Feasibility of Image Inversion for Ventral Hernia Repair Using the Versius System

Introduction

Ventral hernia repair (VHR) is one of the most common surgical procedures in the United States annually with increasing frequency. ¹ Minimally invasive surgical techniques, such as robotic-assisted surgery, have led to a revolution in abdominal wall reconstruction. Minimally invasive hernia repair has advantages when compared with open approach such as lower surgical site infection, less postoperative pain, shorter length of stay, and earlier return to work. ²

Robotic-assisted abdominal wall repair is growing at an exponential rate. ³ The robotic platform offers considerable advantages over the laparoscopic approach. Articulating instruments and 3-D view of the surgical field offer better dexterity, more precision, and improved ergonomics. ⁴ These benefits enable surgeons to execute complex procedures such as intra-corporeal fascial closure, intraperitoneal suturing, finer myofascial release, and extraperitoneal repair using mesh. ⁵ There are a number of new robotic systems entering the market. The Versius^® system from CMR Surgical (CMR Surgical, 1. Evolution Business Park, Cambridge, UK) consists of bedside units for each instrument and a console. ⁶

The image inversion technique is an interesting resource used in the fascial closure in hernia repairs done by the Da Vinci robotic system. ⁷ In this technique, the surgeon is able to perform a conventional suture instead of a more challenging backhand movement. The aim of our technical report is to demonstrate the image inversion technique on the new Versius Robotic System.

Methods

We report a step-by-step surgical maneuver for robotic surgeons when performing robotic VHR with the Versius Robotic System.

Technical Report

The technique involves using a four arms standard Versius Robotic System (CMR Surgical System). This procedure can be performed independent of the docking setup or the surgical approach. In the Versius Robotic System, the process is performed by the surgeon on the console, while in the Da Vinci system, the surgeon needs to do a manual inversion of the camera, change the configurations of the robot, and change the instruments in the arms of the robot.

Port placement included a robotic 30° scope and standard 5 mm robotic instruments. The image inversion artifice (INV) consists in rotating 180° with the scope using the surgeon's master control in a specific rotation command in the right-hand joystick. It is important to highlight that the camera should be in the Up mode, but its configuration should be Looking down (Fig. 1A, B).

OPEN IN VIEWER

FIG. 1.

(A) Normal imaging with backhand suturing in the ceiling. (B) Image inversion with forehand suturing.

The joysticks have specific functions. The right joystick controls zoom in and out, rotation to right and left, while the left joystick pans the image up, down, left, and right without changing the vision angle (Fig. 2). The assisting surgeon can do a manual inversion of the camera without the console being aware that the scope is inverted. In this scenario, the 30° Up configuration should be used while informing the console that the scope is looking down.

OPEN IN VIEWER

FIG. 2.

Right Master Control with the joystick allows a 180° rotation using the thumbstick. To select the instrument, the user presses the clutch button from the joystick, selects the instrument with thumbstick, and presses clutch again.

The surgeon is able to choose which instrument will be controlled by each joystick. When the scope rotates and the image becomes inverted, the instrument that was set to the right joystick will be on the left side of the screen. By clutching the joystick, one can reassign an instrument for that joystick. The same sequence is then performed to reassign the instrument to the corresponding joystick. This results in the right joystick controlling the left instrument and left control controlling the right instrument. Since the image is inverted, the movements will look natural on the surgeon console (Fig. 1B).

Discussion

This technical report is the first to describe the use of image inversion with the new Versius Robotic system. This technique, also named INV, was initially described for the Da Vinci Xi robotic system. ⁷ Using this technique, the ceiling of the surgical field is transformed into the floor, and the surgeon can easily perform a forehand suture instead of the more challenging backhand suture. The key difference between the two robotic systems is that in the Versius system, the surgeon can set up the image inversion from the console, obliviating the need for bedside assistance.

Laparoscopic VHR led to decreased wound morbidity but failed in providing optimal fascial defect closure and tissue approximation. ⁸ The proper closure of the herniary defect is of extreme importance to avoid early recurrence in patients that underwent laparoscopic VHR. ⁹ With the advancement of robotic platforms, surgeons were able to close the defect properly and to fixate the mesh with suture instead of tacks.

Robotic surgery is growing exponentially, and there are new robotic systems being developed. The Versius system from CMR Surgical (CMR Surgical) consists of bedside units for each instrument and a console. ⁶ A recent systematic review showed that there are 17 studies with 328 patients that were operated using the Versius system. ¹⁰ More recently, Soumpasis et al. showed the Versius Surgical Registry, a prospective, multicenter data registry with 2083 patient and good outcomes with different surgical techniques using the Versius system. ¹¹

Regarding abdominal wall reconstruction using the system, Dixon et al. published a case series with 41 patients who underwent transabdominal preperitoneal inguinal hernia repair and intraperitoneal onlay mesh repair for ventral hernias with good results. ⁶ Furthermore, El Dahdah et al. published a case series with four umbilical hernias, two ventral hernias, 11 bilateral inguinal hernias, and 13 unilateral inguinal hernias with good results and no major complications. ¹²

The advantages of the Versius system are the possibility of using a regular size operating room, lower cost of instruments when compared with Da Vinci, and the readiness to use laparoscopic instruments if necessary. The image inversion technique is not mandatory for a proper close of the hernia defect. However, it allows surgeons to more easily perform an intra-corporeal suturing in the ceiling. This can be a useful tool especially for surgeons still in the learning curve for robotic surgery.

Conclusion

The use of the image inversion technique with the Versius Robotic System is an effective tool to help surgeons perform a better intra-corporeal suture: the key step in a proper abdominal wall reconstruction.