Versius surgical system: tips and tricks for OR setting and port placement for pelvic surgery, our experience in a multi-robotic referral centre.

The cases were performed by two senior console surgeons, one experienced with the Da Vinci system (approximately 300 previous procedures) and the other with laparoscopy. The entire surgical team had prior robotic experience, and all surgeons had undergone a 3-day cadaver lab prior to the procedure. During training, trocar positioning and operating room setting were planned, and two full cadaver procedures (promontofixation and total hysterectomy with bilateral lymphadenectomy) were carried out. Nineteen patients, aged 50±15, underwent surgery for benign gynaecological conditions; among these, 11 underwent adnexectomy (57.9%), 4 underwent ovarian cystectomy (21.1%), 2 underwent bilateral hystero-adnexectomy for endometrial hyperplasia (10.5%), 1 underwent bilateral hysterosalpingectomy (5.3%), 1 was a Dubuisson procedure (5.3%). The median BMI was 23.32(8.99) kg/m 2 , range [16.33–42.70]. Ten women were menopausal (52.6%), all from natural causes. The surgical history included laparotomy for seven women, of which three appendectomies, one abdominoplasty, one cesarean section, one cholecystectomy, and one inguinal hernia repair). None had ever had vaginal surgery; two had concomitant prolapses (hysterocele and cystocele in both cases, grade II-III, according to the POP-q classification). Estimated blood loss (EBL) was null for 13 patients and had a median of 0 mL, IQR [0–37], range [range 0-300] in the sample (the woman with a loss of 300 mL underwent hysterectomy with bilateral adnexectomy). No intraoperative complications occurred, nor any conversion to either open or laparoscopic surgery was necessary. The size of the retrieved cysts ranged from 4 to 16 cm (Me = 5, IQR [5–7]). The postoperative course of the nineteen procedures was uneventful, and the patients were discharged on the first or second postoperative day. The characteristics of the operating room are displayed in Supplementary Table 1 . The patients were positioned in a 22° Trendelenburg position. In 17 out of 19 operations, all four arms were used, whereas only three arms were used in the remaining two cases (endometriosis and adnexal surgery). The port configuration reflected the standard technique of the console surgeon (Fig.  1 ). The bedside unit arms for instruments were docked first: a single BSU on the right side (arm 3, scissors) and two BSUs on the left side (arm 2, bipolar and 1, grasper, respectively). The BSU carrying the endoscope (arm 4) was placed above the head on the right side and docked last. One additional port for the assistant was located on the right side. Differently from the Da Vinci system, a port training process is required for each Versius arm. The position of the four robotic trocars was on a semicircular line, as shown in Fig.  1 . Having as a vertex the trocar of the camera (green point). The mean distance between trocars (indicated as A, B, C, and D) was 9 cm. Table  1 reports the mean angles. Table 1 Angles Angle Description Mean±sd EAB Bedside assistant– scissors - endoscope 150±34 ABC Scissors– endoscope - bipolar 145±12 BCD Endoscope– bipolar– grasper 161±16 Angles The mean distance between the iliac spines was 31 ± 6 cm, and the umbilical-bi-iliac distance was 14 ± 3 cm. These measures were taken at 15 mmHg, as the trocar placement was realized at that intra-abdominal pressure and then reduced to 10 mmHg during the procedure. The trocar of the camera was placed 2 cm above the umbilicus in all except one procedure, where it was placed at the level of the umbilicus. The median time from incision to console was 47 (18) minutes, followed by 80 (121) minutes of console time, with an overall surgical time of 127 (88) minutes. Intraoperative pneumoperitoneum was maintained at 12(1) mmHg. The basement of arm four always remained in direct contact with the basement of the operating bed on the right side, except in one case in which the distance was 27 cm, and the trocar of the camera was placed into the umbilicus. The same instruments were used for all the procedures, positioned in the same trocars as shown in Fig.  1 . Collisions of any type occurred in 16 out of 19 operations, ranging from a minimum of 1 event requiring intervention to a maximum of 12 during a single operation. In six cases, the collision involved two arms, and in five others, three. The remaining events were not identifiable as collisions between robotic arms but rather as contact between an arm and other components of the surgical field (e.g., trocars) that did not require a restart. In eleven cases, high impact collisions occurred, necessitating the detachment and reconnection of instruments. In those patients, the mean angle formed by segments AB and BC (scissors, endoscope and bipolar) was 148 ± 14°, range [138–180]. Neither the angles nor the distance between the trocars were factors influencing the occurrence of high-impact collisions (Table  2 ). The only exception was the distance between the bipolar forceps and the grasper, with no collisions recorded. Table 2 Factors related to high priority collisions Factor p-value ABC angle 0.884 BCD angle 0.137 CD segment 0.603 BC segment 0.011 Factors related to high priority collisions The distance between the operative trocar and the target anatomy was also analyzed. In one case of severe collisions, the trocar of the camera was placed in the umbilicus, and the distance between the scissors trocar (third arm, blue in Fig.  1 ) and the target anatomy was 2 cm (a right dermoid cyst of 8 cm in diameter). The same trocar was allocated 2 cm higher from the bi-iliac line at 9 cm from the trocar of the camera. The number of collisions recorded in this specific case was 15, involving the third arm; among these, 11 were of high impact. The distance of the second bedside unit basement (bipolar) from the operating table was also related to the occurrence of collisions. The higher the distance, the higher the collision events were recorded; a distance of the second arm of at least 25 cm was related to fewer collision events ( p  = 0.024). During the three operations in which no collisions occurred, the distance between this arm and the operating table was 8, 15 and 21 cm, respectively, and the angle between the endoscope trocar and the scissors trocar was 145°. No other significant correlations were found between arm-table distances and collisions (patients’ characteristics as age, BMI, and bi-iliac spine distance). The distance between the basement of each BSU and the basement of the operating table is described in Table  3 . Based on these considerations, the correct configuration for trocar positioning is shown in Fig.  1 . Table 3 Distances Distance  Median IQR Min Max Table– BSU 1 (grasper) 29 7.00 14 36 Table– BSU 2 (bipolar) 15 6.00 2 21 Table– BSU 3 (scissors) 18 9.50 0 35 Table– BSU 4 (endoscope) 0 2.50 0 27 BSU 1- BSU 2 45 10.00 26 71 BSU 3– BSU 4 46 15.00 34 72 Fig. 1 Correct configuration for trocar positioning Distances Correct configuration for trocar positioning

The study was approved by the management in charge of the hospital on September 30th 2022. All procedures performed in the operating theatre are compliant with the current guidelines and would have been the same even without this study. The rationale for this study was to identify standardized guidelines for BSU and trocar placement, as none are currently provided by the system’s developers. In their absence, positioning was determined on a case-by-case basis, guided by surgical experience and the consistent targeting of pelvic anatomy.The study aims to collect and analyze factors that impact Versius procedures and related technological issues (i.e., alarms). To do so, we prospectively analyzed 19 cases of benign gynaecological pathologies treated with the Versius system at San Paolo Hospital in Milan, Italy, as of November 2022. Details about trocar placement and surgical setup are reported. Overall, collected variables were: (1) patients’ characteristics (previous surgery, body mass index-BMI, comorbidities, age); (2) operative times (from skin incision to console start-up and overall console time); (3) robotic setup (anatomical references for trocar placement, number of arms, the distance of each bedside tray (measures collected from the basement of each BSU) from the others and the operating table (measures collected from the basement of the operating table), minimal distance from the right and left operative trocar from the target organ; (4) intra-operative events related to the robot (number and characteristics of collisions, need for detaching the instruments during surgery, need for moving the trays during surgery); (5) perioperative clinical outcomes (intraoperative complications, blood loss, surgical conversion, hospital length of stay). As far as intraoperative robot-related events are concerned, two types of collisions may be observed: (a) low-impact collisions, correctable by the console surgeon, without the need to remove the instrument; (b) high-impact collisions, requiring the disconnection of instruments and restarting of the port training. The primary endpoint of the study is to report and analyze factors that affect the occurrence of high-impact collisions. A descriptive analysis of all variables was performed. Continuous variables such as age and BMI were reported as mean ± standard deviation, or median (Me) and interquartile range (IQR) based on the results of Shapiro-Wilk’s test of normality. Spearman’s rho coefficients were calculated to assess the correlation between the number and type of collisions and the distances (arm-to-arm and arm-to-table). Statistical significance was set at a p-value of 0.05. Calculations were performed with R for Mac v. 4.0.

The Versius surgical system has been implemented in several surgical settings to date. A systematic review by Alkatout et al. [ 2 ] analyzed the timeline of preclinical and clinical studies, confirming the feasibility and safety of the Versius. Clinical experiences are available for cholecystectomy [ 10 ] general abdominal surgery [ 11 – 13 ] hernia repair [ 14 ] radical prostatectomy [ 15 , 16 ] and renal surgery [ 17 ]. As far as gynaecological procedures are concerned, Kelkar et al. [ 18 ] reported the results of the first-in-human interim analysis of several gynaecological cases, including six hysterectomies, five diagnostic cases, two oophorectomies, two fallopian tubal anastomosis procedures, an ovarian cystectomy, and a salpingo-oophorectomy procedure. The article analyzed the safety profile of the Versius system and highlighted the feasibility of successful procedures without the need for conversion to pure laparoscopy or open surgery. A further prospective clinical cohort study from the same group [ 19 ] involved 144 women undergoing hysterectomy with the Versius. In this updated article, the rate of unplanned conversion to conventional laparoscopy was 1.4%, with no conversions to open surgery occurring. Dixon et al. reported similarly on 160 operations, including 60 gynaecological cases, and found that the conversion rate ranged from 0% (gynaecology) to 4.4% (general surgery). In most published articles , 3, 15, and 16 , safety, in terms of conversion rate, was the primary endpoint. To our knowledge, this is the first article of gynaecological interest specifically addressing the setup of the OR for the Versius system and reporting a comprehensive analysis of technological errors. Beyond details about the operating room configuration, technological issues were categorized into low- and high-impact incidents. The risk factors affecting the number of high-impact collisions were analyzed, as these errors may necessitate a system restart, which can result in related clinical drawbacks. Based on our initial experience with the Versius Robotic System, only the distance between BSU 2 and the operating table can be considered a significant driver of high impact collisions. Such distance may lead to an acute angle of the robotic elbow joint, which would then interfere with the stereoscopic workspace of the other arms, thus leading to collisions that cannot be resolved without undocking the instruments. For pathology located at the extremities of the pelvis, like ovarian pathology, the angles formed by segments AB and BC, as described in the present paper, did not yield any significant effect on the number of collisions, regardless of the type of operation (adnexectomy, or cystectomy). The values of such angles in our experience are compatible with the trajectory of the movement of Versius robotics arms. In our study, two different surgeons performed all the operations: one with more than 300 cases of successful robotic surgery on a traditional platform (Da Vinci Xi) and the other with major experience in laparoscopic surgery but no experience in robotic-assisted surgery. No significant differences were detected in the number of collisions that occurred during the operations performed by the two surgeons ( p  = 0.081). While the Da Vinci arms are working concurrently [ 20 ] the Versius system arms can work in any direction in space, mimicking the human-like joint trajectory. The Versius platform operates on 2R geometry, utilizing joint spherical arm geometry and revolute coordinates rather than Cartesian coordinates in 3P (Prismatic) geometry. This type of movement utilizes a spherical work envelope generated by the rotation of the base, shoulder, and elbow, which does not require entry into the workspace of the adjacent arm. Second, the minimal distance between the operative trocar and the target anatomy was another measure related to the number of high impact collisions. Our experience suggests that a minimum distance of 19 cm from the bipolar operative trocar and the target organ, as well as a minimum distance of 15 cm between the scissors operative trocar and the target organ, is recommendable to avoid any collisions, or 11 and 9 cm to avoid high impact collisions. When the distance was shorter than the above-mentioned measures, the precision of the robotic dexterity was compromised, and the technology’s advantages were underutilized. Besides the measures of the inflated abdomen, the inner dimensions and localization of the target anatomy are relevant points, just as in traditional laparoscopy. However, in conventional laparoscopy, an inappropriate trocar placement can often be managed through human adaptability. In contrast, in robotic surgery, suboptimal port training may result in reduced dexterity of the robotic arm, high-grade collisions, system arrest, longer operative time, the need for BSU replacement, and discontinuous work, with all the potential consequences. This is related to the structure of the platform, which can work on a perfectly spherical area when it is sufficiently displaced but not when it is very close to its own body. The BMI ( p  = 0.286) and the length of the bisiliac spines ( p  = 0.167) did not affect the number of collisions in any way. The small sample size we considered is the main limitation of the study. However, the primary endpoint was to provide a detailed analysis of trocar placement and BSU configuration. Despite the early experience, all surgical procedures were performed without any intraoperative or postoperative complications. As previously reported [ 21 ] an important fact worth emphasising that results from the location of the trocars in a similar fashion to the traditional, laparoscopic methods of minimally invasive surgery is the possibility of a smooth transition from robotic to laparoscopic surgery if unexpected complications arise. Besides the feasibility and safety of these initial cases, further clinical knowledge is recommended to standardize the use of the Versius, thereby making the procedure more reproducible and facilitating the widespread adoption of the system in robotic gynaecological surgery.

Based on our series, Versius surgical system has been confirmed as a safe option for the treatment of benign gynaecological diseases. The implementation of this technology will benefit from the reproducible gynaecological port placement and surgical setting described in this paper.

The last few decades have witnessed the spread of robotic surgery for several gynaecological indications [ 1 ]. Novel robotic contenders recently emerged to reduce costs and improve access to robotics. Hugo RAS and Versius CMR, both available at our tertiary referral multi-robotic centre, are the primary competitors of the Da Vinci System. Versius (CMR Surgical, Cambridge, UK) is a new robotic platform introduced after the original patent of the DaVinci system expired. In the gynaecological field, the use of Versius has been described for adnexal benign pathology and urogynecology [ 2 – 4 ]. Unlike the DaVinci system, both Versius and Hugo have four independent bedside units (BSU), which must be individually positioned with adequate angles and distance from the operating field and the target organ to avoid collisions during surgery [ 5 ]. Additionally, the length of the Versius stem (30 cm) is significantly shorter than that of the traditional Da Vinci robotic platform. The manufacturers have conducted preclinical studies to determine the optimal positions of the robotic arms and the tilting angles, and our group has analyzed the perspective of the bedside assistant for both systems. The general surgery team at our institution has already highlighted the need to standardize the angles and distances on the Versius [ 6 , 7 ]. Reports on OR setup on different robotic systems have been recently emerging [ 8 , 9 ], nonetheless, data for the Versius system on such aspects are still lacking in the literature. This study aims to describe OR setting and port placement with a focus on how to avoid instrument collision; for this purpose, we analyzed 19 consecutive procedures for benign gynaecological pathology at the ASST Santi Paolo and Carlo, University of Milan La Statale, Milan, Italy.

Below is the link to the electronic supplementary material. Supplementary Material 1 Supplementary Material 1