Introduction
Minimal access surgery (MAS) was pioneered in the late twentieth century and is increasingly used for a range of surgical procedures, particularly prostatectomies, hysterectomies and partial nephrectomies.1 2 Research demonstrates multiple advantages of MAS over open surgery, including reduced blood loss3 and reduced intraoperative and postoperative complications, such as incisional hernias,4 infections and pain; together these benefits lead to reduced average hospital stays and improved clinical outcomes.3 5 6
MAS uptake has been lower than expected. Reasons for this are likely to be multifactorial.7 MAS is associated with a steep learning curve, meaning surgeons completing few surgical procedures are less likely to use MAS techniques.5 8 This is particularly likely to affect surgeons in smaller, rural hospitals where a lack of training opportunities will limit the number of surgeons performing MAS procedures.5 Low numbers of patients requesting MAS may also limit uptake, either because patients are unaware of MAS or that the technique is associated with improved outcomes.5 9
Over the last 20 years, several robot-assisted surgical devices have been developed that overcome some of the challenges associated with performing MAS. Robot-assisted devices are now available to support many procedures, including laparoscopic, cardiovascular, orthopedic, and brain and spine surgery.10–13 Robotic-assisted MAS has the potential to bring the benefits of MAS to a wider population of patients, and research suggests it may provide benefits over standard laparoscopic surgery.14–17 However, the use of robotics is still relatively uncommon, accounting for ~5% to 10% of all MAS procedures performed,2 and installed robotic surgical systems are rarely used to full capacity.
Available robot-assisted surgical devices have limitations that may reduce surgeon uptake. Current devices often struggle to provide the same degrees of freedom as the human arm, reducing surgical access, especially when operating across multiple quadrants.18 MAS robots are large and difficult to move, requiring specifically designed operating rooms (ORs), increasing cost and reducing flexibility of use.19 The use of surgical robots is often associated with communication challenges, particularly when the device employs a closed console design in which the surgeon places their head.20 Finally, ergonomics do not always provide optimal surgical experience, for example, robots do not cater to a wide range of grip sizes, and surgeons often maintain a single operating position for extended periods, which can result in back and neck pain, two common causes of sickness and early retirement for surgeons.21–23
Here we describe the development of the Versius Surgical System, a teleoperated robotic surgical system designed to assist surgeons in performing MAS and to overcome challenges associated with currently available systems. Versius is designed to aid surgical procedures, increase team communication, and improve surgeons’ work environment and career longevity. The system comprises an open surgeon console with hand controllers that the surgeon uses to control the arms and instruments. The surgeon receives three-dimensional (3D), high-definition video feedback from the endoscope camera via the head-up display. The display also has an overlay showing active instruments, system warnings and system function. The visualization bedside unit (BSU) supports the endoscope arm and has an auxiliary display that provides a two-dimensional, high-definition version of the endoscope feed for the surgical team. The team and surgeon are able to access controls and feedback on up to four individual BSUs, each supporting an instrument arm (online supplementary figure S1). These studies were designed considering IDEAL (Idea, Development, Exploration, Assessment, Long-term study) Framework guidelines and recommendations for surgical innovation.24 25 The studies aligned with Stage 0 of the framework and aimed to ensure end-user feedback was incorporated into all steps of the design process and that the resulting design meets surgeon and surgical team needs.