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Preclinical Evaluation of the Versius Surgical System, a New Robot-Assisted Surgical Device for use in Minimal Access Renal and Prostate Surgery

Benjamin C. Thomas, Mark Slack, Muddassar Hussain, Neil Barber, Ashish Pradhan, Eoin Dinneen, Grant D. Stewart

SUPPLEMENTARY MATERIALS

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Supplemental Table 1. Surgical steps in end-to-end procedures

Procedure Surgical steps

Transperitoneal radical nephrectomy

Mobilise colon Mobilise duodenum (right-sided case) Identify ureter and retract laterally Identify gonadal vein and inferior vena cava (right

sided case) Skeletonise hilum Ligate and divide renal artery(s) Ligate and divide renal vein(s) Dissect away and spare adrenal gland Mobilise upper pole of the kidney Mobilise entire kidney Ligate and divide ureter +/- gonadal vein Bag and extract specimen

Prostatectomy

Incise the peritoneum lateral to medial and lumbar ligaments from the urachus to internal vein (right side)

Drop the bladder (reaching further into pelvis) going into pubic arch

Clean endopelvic fascia and remove fat from bladder

Incise puboprostatic ligaments and open endopelvic fascia

Ligate dorsal venous complex

Incise anterior bladder neck and deliver catheter

Incise posterior bladder neck

Mobilise vas and seminal vesicles

Mobilise Denonvilliers fascia to apex

Incise anterior and posterior urethra and deliver catheters

Rocco stitch and urethrovesical anastomosis

Bag and extract specimen

Pelvic lymph node

Cut the vas deferens Reach left pelvic nodes

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dissection

Remove nodes, incise the peritoneum over the iliac vessel to reach lymph node

Incise the endopelvic fascia Dissect lymph nodes Bag and extract specimen

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Supplemental Figure 1. Versius Surgical System Overview

A. Schematic overview of the Versius Surgical System. Adapted from Haig et al. 2019.1 B. Image of the Versius Surgical System

Supplemental Figure 2. Record keeping of bedside unit positions

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Outline of the grid template used to measure BSU location. To ensure reliable and standardised reporting of measurements, a grid of 20 cm x 20 cm squares was laid out on the OR floor such that the overall grid was 320

cm x 320 cm. Pink dot indicates the umbilicus. BSU: bedside unit; OR: operating room

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Supplemental Figure 3. Additional port positions tested in cadaver studies

A. Additional port positions for radical nephrectomy, used in one procedure each unless otherwise specified. B. Additional port positions for prostatectomy, used in one procedure each. C. Additional port positions for pelvic lymph node dissection, used in one procedure each unless stated otherwise

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*Used in two procedures. Umbilicus is where the ML crosses the SUL. ASIS: anterior superior iliac spine; MCL: midclavicular line; ML: midline; SUL: supine-umbilical line

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Supplemental Figure 4. Additional BSU positions tested in cadaver studies

A. BSU positions used for the retroperitoneal radical nephrectomy procedure. B. Additional BSU positions for prostatectomy and pelvic lymph node dissection procedures used in one procedure each

Superimposed rectangle represents the surgical table with measurements detailing the distance between instrument BSUs and the surgical table or other BSUs. Diagrams not drawn to scale. Pink dot indicates the umbilicus. 1st Asst: bedside assistant; Asst: bedside assistant; BSU: bedside unit; Endo: endoscope; Instr: instrument

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REFERENCE

[1] Haig F, Chitty K, Medeiros A, Slack M. Usability Assessment of Versius, a Minimally Invasive Robot-Assisted Surgical Device. In press BMJ Surg Interven Health Technol. 2020.

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