrograde manner. This distinction in design does not inherently indicate a virtue or a flaw, but rather underlines a difference between the systems.

5. Console

The surgeon’s console exhibits two notable differences compared to the previous design. Firstly, the visual system has transitioned from a visor to a monitor. Secondly, the absence of pedals is apparent.

The surgeon now observes the surgical field through a flat monitor positioned directly in front of them while seated at the console. In order to perceive a three-dimensional effect, polarized glasses are required to ensure each eye receives distinct images. However, due to this open design, individuals in the vicinity can also view the surgical field on the console (as far as they also use polarized glasses). This differs from other devices that employ a visor design, where a double console is necessary to attain the same three-dimensional surgical field image (with just one console available for an additional surgeon). The company contends that the open design facilitates communication between the surgeon and the surgical team.

Notably, pedals are absent from the console, and all functions are controlled manually using the hands. The manipulators feature a completely redesigned interface resembling a joystick. The index finger is responsible for basic pinching movements, and wrist movements are also incorporated. The thumb controls various functions, including clutches, energy adjustments, and menu options. Consequently, surgeons accustomed to the previous devices will require some training to adapt to these changes.

5. Simulator and recording

To be continued…

References

Preclinical studies

Faulkner J, Arora A, Swords C, Cook E, Rajangam A, Jeannon JP. Pre-clinical evaluation of a novel robotic system for transoral robotic surgery. Clin Otolaryngol. 2021 Jul;46(4):869-874. doi: 10.1111/coa.13740. Epub 2021 Feb 27. PMID: 33590692

Faulkner J, Naidoo R, Arora A, Jeannon JP, Hopkins C, Surda P. Combined robotic transorbital and transnasal approach to the nasopharynx and anterior skull base: Feasibility study. Clinical Otolaryngology 2020; 45:630-633. doi: 10.1111/coa.13550. Epub 2020 May 11. PMID: 32301568

Granell J, Ramirez-Rosa A, Fernandez-Rastrilla I, Granados-Sitges J, Caballero P, Granell L, Sanchez-Camon I, Mendez-Benegassi I, Gutierrez-Fonseca R. Feasibility of the set-up for the different approaches in robotic head and neck surgery with the Versius Surgical System. J Robot Surg. 2023 Aug 23. doi: 10.1007/s11701-023-01696-7. Epub ahead of print. PMID: 37610537

Arora A, Faulkner J, Paleri V, Kapoor K, Al-Lami A, Olaleye O, Winter S, Oikonomou G, Ofo E, Ourselin S, Dasgupta P, Slack M, Jeannon JP. New robotic platform for transoral robotic surgery: an IDEAL stage 0 study. BMJ Surg Interv Health Technol. 2024 Mar 15;6(1):e000181. doi: 10.1136/bmjsit-2022-000181. PMID: 38500710; PMCID: PMC10946345

Clinical series

Faulkner J, Arora A, McCulloch P, Robertson S, Rovira A, Ourselin S, Jeannon JP. Prospective development study of the Versius Surgical System for use in transoral robotic surgery: an IDEAL stage 1/2a first in human and initial case series experience. Eur Arch Otorhinolaryngol. 2024 May;281(5):2667-2678. doi: 10.1007/s00405-024-08564-6. Epub 2024 Mar 26. PMID: 38530463; PMCID: PMC11023952

Notice. The Versius Surgical System has not the CE mark for Head and Neck Surgery (September 2024)