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5 Versius Surgical Robot
61
Surgical andTechnical Considerations
Before taking up any surgery on this platform, the entire surgical team, including
the scrub nurses, has to complete the introductory training course. Before using the
system, users should complete basic system training, which includes online and
practical training. There are 10 online modules, and the time to complete the entire
online training is estimated as 8–10h. The minimum time for practical training for
the surgeon and surgical team is as follows:
Introduction to versius training course
Time
Session
System use: system setup & post-operative task training 12h 20min 12h 50min
Surgical time– wet lab and dry lab 9h 8h 45min
Team building 1h 20min 1hr 20min
Where a Versius Surgical System is already in use at a hospital and at least one
surgical team in the hospital has been trained in the full training course, additional
sterile nurses can be trained in a shorter training course. The online element of this
sterile nurse training is estimated as 15h. The minimum time for practical training
in the sterile nurse course is as follows:
Sterile nurse training course
Session Time
Team building exercises and troubleshooting 1h 10min
System use (set-up and post- operative tasks) 3h 40min
Surgical time dry-lab (hands on) 3h
Surgeon Bedside team
Approved Procedures
The following are the approved surgical procedures on the Versius robotic platform.
Procedures
Gynaecology General
Salpingo-Oophorectomy
Endometriosis resection
Radical hysterectomy
Hysterectomy
Colorectal Urology
Left & Right hemicolectomy (Low) anterior resection Nephrectomy
Although thoracic procedures like esophagectomy can also be done in this system.
Cholecystectomy
Inguinal Hernia
Hernia repair
Gastrectomy
Pyeloplasty
Prostatectomy
62
S. Khanna and A. Barua
Warnings andPrecautions
• Prolonged use of the 3D display can lead to side effects such as headache, eye
strain, and nausea.
• Versius Surgical System should not be used near an X-ray source.
• The surface of the Versius arm may reach up to 55 °C during use, so direct con-
tact with patient/assistant surgeon’s skin should be avoided.
• The robotic arms should be handled only at the areas that are designated safe to
hold. There is a risk of hand traps if the arm is touched on a joint when the arm
is moving.
• To avoid the risk of permanent damage, the Versius Surgical System must be
disconnected and removed before debrillation.
• The Versius Surgical System should not be used for procedures involving the
heart, circulatory system, or central nervous system.
Some Important Safety Features
1. After the arm has been port-trained, the bedside unit brake cannot be deactivated
unless the instrument or endoscope is fully retracted out of the port or detached
from the arm.
2. If the endoscope camera gets detached accidentally, the control of the surgeon on
the movement of the instrument arms is gone and the instruments freeze in that
position.
3. If no hands are detected, the instrument gets disengaged, so that the accidental
movement of the hand controllers, not made by the surgeon’s hands does not
injure the patient’s organs.
4. In the instrument change mode, the robot memorizes the position of the instru-
ment just prior to getting the arm in that mode. The robot does not let the instrument advance beyond this point to avoid visceral injury.
5. If the brake button is released before the brake is fully activated, the bottom of
the bedside unit will rise again. This is a safety feature designed to prevent injuries to the surgical team.
Conclusion
With the Versius taking over the robotic surgery arena rapidly, there has been a signicant leap forward in the way minimally invasive surgery is being done globally.
However, the true impact of Versius system remains to be seen, how it fares clinically and commercially. Ultimately, the Versius system's success depends on its
capacity to bring actual benets to both healthcare providers and patients. If it can
consistently provide better surgical outcomes, lower costs, and a favorable patient
experience, it has the potential to transform the area of minimally invasive surgery.
However, the question remains unanswered, and only time will tell if the Versius
system actually ushers in a new age of surgical care.
Virtual Incision: MIRA Surgical System
DmitryOleynikov andShaneFarritor
Introduction
Founded in Nebraska in 2006 by Shane Farritor, MS, PhD and Dmitry Oleynikov,
MD, FACS, Virtual Incision has become a trailblazer in the realm of minimally
invasive surgery. The company was established with a core principle of advancing
robotically assisted surgical (RAS) technology allowing surgeries to be more precise, less invasive, and ultimately enhance patient recovery experiences. The company is committed to make every operating room robot ready.
Like other RAS approaches, the MIRA Surgical System offers similar benets
in ergonomics and dexterity. Robotic systems can increase dexterity by eliminating
the motion reversal associated with LAP procedures (when the surgeon’s hand
movements are perceived in the opposite direction when using laparoscopic instruments). MIRA also allows for motion scaling for more consistent and precise
manipulation.
Virtual Incision’s groundbreaking work revolves around the development of a
rst-in-class miniaturized robotically assisted surgical platform, designed to navigate a wide range of soft-tissue procedures. The MIRA Surgical System has benets over other “mainframe” RAS systems that set it apart in a class of its own,
namely miniaturized RAS.The MIRA Surgical System was developed to mitigate
many of the issues that current “mainframe” robotic systems pose. Mainframe
refers to the currently available RAS systems (e.g., Da Vinci Xi) that have a
6
D. Oleynikov (*)
Department of Surgery, Monmouth Medical Center, Long Branch, NJ, USA
Department of Surgery, Rutgers Robert Wood Johnson Medical School,
Long Branch, NJ, USA
e-mail: Dmitry.Oleynikov@rwjbh.org
S. Farritor
David B. and Nancy K.Lederer Professor of Engineering, Lincoln, NH, USA
e-mail: sfarritor@unl.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_6
63
64
robust, large, and heavy design to support the external articulation of their robotic
arms. These “traditional” RAS systems’ large external footprint can lead to cumbersome and long setup times, the need for draping and docking, all while the
patient cart and boom are looming over the patient that can interfere with ready
access to patient and communication with the operating team. The MIRA Surgical
System, on the other hand, can be deployed anywhere, eliminating the need for
dedicated robotic rooms and assigned blocks. Its design simplies setup time and
optimizes both access to the patient and communication with the operating team,
while allowing seamless operating in multiple quadrants. This lightweight, reusable, “out-of-a-tray” design and potential cost reductions hold the promise to
allow wider adoption of robotic surgery programs, allowing for more patients to
benet from better outcomes and faster recovery associated with minimally invasive procedures.
D. Oleynikov and S. Farritor
The MIRA Surgical System
Indication
In the United States, marketing authorization was granted by the FDA on February
23, 2024, via the De Novo Classication Pathway (Class II). The MIRA Surgical
System is a miniaturized robotic-assisted surgery device indicated for the mobilization of the colon in adults at least 5’0” (1.52m) tall and having a weight of at
least 100 lbs. (45.36kg) who are undergoing minimally invasive colectomy procedures. It is intended to assist in the visualization of tissues and provide accurate
and precise control of surgical instruments to grasp, retract, and dissect while
maintaining hemostasis with electrocautery during manipulation of tissues. It is for
prescription use only and is to be used by trained physicians in any operating room
environment.
Architecture ofPlatform
The MIRA surgical system consists of an integrated Minibot and Camera, an openconcept surgeon console, and a companion cart (see Fig.6.1a-c). MIRA is designed
to be used with the GelPort® Laparoscopic System made by Applied Medical. The
single insertion port is the same device used in hand-assisted laparoscopic surgery
(HALS). The Minibot and Camera are inserted into the patient’s abdominal cavity
through the insertion port and are remotely controlled via the surgeon console
located outside the sterile eld. The surgeon console includes a main display showing the real-time video feed from the camera, hand input devices, pedal inputs, and
an interactive touchscreen. The system is designed to be operated by a minimum of
one surgeon and one surgical assistant.
The rst-generation system has sterile, single-use bipolar graspers and monopolar scissors instruments. Additional instruments (e.g., needle driver, monopolar
hook, vessel sealer) are currently under development.
bc
6 Virtual Incision: MIRA Surgical System
a
65
Fig. 6.1 The MIRA surgical system. (a) The surgical Minibot and articulating camera, (b) The
surgeon console, (c) The patient cart
Additional Technical Information
The technical differentiator to mainframe robotics is that the motorized robotic
arms triangulate inside the patient’s abdominal cavity as opposed to externally.
Because the instruments triangulate internally, there are no constraints imposed by
trocar port placement, which is inherent to the mainframe robotic approach. The
MIRA Surgical System has two motorized arms that have six degrees of freedom
(Fig. 6.2). Its cross-sectional workspace is 6.7 inches (170 mm) wide and
3.125inches (80mm) deep. This cross section is swept approximately 180° about
the shoulder pitch joint (Fig.6.3). The mRASD functions equally over any sweep
angle from +90° to −90°, while the articulating camera ensures that the instruments
can be in view at all times. Repositioning can be easily performed by adjusting the
support arm. This ability to change MIRA’s overall position, combined with the
reach and dexterity of the arms enable surgery throughout the abdominal cavity.
66
Fig. 6.2 The mRASD
arms have six degrees of
freedom, including the
open/close function of the
tool. The shoulder joint can
yaw (θ1), pitch (θ2), and
roll (θ3) about the upper
arm segment. These rst
three axes of rotation
approximately intersect at
the shoulder joint. The
mRASD elbow allows
rotation (θ4) of the forearm
with respect to the upper
arm. Finally, the
instrument can roll (θ5)
about the long axis of the
instrument with
instruments having an
open/close actuation
capability
D. Oleynikov and S. Farritor
Fig. 6.3 MIRA’s reachable workspace: the cross section is swept approximately 180° about the
shoulder pitch joint. The workspace cross section is approximately 6.7inches (170mm) wide and
3.125inches (80mm) deep. The mRASD functions equally over any sweep angle from +90° to
−90°. The camera can sweep between +70° to −70°
Clinical Data
The MIRA Surgical System was studied in a prospective, Investigational Device
Exemption (IDE) clinical study in three centers in the United States. Based on the
patient demographics and clinical characteristics, the study population was found
to be representative of the US population for patients undergoing colectomy. The
6 Virtual Incision: MIRA Surgical System
67
indications for surgery were cancer (40.0%), polyp(s) (40.0%), diverticulitis
(16.7%), and cecal mass (3.3%). Seventy percent of patients were overweight or
obese, and 53.3% had prior abdominal surgery. Sixty percent had mild systemic
disease (ASA II), and 40% had severe systemic disease (ASA III). The cases performed were 15 (50.0%) right colectomy and 15 (50.0%) left colectomy. The overall mean operating time was 163 (SD 56.5) minutes, with an average console time
of 77min. For right colectomy, it was 147min (range, 80–228), while for left it
was 179min (range, 112–309). One assist port (in addition to the hand-assist gelport) was placed in 63% of patients, and two were used in 37%. The device was
manually repositioned a mean six times. Anastomoses were performed extracorporeally in all colectomies. Setup time of the robot was determined to be 5.6min,
median 5min (range, 1–20min). All cases had the primary dissection successfully
completed and hemostasis achieved with the device. No patients required intraoperative conversion to open surgery. There were no intraoperative adverse events or
surgical complications. On pathology, all malignant cases had a complete resection
with negative margins and adequate lymph node sampling (median, 26; range,
17–64). Mean intraoperative blood loss was 55.8cc, and one patient received a
postoperative transfusion during management of an anastomotic leak.
The median length of stay was 2 days (range, 2–26). There was one unplanned
reoperation (3.3%). There were no readmissions. There were no device-related complications and no mortality. According to the Clavien–Dindo classication, 15 surgical complications were observed in nine patients (Gr I: 6; Gr II: 5; Gr IIIa: 2; Gr IIIb:
1; Gr IVb: 1). All major/Clavien–Dindo grade III and greater complications occurred
in a single patient. This patient, with severe comorbidities, operated for a stage II
sigmoid adenocarcinoma, had an anastomotic leak that required reoperation with a
diverting ileostomy. (Figure6.4 shows an intraoperative view of a colectomy case.)
Telesurgery
Rural and remote populations do not have access to high-quality surgical care, including
critical access hospitals, requiring patients to either travel long distances. Remote surgery allows for experts to use the latest robotic technology to assist patients and healthcare providers. Virtual Incision partnered with Savato (CA, USA) telesurgical presence
system to perform experimental remote surgery at a distance of 5 miles. The Connectivity
System provides highly reliable, low-latency, broad bandwidth connectivity using a
Fig. 6.4 Intraoperative
view during left colectomy,
dissection of left ureter
68
D. Oleynikov and S. Farritor
dedicated, private network that includes monitoring and immediately available backup
networks. The A/V system provides high-quality telepresence that enables clear verbal
communication between and among all caregivers and provides multiple video images
of the patient and remote operating room for the surgeon who is not in the room. Multiple
wet lab procedures across a distance of 5 miles using either public Internet or a dedicated network conrmed reliable connectivity with acceptable latency that enabled
completion of hysterectomy, colectomy, and cholecystectomy in a porcine model. The
surgeon and remote care team could verbally communicate naturally and effectively.
The Sovato App enabled the implementation of the surgical time-out and the preoperative checklists, as well as providing other safety measures. The surgeon and remote care
team maintained effective and comfortable verbal and visual communication throughout the setup and completion of the procedures. Remote surgery is safe and feasible, and
future use in clinical trials is likely next steps.
MIRA inSpace
The MIRA Surgical System is designed to be used in an operating room and to be
quickly and easily moved from room to room. The compactness and ease of use
of the miniaturized RAS might enable the device to be considered an ideal candidate for remote telesurgery in the future (e.g., for rural areas and military battleelds). Exploring the use of miniaturized RAS in extreme environments helps
understand how to remove barriers for patients. An experiment to further validate
the proof of concept regarding remote telesurgery was funded by a grant awarded
from the National Aeronautics and Space Administration (NASA) to the University
of Nebraska through the Established Program to Competitive Research (EPSCoR)
program. In January 2024, space-MIRA (a shortened version of MIRA Surgical
System) was sent to the International Space Station aboard a Northrop Grumman
Cygnus cargo spacecraft carried by a SpaceX Falcon 9 rocket. Testing with spaceMIRA on the International Space Station assessed the impact of zero gravity
when performing simulated surgical tasks. Six surgeons successfully operated
from Virtual Incision’s headquarters, utilizing remote-controlled technology to
direct the movements of the robot on simulated tissue (Fig.6.5).
Fig. 6.5 Space-MIRA
being shown aboard the
International Space Station
by astronaut Loral O’Hara
(February 2024)
Starting andDeveloping aRobotic
Program
C.Franco-Mesa andSarahSamreen
Purpose
The advantages of minimally invasive surgery (MIS) have been known since the early
twentieth century [1]. Nonetheless, the incursion of robotics drastically changed the
surgical eld. Unlike other MIS tools, these consoles provide countless benets,
including an increase in accuracy, three-dimensional image with depth perception,
fully articulated instruments, and improved ergonomics. As a result, surgeons can complete meticulous surgical procedures in unfavorable anatomic locations where open or
laparoscopic approaches are unable to be performed or associated with a myriad of
complications that outweigh the benets. While postoperative outcomes with robotic
consoles remain comparable to those with other techniques, there is a rising trend in the
literature that describes shorter hospital stays, decreased complication rates, and better
quality of recovery associated with the use of robotic surgery (RS) [2, 3].
RS is a rapidly growing eld in the United States that will continue to expand as
training programs incorporate innovative techniques into education curriculums [4].
In the pursuit of providing outstanding patient care, surgeons expand their skill sets
to deliver the tools that best t their patient’s needs. Thus, learning additional surgical techniques provides a wider range of options to deliver care. RS has also been
known to complement different areas of surgery. For instance, in the setting of acute
care surgery (ACS), RS continues to gain favor in cases of cholecystectomy with
intraoperative cholangiogram and common biliary duct exploration [5]. In this scenario, patients undergo a one-stage procedure compared to the more common
7
C. Franco-Mesa · S. Samreen (*)
Division of General Surgery, University of Texas Medical Branch, Galveston, TX, USA
e-mail: sasamree@utmb.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_7
69
70
C. Franco-Mesa and Sarah Samreen
two- stage with endoscopic retrograde cholangiopancreatography. RS is part of the
modernization of medicine and will widely spread to complement the general surgeon’s armamentarium.
Identifying theLandscape
Before diving into developing a robotic program, it is crucial to understand the current setting and surroundings where such a program will emerge. Factors such as the
type of hospital system, number of beds, operating rooms available, and functioning
robotic systems will inuence the type of program built. The most known FDAapproved system in the United States is the da Vinci Surgical System from Intuitive
Surgical [6]. While this may change in the future as different robots are released, it
is relevant to identify the strengths and weaknesses that can be encountered in all
aspects of project development (logistics, infrastructure, personnel, funding, etc.).
Once the starting baseline is recognized, coherent program goals can be established.
Pillars forStarting andDeveloping aRobotic Surgery Program
Three overlapping phases constitute the tract toward building an RS program
(Fig.7.1). The “adopting” stage encompasses all related to the initial engagement of
leadership, basic training, and support. Followed by the “operationalizing” phase,
where the learning curve takes place, complexity is escalated, cultural change is
promoted, and data collection begins. Finally, during the “standardizing” period,
optimization is the priority from both the procedural standpoint and the economic
perspective. Other topics such as scheduling priorities, goals, and established teaching curriculums are also approached in the Standardizing phase.
Adopting
The rst step of the journey is to identify a leader who is knowledgeable in the eld
(Fig.7.2). This “surgeon champion” should have experience with robotic systems
and, more importantly, the initiative and desire to participate in the development of
the RS program. The leader’s goal is to establish a vision of the future of the program and share that vision with other teammates. Furthermore, they are responsible
for delivering the knowledge and methods required to manufacture said vision [7].
Adopting Operationalizing Standardizing
Fig. 7.1 Pillars of building a robotic surgery program