Robotic excision of parametrial endometriosis with the new Versius robotic system: a preliminary case series.

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Giorgia Gaia, Margarita Afonina, Mauro Felline, Maria Chiara Sighinolfi, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2937886/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Endometriosis affects 10% of the female population in reproductive age. Although a greater awareness of the condition and constant progress in understanding its natural history, its treatment remain challenging. When it comes to surgical intervention, the minimally invasive, laparoscopic, or robotic approach is the gold standard. While offering better visualization and refinement of movements, the robotic system is burdened by often unaffordable costs. Since the Da Vinci patent expired, new platforms have entered this scene, trying to preserve the advantages of robotics, while cutting costs. To date, there are no deep infiltrating endometriosis cases reported in literature afforded with the new Versius surgical system. Materials and methods: We considered prospectively 3 patients undergoing robotic surgery for parametrial endometriosis with the versius system, in our tertiary referral multiplatform robotic center. The surgical technique was described step by step. Demographics, intra-operative robotic events and peri-operative outcomes were collected. Results: A total of 3 procedures were performed. The median BMI was 18.52 kg/m 2, [16.33-20.96]. The median age was 41 years [36-51]. Median docking time was 51 minutes [37-60], median console time 180 [136-223] minutes. Pneumoperitoneum was maintained at 9 mmHg. A single high priority collision occurred. Blood loss was negligible. There were no peri-operative complications nor conversions. Conclusions: Versius appeared to be a safe and feasible option for deep infiltrating endometriosis surgery. Our experience suggests operative room configuration and port placement to better perform these challenging procedures. These suggestions may enhance the mini-invasiveness while beating costs and making robotics worldwide approachable. parametrial endometriosis robotic surgery versius surgical system versius CMR new technology. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 INTRODUCTION During the last decades, robotic surgery has spread with indications extending to different fields and complex interventions, such as radical cystectomy, rectal excision, and deep infiltrating endometriosis (DIE). To now, those procedures were meant to be performed with the Da Vinci® system. After its patent’s expiry, new robotic competitors emerged to reduce costs and improve the accessibility and sustainability of robotic surgery. The Versius surgical system (CMR Surgical, Cambridge, UK) is a novel platform consisting of an open surgeon console, a visualization bedside unit (BSU), up to four operative BSUs for instruments, endoscopes (0° and 30°), camera and instruments; each arm has a wristed joint that provides 7 degrees of freedom at the tip for an overall 720° rotation. To date a full description of DIE excision with parametrial involvement by the Versius system is lacking. This study aims to report a stepwise surgical technique for the excision of parametrial endometriosis with the new Versius robotic platform. The operative room (OR) setup, docking, and robot-related issues (critical errors) are considered. MATERIALS AND METHODS This is a case series on three patients affected by DIE and managed with Versius robotic system at the San Paolo University Hospital, Milan. The patients were evaluated for dyspareunia (visual analogical scale, VAS, score 8) and had a previous diagnosis of DIE; they were undergoing medical estro-progestinic therapy for at least 1 year and were diagnosed as unresponsive to the treatment. A complete physical examination combined with bi-digital vagino-rectal examination, transvaginal ultrasonography together with a computed tomography (CT) scan in a single case was performed. Surgical treatment with the Versius system was planned thereafter and performed in November 2022. The following data were collected: 1) patients’ demographics and characteristics (previous surgery, body mass index, 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, 4) peri-operative clinical outcomes (intraoperative complications, blood loss, surgical conversion, hospital length of stay). The primary endpoint of the study is to provide details about Versius OR setup, trocar placement, docking, and surgical technique for the management of DIE. Data presentation and analysis A descriptive analysis of all variables was performed. Continuous variables such as age and body mass index (BMI) were reported as median (Me) and interquartile range (IQR) after the failure 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 distances (arm-to-arm, arm-to-table). Statistical significance was set at 5%. Calculations were performed with R for Mac v. 4.0. OR setup and robotic configuration The patients were positioned in a 22° Trendelenburg position with the legs abducted to 60˚ and flexed to 45˚. A uterine manipulator (ClearView®, Clinical Innovation) was positioned and manipulated by a third assistant. In all cases, a 4-robotic arm arrangement was used. Port configuration reflected the first surgeon standard technique (Fig. 1).The bedside unit arms (BSU) 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 reverse semicircular line. The abdomen was insufflated with CO2 gas and maintained at a pressure of 9 mm Hg during the whole surgery. Surgical technique Adhesiolysis begins by grasping the epiploic appendage of the sigmoid and putting it under traction by the laparoscopic grasper and higher by the fourth robotic arm; through the right robotic arm carrying the monopolar scissors and left robotic arm carrying the bipolar the adhesions are removed among the antimesenteric border of the large bowel. The large traction from the simultaneous action of the two graspers allows fast removal of the adhesions. The large bowel is then mobilized as much as possible out of the pelvis. Retroperitoneal space dissection begins high at the level of the promontory lateral to the sigmoid at the entry level of the ureter into the pelvis, extending the incision caudally almost up to the ipsilateral uterosacral ligament. The fourth robotic arm is retracting the peritoneum, the laparoscopic assistant is keeping the area of dissection clean using the suction system and the dissection is carried out by scissors and bipolar. The port configuration on the semicircular line allowed an easy movement of instruments without collision between the 2nd and 3rd arms. At the level of the ovarian fossa, the fourth arm is pulling the ovary up while the laparoscopic assistant is retracting the edge of the excised peritoneum, and the dissection is safely carried out keeping the ureter under vision. The unavoidable opening of the endometrioma at this stage introduces the time of the ovarian stripping and suspension of the ovary to the abdominal wall. The resistance of the robotic grasper at the stripping stage was the first weakness subjectively detected by the first operator. Using the robotic augmented twist and range of articulation of the needle drivers, the enhanced dexterity and precision in suturing make this step extremely fast. Once the suspension is performed keeping the ureter under the vision and retracted laterally, the loose areolar tissue within this region is cut to expose the lateral pararectal space (Latzko space), Fig. 2, medial to internal iliac artery. While the fourth robotic arm is gently grasping the obliterated umbilical artery, the dissection is carried out to expose the paravesical space, until its base. While the fourth arm retracts laterally to the ureter and the assistant is pulling the edge of the peritoneum, the uterine artery is dissected from its origin to the ureteral tunnel. It was always spared. At this step, the 3-D vision of the robotic system provides advantages to identifying the deep uterine vein, used as a landmark to preserve the neural portion of the parametrium. The ureter is then lateralized from its medial peritoneal attachments preserving its vascular adventitia intact. Meso-ureter is held under gentle traction by the surgeon using an atraumatic grasper, and the ureter is separated and lateralized (Fig. 3). The dissection proceeds in a craniocaudal direction, and the ureter is traced from its medial surface up to the tunnel. Bilateral Inferior Hypogastric Nerve (IHN) is identified in the medial pararectal space (Okabayashi space) (Fig. 4) as a white shiny cord. Further bilateral IHNs are lateralized from their medial peritoneal attachment and safeguarded till the hypogastric plexus at the uterosacral ligament. The whole layer of the posterior pelvic peritoneum involved with endometriotic implants is excised (Fig. 5). The excision depends on the extent of the involvement, approximately the posterior peritoneum from the sacral promontory to the uterosacral ligament, adjacent to the ureter. Traction is applied with atraumatic forceps over the diseased peritoneum to be excised in the opposite direction, and dissection is completed while the fourth arm protects laterally the ureter (Fig. 6). RESULTS All surgical procedures (3) were carried out by a single senior surgeon with previous extensive expertise in pure laparoscopy and little experience with the Da Vinci platform. The median BMI of patients was 18.52 kg/m 2, [16.33–20.96]. No one was menopausal and no one had past surgical history. The median age was 41 years [36–51]. Median docking time (from incision to console) was 51 minutes [37–60], followed by 180 [136–223] minutes of console time, with an overall surgical time of 238 minutes [232–242]. Pneumoperitoneum was maintained at 9 mmHg. Collisions between instruments occurred during all interventions (1 each intervention) but included a single High Priority Collision with the need to detach the instrument without BSU restart. The collision occurred between the camera and the bipolar at the level of the left uterosacral ligament. In all cases, the localization of parametrial endometriosis was unilateral on the left side. The pathological analysis confirmed the presence of endometriotic lesions; in a single case, an extensive dissection of the vesicouterine pouch was required (unreported description). Blood loss was unremarkable for all patients. There were no intra-operative complications requiring a change in surgical strategy nor conversions to open or laparoscopic surgery. The postoperative course was uneventful; patients were mobilized, with spontaneous urination and canalization on post operative day 1 and were discharged on post operative day 2 or 3. DISCUSSION Deep infiltrating endometriosis is an invalidating disease that may require complex surgical management. It is defined as the presence of ectopic endometrial tissue infiltration under the peritoneum, pelvic structure, and organ, including the uterosacral ligaments, rectosigmoid colon, vagina, rectovaginal septum, bladder, ureter, and lateral parametrium. The parametrium constitutes a complex connective tissue that forms a lamina containing blood vessels, the ureter, and the inferior hypogastric plexus and runs from the lateral face of the cervix and vagina to the lateral pelvic wall [ 1 ]. Parametrial endometriosis can spread from uterosacral ligaments to ovarian fossa and parametrium, leading to symptoms such as chronic pelvic pain, dysmenorrhea, and dyspareunia. It can involve also adjacent structures and gradually lead to severe complications, such as the bowel and the ureter, leading to dreadful consequences like hydroureter, hydronephrosis, and kidney failure [ 2 ]. Lateral parametrial endometriosis (LPE) is a specific localization of endometriotic implants in the field of DIE. Patients with LPE present with severe dyspareunia and dysmenorrhea. When symptoms do not respond to medical treatments, surgical intervention plays a key role in disease management [ 2 ]; it should consist of a complete excision - given the high rate of relapse - with a careful spare of nerve structures [ 3 , 4 ]. A minimally invasive approach with laparoscopy represented so far, the best choice for the management of DIE [ 5 , 6 ]. However, in more recent years, the robotic approach to DIE has emerged and recent evidence supports the safe implementation of robotics for the effective excision of DIE, postoperative course, and recovery [ 7 , 8 ]. Indeed, previous reports dealt only with the Da Vinci robotic system, that has been introduced in the market after the approval of the Food and Drug Administration in June 2000. Since the Intuitive Surgical patent has expired, novel robotic platforms have entered the market aiming to maintain the same advantages of robotic surgery while improving its accessibility and sustainability in the health care system. The new Versius Surgical System (CMR Surgical, Cambridge, UK) is among these new platforms. The system has been successfully applied in several surgical settings. A systematic review by Alkatout et al analyzed the timeline of preclinical and clinical studies, which confirmed the feasibility and safety of the Versius platform [ 9 ]. Thereafter, the Versius has been used for cholecystectomy, general abdominal surgery, hernia repair, radical prostatectomy, and renal surgery [ 10 – 15 ]. We recently reported a detailed description of the Versius surgical management of pelvic organ prolapse, by using the Shull surgical technique [ 16 ]. Similarly, Kelkar et al reported data from different gynecological cases, including 6 hysterectomies, 5 diagnostic cases, 2 oophorectomies, 2 fallopian tube recanalization procedures, an ovarian cystectomy, and a salpingo-oophorectomy procedure [ 17 ], as well as Borse et al [ 18 ] that analyzed 144 women who underwent total hysterectomy with the Versius. Both Authors emphasize the feasibility of gynecological surgery with this new robotic system, with a 1.4% conversion rate and without significant intra- or post-operative complications. To our knowledge, the current study represents the very first report concerning the excision of parametrial endometriosis with the Versius, confirming the feasibility of complex gynecological procedures with this novel platform. In our small series, operative times were acceptable, and blood loss and intraoperative complications were unremarkable. All three cases were performed by an experienced laparoscopic surgeon, who underwent a prior 3-day cadaver lab a full training program of 50 hours of a dry lab (simulator), and three prior human cases of adnexal surgery. These findings supporting the hypothesis of a simple learning curve of the Versius - especially if compared to traditional laparoscopy – are seemingly consistent with previous literature [ 19 , 20 ]. The loss of tactile feedback is seemingly replaced by the enhanced 3D visualization of the robotic system, which allows magnification of deep spaces and cavities otherwise less accessible. This advantage is highly useful for the management of endometriosis, where planes and anatomy may be disrupted by the disease and thus vision and exposure gain paramount importance. The Versius system turned out effective and safe, with few alarms and collisions and peri-operative outcomes (median blood loss, hospital stay, and complications rate) comparable to those of Da Vinci robotic surgery [ 21 ]. The small sample size is the main limitation of this study; however, it should be remarked that the primary aim was to report the feasibility of the procedure and to provide details of the Versius setup to make it reproducible. CONCLUSIONS Our initial experience suggests that the use of the Versius surgical system for parametrial endometriosis is safe and feasible. The better visualization – compared to laparoscopy - allows one to work in spaces otherwise difficult to be accessed; the learning curve is seemingly fast for an experienced robotic and laparoscopic surgeon. Further clinical experience is required to better standardize pelvic procedures and implement the use of Versius in gynecological surgery. Declarations Financial support and sponsorship: None. Conflicts of interest: All authors declared no conflicts of interest. Ethical approval and consent to participate: Not applicable (Our institution doesn’t provide an IRB written in English language, even so our study was approved by the management in charge of our hospital on September 30 th , 2022. Since our study is not an experimental but a descriptive one, we take on the responsibility to guarantee for the study protocol in any case; all procedures performed in the operating theatre are compliant with the current guidelines and would have been the same even without this study). Patient Consent Statement: Patients consent is not required because no personal information or details are included that may identify the patients. 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Surg Technol Int. 2022 May 19; 40:197–202. doi: 10.52198/22.STI.40.GY1562 . PMID: 35415833. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2937886","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":200935511,"identity":"f8d13829-1c30-4b97-a44f-bdff2e135a1e","order_by":0,"name":"Giorgia Gaia","email":"","orcid":"","institution":"ASST Santi Paolo e Carlo, San Paolo University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Giorgia","middleName":"","lastName":"Gaia","suffix":""},{"id":200935513,"identity":"0b63dc18-8202-4d49-9351-9bc0918d13bf","order_by":1,"name":"Margarita 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13:31:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2937886/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2937886/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":37195975,"identity":"7350bb72-16e1-4c54-9d26-0824776259df","added_by":"auto","created_at":"2023-05-18 13:41:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54834,"visible":true,"origin":"","legend":"\u003cp\u003eAccording to the experience of this centre, the angle formed by segments A and B between the trocars should be approximately 140°, while the angle between B and C should not exceed 170°, as using a flat angle increases the risk of collisions. The experience reported in this paper suggests an optimal angle of about 150°. The trocar used by the second operator can instead be positioned more freely.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2937886/v1/8ff8f48b927366d5e427fc21.png"},{"id":37195972,"identity":"eeb9ae57-e8da-4496-8870-f7a5afe21990","added_by":"auto","created_at":"2023-05-18 13:41:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1162915,"visible":true,"origin":"","legend":"\u003cp\u003eThe loose areolar tissue within this region is cut to expose the lateral pararectal space (Latzko space).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-2937886/v1/3ae21b77fdada30fa283a3f8.png"},{"id":37197461,"identity":"66f065a0-99a5-41b7-91ba-7675e544f9de","added_by":"auto","created_at":"2023-05-18 13:49:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1150531,"visible":true,"origin":"","legend":"\u003cp\u003eThe ureter is then lateralized from its medial peritoneal attachments.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-2937886/v1/4a5d18c4e7468184e9188594.png"},{"id":37197460,"identity":"f8c8bc22-64ad-4109-984b-20e11dee1fc7","added_by":"auto","created_at":"2023-05-18 13:49:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1157387,"visible":true,"origin":"","legend":"\u003cp\u003eUsing the bimanual dissection the medial pararectal space is opened medial to the ureter.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-2937886/v1/905614d6831ad6f11a49be47.png"},{"id":37195978,"identity":"810e06cd-2845-4249-81cf-374fb358edc4","added_by":"auto","created_at":"2023-05-18 13:41:54","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1167363,"visible":true,"origin":"","legend":"\u003cp\u003eThe layer of posterior pelvic peritoneum involved with endometriotic implants is excised.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-2937886/v1/d74bfa3df8d6732fbd67d94a.png"},{"id":37195977,"identity":"30b4dba4-0b7f-49a8-b225-d4072da44986","added_by":"auto","created_at":"2023-05-18 13:41:54","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1207974,"visible":true,"origin":"","legend":"\u003cp\u003eThe endometriotic nodule is stretched by the assistant while robotic scissors and bipolar are detaching it from the ureter.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-2937886/v1/3e89c06ceba979582d31092d.png"},{"id":37290608,"identity":"2f6fb8df-f50d-4e61-abc3-fb00c44e006b","added_by":"auto","created_at":"2023-05-21 14:14:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5621772,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2937886/v1/5f23e399-dd9b-4d5b-aa62-001478a9fd83.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robotic excision of parametrial endometriosis with the new Versius robotic system: a preliminary case series.","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDuring the last decades, robotic surgery has spread with indications extending to different fields and complex interventions, such as radical cystectomy, rectal excision, and deep infiltrating endometriosis (DIE). To now, those procedures were meant to be performed with the Da Vinci\u0026reg; system. After its patent\u0026rsquo;s expiry, new robotic competitors emerged to reduce costs and improve the accessibility and sustainability of robotic surgery. The Versius surgical system (CMR Surgical, Cambridge, UK) is a novel platform consisting of an open surgeon console, a visualization bedside unit (BSU), up to four operative BSUs for instruments, endoscopes (0\u0026deg; and 30\u0026deg;), camera and instruments; each arm has a wristed joint that provides 7 degrees of freedom at the tip for an overall 720\u0026deg; rotation. To date a full description of DIE excision with parametrial involvement by the Versius system is lacking. This study aims to report a stepwise surgical technique for the excision of parametrial endometriosis with the new Versius robotic platform. The operative room (OR) setup, docking, and robot-related issues (critical errors) are considered.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis is a case series on three patients affected by DIE and managed with Versius robotic system at the San Paolo University Hospital, Milan. The patients were evaluated for dyspareunia (visual analogical scale, VAS, score 8) and had a previous diagnosis of DIE; they were undergoing medical estro-progestinic therapy for at least 1 year and were diagnosed as unresponsive to the treatment. A complete physical examination combined with bi-digital vagino-rectal examination, transvaginal ultrasonography together with a computed tomography (CT) scan in a single case was performed.\u003c/p\u003e\n\u003cp\u003eSurgical treatment with the Versius system was planned thereafter and performed in November 2022. The following data were collected: 1) patients\u0026rsquo; demographics and characteristics (previous surgery, body mass index, 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, 4) peri-operative clinical outcomes (intraoperative complications, blood loss, surgical conversion, hospital length of stay).\u003c/p\u003e\n\u003cp\u003eThe primary endpoint of the study is to provide details about Versius OR setup, trocar placement, docking, and surgical technique for the management of DIE.\u003c/p\u003e\n\u003cp\u003eData presentation and analysis\u003c/p\u003e\n\u003cp\u003eA descriptive analysis of all variables was performed. Continuous variables such as age and body mass index (BMI) were reported as median (Me) and interquartile range (IQR) after the failure of Shapiro-Wilk\u0026apos;s test of normality. Spearman\u0026apos;s rho coefficients were calculated to assess the correlation between the number and type of collisions and distances (arm-to-arm, arm-to-table). Statistical significance was set at 5%. Calculations were performed with R for Mac v. 4.0.\u003c/p\u003e\n\u003cp\u003eOR setup and robotic configuration\u003c/p\u003e\n\u003cp\u003eThe patients were positioned in a 22\u0026deg; Trendelenburg position with the legs abducted to 60˚ and flexed to 45˚. A uterine manipulator (ClearView\u0026reg;, Clinical Innovation) was positioned and manipulated by a third assistant. In all cases, a 4-robotic arm arrangement was used. Port configuration reflected the first surgeon standard technique (Fig.\u0026nbsp;1).The bedside unit arms (BSU) 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 reverse semicircular line. The abdomen was insufflated with CO2 gas and maintained at a pressure of 9 mm Hg during the whole surgery.\u003c/p\u003e\n\u003cp\u003eSurgical technique\u003c/p\u003e\n\u003cp\u003eAdhesiolysis begins by grasping the epiploic appendage of the sigmoid and putting it under traction by the laparoscopic grasper and higher by the fourth robotic arm; through the right robotic arm carrying the monopolar scissors and left robotic arm carrying the bipolar the adhesions are removed among the antimesenteric border of the large bowel. The large traction from the simultaneous action of the two graspers allows fast removal of the adhesions. The large bowel is then mobilized as much as possible out of the pelvis.\u003c/p\u003e\n\u003cp\u003eRetroperitoneal space dissection begins high at the level of the promontory lateral to the sigmoid at the entry level of the ureter into the pelvis, extending the incision caudally almost up to the ipsilateral uterosacral ligament. The fourth robotic arm is retracting the peritoneum, the laparoscopic assistant is keeping the area of dissection clean using the suction system and the dissection is carried out by scissors and bipolar. The port configuration on the semicircular line allowed an easy movement of instruments without collision between the 2nd and 3rd arms. At the level of the ovarian fossa, the fourth arm is pulling the ovary up while the laparoscopic assistant is retracting the edge of the excised peritoneum, and the dissection is safely carried out keeping the ureter under vision. The unavoidable opening of the endometrioma at this stage introduces the time of the ovarian stripping and suspension of the ovary to the abdominal wall. The resistance of the robotic grasper at the stripping stage was the first weakness subjectively detected by the first operator. Using the robotic augmented twist and range of articulation of the needle drivers, the enhanced dexterity and precision in suturing make this step extremely fast. Once the suspension is performed keeping the ureter under the vision and retracted laterally, the loose areolar tissue within this region is cut to expose the lateral pararectal space (Latzko space), Fig.\u0026nbsp;2, medial to internal iliac artery. While the fourth robotic arm is gently grasping the obliterated umbilical artery, the dissection is carried out to expose the paravesical space, until its base.\u003c/p\u003e\n\u003cp\u003eWhile the fourth arm retracts laterally to the ureter and the assistant is pulling the edge of the peritoneum, the uterine artery is dissected from its origin to the ureteral tunnel. It was always spared. At this step, the 3-D vision of the robotic system provides advantages to identifying the deep uterine vein, used as a landmark to preserve the neural portion of the parametrium. The ureter is then lateralized from its medial peritoneal attachments preserving its vascular adventitia intact. Meso-ureter is held under gentle traction by the surgeon using an atraumatic grasper, and the ureter is separated and lateralized (Fig.\u0026nbsp;3).\u003c/p\u003e\n\u003cp\u003eThe dissection proceeds in a craniocaudal direction, and the ureter is traced from its medial surface up to the tunnel.\u003c/p\u003e\n\u003cp\u003eBilateral Inferior Hypogastric Nerve (IHN) is identified in the medial pararectal space (Okabayashi space) (Fig. 4) as a white shiny cord. Further bilateral IHNs are lateralized from their medial peritoneal attachment and safeguarded till the hypogastric plexus at the uterosacral ligament.\u003c/p\u003e\n\u003cp\u003eThe whole layer of the posterior pelvic peritoneum involved with endometriotic implants is excised (Fig.\u0026nbsp;5).\u003c/p\u003e\n\u003cp\u003eThe excision depends on the extent of the involvement, approximately the posterior peritoneum from the sacral promontory to the uterosacral ligament, adjacent to the ureter. Traction is applied with atraumatic forceps over the diseased peritoneum to be excised in the opposite direction, and dissection is completed while the fourth arm protects laterally the ureter (Fig.\u0026nbsp;6).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAll surgical procedures (3) were carried out by a single senior surgeon with previous extensive expertise in pure laparoscopy and little experience with the Da Vinci platform. The median BMI of patients was 18.52 kg/m 2, [16.33\u0026ndash;20.96]. No one was menopausal and no one had past surgical history. The median age was 41 years [36\u0026ndash;51]. Median docking time (from incision to console) was 51 minutes [37\u0026ndash;60], followed by 180 [136\u0026ndash;223] minutes of console time, with an overall surgical time of 238 minutes [232\u0026ndash;242]. Pneumoperitoneum was maintained at 9 mmHg. Collisions between instruments occurred during all interventions (1 each intervention) but included a single High Priority Collision with the need to detach the instrument without BSU restart. The collision occurred between the camera and the bipolar at the level of the left uterosacral ligament. In all cases, the localization of parametrial endometriosis was unilateral on the left side. The pathological analysis confirmed the presence of endometriotic lesions; in a single case, an extensive dissection of the vesicouterine pouch was required (unreported description). Blood loss was unremarkable for all patients. There were no intra-operative complications requiring a change in surgical strategy nor conversions to open or laparoscopic surgery. The postoperative course was uneventful; patients were mobilized, with spontaneous urination and canalization on post operative day 1 and were discharged on post operative day 2 or 3.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eDeep infiltrating endometriosis is an invalidating disease that may require complex surgical management. It is defined as the presence of ectopic endometrial tissue infiltration under the peritoneum, pelvic structure, and organ, including the uterosacral ligaments, rectosigmoid colon, vagina, rectovaginal septum, bladder, ureter, and lateral parametrium. The parametrium constitutes a complex connective tissue that forms a lamina containing blood vessels, the ureter, and the inferior hypogastric plexus and runs from the lateral face of the cervix and vagina to the lateral pelvic wall [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Parametrial endometriosis can spread from uterosacral ligaments to ovarian fossa and parametrium, leading to symptoms such as chronic pelvic pain, dysmenorrhea, and dyspareunia. It can involve also adjacent structures and gradually lead to severe complications, such as the bowel and the ureter, leading to dreadful consequences like hydroureter, hydronephrosis, and kidney failure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLateral parametrial endometriosis (LPE) is a specific localization of endometriotic implants in the field of DIE. Patients with LPE present with severe dyspareunia and dysmenorrhea. When symptoms do not respond to medical treatments, surgical intervention plays a key role in disease management [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]; it should consist of a complete excision - given the high rate of relapse - with a careful spare of nerve structures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A minimally invasive approach with laparoscopy represented so far, the best choice for the management of DIE [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, in more recent years, the robotic approach to DIE has emerged and recent evidence supports the safe implementation of robotics for the effective excision of DIE, postoperative course, and recovery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIndeed, previous reports dealt only with the Da Vinci robotic system, that has been introduced in the market after the approval of the Food and Drug Administration in June 2000. Since the Intuitive Surgical patent has expired, novel robotic platforms have entered the market aiming to maintain the same advantages of robotic surgery while improving its accessibility and sustainability in the health care system. The new Versius Surgical System (CMR Surgical, Cambridge, UK) is among these new platforms. The system has been successfully applied in several surgical settings. A systematic review by Alkatout et al analyzed the timeline of preclinical and clinical studies, which confirmed the feasibility and safety of the Versius platform [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Thereafter, the Versius has been used for cholecystectomy, general abdominal surgery, hernia repair, radical prostatectomy, and renal surgery [\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. We recently reported a detailed description of the Versius surgical management of pelvic organ prolapse, by using the Shull surgical technique [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, Kelkar et al reported data from different gynecological cases, including 6 hysterectomies, 5 diagnostic cases, 2 oophorectomies, 2 fallopian tube recanalization procedures, an ovarian cystectomy, and a salpingo-oophorectomy procedure [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], as well as Borse et al [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] that analyzed 144 women who underwent total hysterectomy with the Versius. Both Authors emphasize the feasibility of gynecological surgery with this new robotic system, with a 1.4% conversion rate and without significant intra- or post-operative complications. To our knowledge, the current study represents the very first report concerning the excision of parametrial endometriosis with the Versius, confirming the feasibility of complex gynecological procedures with this novel platform. In our small series, operative times were acceptable, and blood loss and intraoperative complications were unremarkable. All three cases were performed by an experienced laparoscopic surgeon, who underwent a prior 3-day cadaver lab a full training program of 50 hours of a dry lab (simulator), and three prior human cases of adnexal surgery. These findings supporting the hypothesis of a simple learning curve of the Versius - especially if compared to traditional laparoscopy \u0026ndash; are seemingly consistent with previous literature [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The loss of tactile feedback is seemingly replaced by the enhanced 3D visualization of the robotic system, which allows magnification of deep spaces and cavities otherwise less accessible. This advantage is highly useful for the management of endometriosis, where planes and anatomy may be disrupted by the disease and thus vision and exposure gain paramount importance. The Versius system turned out effective and safe, with few alarms and collisions and peri-operative outcomes (median blood loss, hospital stay, and complications rate) comparable to those of Da Vinci robotic surgery [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The small sample size is the main limitation of this study; however, it should be remarked that the primary aim was to report the feasibility of the procedure and to provide details of the Versius setup to make it reproducible.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eOur initial experience suggests that the use of the Versius surgical system for parametrial endometriosis is safe and feasible. The better visualization \u0026ndash; compared to laparoscopy - allows one to work in spaces otherwise difficult to be accessed; the learning curve is seemingly fast for an experienced robotic and laparoscopic surgeon. Further clinical experience is required to better standardize pelvic procedures and implement the use of Versius in gynecological surgery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFinancial support and sponsorship: None.\u003c/p\u003e\n\u003cp\u003eConflicts of interest: All authors declared no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eEthical approval and consent to participate: Not applicable (Our institution doesn\u0026rsquo;t provide an IRB written in English language, even so our study was approved by the management in charge of our hospital on September 30\u003csup\u003eth\u003c/sup\u003e, 2022. Since our study is not an experimental but a descriptive one, we take on the responsibility to guarantee for the study protocol in any case; all procedures performed in the operating theatre are compliant with the current guidelines and would have been the same even without this study).\u003c/p\u003e\n\u003cp\u003ePatient Consent Statement: Patients consent is not required because no personal information or details are included that may identify the patients.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eLouise Benoit a, *, Yohann Dabi a, Marc Bazot b, Isabelle Thomassin-Naggara b, Cl ́ement Ferrier b, Anne Pucharb, Cl ́ementine Owena, Cyril Touboula,c, Emile Daraia,d, Sofiane Bendifallaha, Parametrial endometriosis: A predictive and prognostic factor for voiding dysfunction and complications European Journal of Obstetrics and Gynecology 276 (2022) 236\u0026ndash;243, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ejogrb.2022.07.035\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMabrouk, M., Raimondo, D., Arena, A., Iodice, R., Altieri, M., Sutherland, N.,Seracchioli, R. 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Assessment of the Versius Robotic Surgical System in Minimal Access Surgery: A Systematic Review. J Clin Med. 2022 Jun 28;11(13):3754. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jcm11133754\u003c/span\u003e\u003c/span\u003e. PMID: 35807035; PMCID: PMC9267445\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKelkar DS, Kurlekar U, Stevens L, Wagholikar GD, Slack M.An Early Prospective Clinical Study to Evaluate the Safety and Performance of the Versius Surgical System in Robot-Assisted Cholecystectomy. Ann Surg. 2022 Feb 15. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/SLA.0000000000005410\u003c/span\u003e\u003c/span\u003e;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eEl Dahdah J, Halabi M, Kamal J, Zenilman ME, Moussa H.Initial experience with a novel robotic surgical system in abdominal surgery. 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J Robot Surg. 2022 Aug 11:1\u0026ndash;5. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11701-022-01451-4\u003c/span\u003e\u003c/span\u003e;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRocco B, Turri F, Sangalli M, Assumma S, Piacentini I, Grasso A, Dall\u0026rsquo;Orto P, Calcagnile T, Sighinolfi MC. Robot assisted radical prostatectomy with the Versius Robotic Surgical System: first description of a clinical case. Eur Urol Open Science, in press;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHussein AA, Mohsin R, Qureshi H, Leghari R, Jing Z, Ramahi YO, Rizvi I, Guru KA, Rizvi A.Transition from da Vinci to Versius robotic surgical system: initial experience and outcomes of over 100 consecutive procedures. 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Acta Obstet Gynecol Scand. 2022 Sep;101(9):978\u0026ndash;986. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/aogs.14407\u003c/span\u003e\u003c/span\u003e. Epub 2022 Jul 21.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSinha R, Rupa B, Reddy M. Beyond the learning curve: improving outcomes in Robotic myomectomy compared to laparoscopic myomectomy. J Robot Surg. 2022 Nov 1. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11701-022-01470-1\u003c/span\u003e\u003c/span\u003e. Epub ahead of print. PMID: 36319791;\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTorng PL, Pan SP, Hwang JS, Shih HJ, Chen CL. Learning curve in concurrent application of laparoscopic and robotic-assisted hysterectomy with lymphadenectomy in endometrial cancer. Taiwan J Obstet Gynecol. 2017 Dec;56(6):781\u0026ndash;787. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.tjog.2017.10.014\u003c/span\u003e\u003c/span\u003e. PMID: 29241920.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMikhail E, Pavlovic ZJ, Al Jumaily M, Kheil MH, Moawad GN, Soares T. Robot-Assisted Surgery for Endometriosis Current and Future Perspectives. Surg Technol Int. 2022 May 19; 40:197\u0026ndash;202. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.52198/22.STI.40.GY1562\u003c/span\u003e\u003c/span\u003e. PMID: 35415833.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"parametrial endometriosis, robotic surgery, versius surgical system, versius CMR, new technology. ","lastPublishedDoi":"10.21203/rs.3.rs-2937886/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2937886/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Endometriosis affects 10% of the female population in reproductive age. Although a greater awareness of the condition and constant progress in understanding its natural history, its treatment remain challenging. When it comes to surgical intervention, the minimally invasive, laparoscopic, or robotic approach is the gold standard. While offering better visualization and refinement of movements, the robotic system is burdened by often unaffordable costs. Since the Da Vinci patent expired, new platforms have entered this scene, trying to preserve the advantages of robotics, while cutting costs. To date, there are no deep infiltrating endometriosis cases reported in literature afforded with the new Versius surgical system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods:\u003c/strong\u003e We considered prospectively 3 patients undergoing robotic surgery for parametrial endometriosis with the versius system, in our tertiary referral multiplatform robotic center. The surgical technique was described step by step. Demographics, intra-operative robotic events and peri-operative outcomes were collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 3 procedures were performed. The median BMI was 18.52 kg/m 2, [16.33-20.96]. The median age was 41 years [36-51]. Median docking time was 51 minutes [37-60], median console time 180 [136-223] minutes. Pneumoperitoneum was maintained at 9 mmHg. A single high priority collision occurred. Blood loss was negligible. There were no peri-operative complications nor conversions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Versius appeared to be a safe and feasible option for deep infiltrating endometriosis surgery. Our experience suggests operative room configuration and port placement to better perform these challenging procedures. These suggestions may enhance the mini-invasiveness while beating costs and making robotics worldwide approachable.\u003c/p\u003e","manuscriptTitle":"Robotic excision of parametrial endometriosis with the new Versius robotic system: a preliminary case series.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-18 13:41:49","doi":"10.21203/rs.3.rs-2937886/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf1aefcc-0552-46e9-8996-4e3d07dfb60a","owner":[],"postedDate":"May 18th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-05-21T14:14:19+00:00","versionOfRecord":[],"versionCreatedAt":"2023-05-18 13:41:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2937886","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2937886","identity":"rs-2937886","version":["v1"]},"buildId":"2u56kwukJI3zHK-uzyFNs","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}