Introduction

Robotic surgery has undergone several iterations of innovation in terms of instrumentation and surgical platform efficiency, with a rapidly and constantly growing utilization rate during the last years in several subspecialties of general surgery [1, 2].

To date, Intuitive Surgical (Sunnyvale, CA, USA) has represented the main and leading actor in the field of robotic surgery. Different systems have been implemented by this vendor and entered into the market over the last decades, with newer, faster and more efficient instrumentations and setups. All these systems were made up by a common core technology, including a surgical console, a vision cart and four robotic arms coming all from a unique boom called patient cart.

Though data on robotic surgery in different surgical fields are constantly increasing with promising results, one of the most frequently reported concern in the literature has been always represented by higher costs. Recently, novel robotic competitors have entered into the market in an effort to potentially reduce costs while improving access to robotic surgery at the same time.

Versius system (CMR Surgical, Cambridge, UK) and Hugo RAS™ system (Medtronic, Minneapolis, MN, USA) share the same core concept technology, namely a modular system characterized by separate arm carts, thus investing in terms of flexibility and adaptability for surgical procedures and operating room placement.

To date, most of the available reports in the literature about their clinical use have focused on gynecological and urological surgical procedures [3,4,5]. To the best of our knowledge, only transperitoneal adrenalectomies (five case series) and inguinal hernia (case report) have been published to date with Hugo RAS™ system in the field of general surgery [6, 7], with no available data in colorectal surgery.

Herein, we describe the first colorectal resections performed with the Hugo RAS™ system at Azienda Socio-Sanitaria Territoriale (ASST) Santi Paolo e Carlo, University of Milan, Italy. We will focus on operating room (OR) setup and trocar placement for right and left colectomy, alongside with technical feasibility and possible issues.

Materials and methods

All surgical team members had completed the official technical training on Hugo RAS™ technology delivered by the company and available at the time, and had long-lasting experience in the field of robotic surgery with da Vinci surgical platform (Intuitive Surgical, Sunnyvale, CA, USA).

Simulation training was performed by the surgical team in October 2022. Formal training was then completed by two console surgeons, one bedside assistant surgeon and three scrub nurses on human cadaver lab at the ORSI Academy in Ghent, Belgium, in November 2022. The robot was installed in a dedicated OR and dry-run sessions were then completed for both right and left colectomy before tacking clinical cases. All procedures were performed by one surgical team, that was composed by high-volume surgeons with long-lasting experience in both robotic surgery and colorectal surgery.

OR setup and trocar layout for right colectomy

The patient is placed on the operating room table in supine position, with arms tucked and legs closed. After induction of pneumoperitoneum using a Veress needle at the Palmer’s point, a 12 mm trocar for the assistant is inserted in the left flank, about 10–12 cm above the left iliac spine; 12 mm optical port is placed along the midclavicular line, in the left pararectal area in the left iliac fossa 6–8 cm away from the midline.

Three 8 mm trocars are placed in the left hypochondrium along the midclavicular line (right hand, monopolar scissors), in the suprapubic area few cm away from the midline (left hand, Maryland bipolar forceps), and in the right iliac fossa (at least 2–3 cm away from the right anterior superior iliac spine, reserve arm, cadiere forceps), respectively. Trocar layout for right colectomy is shown in Fig. 1. The table is placed in a Trendelenburg position with a slight angle (5–10°) and left tilt (5–10°). The four-arm carts are disposed as shown in Fig. 2. Docking and tilt angles for setup are shown in Table 1. After final table position has been reached and before docking robotic arms, care must be taken in checking the lowest trocar (as far as height from the floor is concerned) that should be at least at the level of 70% (or higher) of the numeric scale that is depicted on each cart in percentage (Fig. 3).

Fig. 1
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Trocar layout for robotic right colectomy

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Fig. 2
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OR setup for robotic right colectomy

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Table 1 Docking and tilt angles settings for robotic right colectomy
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Fig. 3
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Numeric scale depicted on each cart in percentage

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OR setup and trocar layout for left colectomy

The patient is placed on the operating room table supine in a modified lithotomic position with arms alongside the body and legs in adjustable stirrups. The patient is carefully secured with a dedicated soft foam pad to prevent sliding in Trendelemburg position. After induction of pneumoperitoneum using a Veress needle at the Palmer’s point, a 12 mm trocar for the assistant is inserted in the right flank, about 10–12 cm above the left iliac spine; a 12 mm optical port is placed in the right pararectal area, about 5–6 cm away from the midline. Three 8 mm trocars are placed in the epigastric area (right paramedian, about 3-4 cm away from the midline), along the left midclavicular line in the left iliac fossa and in the right iliac fossa (both at least 2–3 cm away from the anterior superior iliac spine bilaterally), respectively. The table is placed in a Trendelenburg position (10–15°) and right tilt (10–15°). Trocar layout is shown in Fig. 4. The four-arm carts are disposed as shown in Fig. 5. Docking and tilt angles for splenic flexure takedown and vascular control/rectal transection are shown in Table 2a, b, respectively. The procedure is full-robotic single-docking, but instruments in arm 3 and 4 will be swapped during vascular control and rectal transection.

Fig. 4
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Trocar layout for robotic left colectomy

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Fig. 5
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OR setup for robotic left colectomy

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Table 2 Docking and tilt angles settings for left colectomy
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Results

To date, 3 procedures have been performed (1 left colectomy and 2 right colectomies with CME and HVL for colorectal cancer). All the surgical steps were completed without critical surgical errors or intraoperative complications. There were no system failures. All procedures were completed without conversion to open surgery. Mean docking time was 8 min. Console times were 260, 255 and 264 min, respectively. Few low-priority alarms occurred during the procedures because of external clashing, allowing for fast resuming of the surgical steps and without interfering with total operative time. Adjustment on fulcrum of the trocar and little modifications in docking and tilt angles had to be made on arm 1 (Maryland bipolar) in order to avoid external conflicts in one case (right colectomy, BMI 16), in which a 30° down scope was used instead of 0° scope (docking angle 138° instead of 120°, tilt angle + 15° instead of + 30). Docking angle modifications were required because of external clashing between arm 1 and 3 (scope), tilt angle was modified in order to avoid collision with operative room table. A distance of at least 8 cm has been ensured in between each robotic trocar. Postoperative courses were uneventful with a mean length of stay of 5 days. Intraoperative, postoperative and pathological outcomes are shown in Table 3.

Table 3 Intra, postoperative and pathological outcomes
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Discussion

Robotic surgery diffusion is constantly increasing worldwide in several surgical specialties [1, 2]. Though data on robotic surgery increased over the last years, the absence of sound and strong evidence in favor of robotic surgery has not prevented diffusion and implementation of robotic surgical programs. Moreover, different systems have recently entered into the market, thus confirming the interest in robotic surgery for further diffusion of robotics and the formation of a competitive environment.

However, to date, poor data are available in the literature about clinical use and outcomes of the newborn surgical robots, mostly consisting of case reports and case series of low sample size. Gynecological, urological and general surgery procedures have been performed with Versius robotic surgical platform [8, 9]. Data on Hugo RAS™ are mostly limited to gynecological and urological procedures, and only adrenalectomies (5 case series) and inguinal hernia (case report) have been published to date as far as general surgery is concerned [6, 7]. To the best of our knowledge, this is the first report on robotic right and left colectomy with Hugo RAS™ surgical system. In this study, we described our preliminary experience and the surgical technique for robotic right and left colectomy.

Hugo RAS™ has been recently introduced at our Department and it is currently used in the setting of a multidisciplinary program (general surgery, urology, gynecology) of a high-volume robotic center (two daVinci Xi surgical systems and a CMR Versius system are also available). Dedicated and specific surgical training programs have been introduced by different vendors to provide specific competences required to perform surgical procedures in terms of OR setup, trocar placement and console training. Onsite simulation training, cadaver lab at ORSI Academy (Ghent, Belgium) and onsite dry-run sessions were completed before tackling clinical cases. Colectomies were performed since the beginning of the experience with HugoRAS system because of long-lasting experience in both robotic surgery (approximately 2000 procedures) and colorectal surgery of the console surgeon (PPB), in the setting of high-volume robotic center and availability of dedicated surgical team (bedside assistant and scrub nurses). Intraoperative, short-term postoperative and pathological outcomes were favorable, and neither conversions nor postoperative complications were recorded. Operative times, when compared to other platforms, are longer and related to the initial experience and are expected to decrease over time. Raffaelli et al. reported, on the other hand, comparable operative of Hugo RAS™ versus Davinci adrenalectomies in term of console and overall operative time, and this is probably related to less complex single quadrant surgery. Docking time, ranging in our experience from 6 to 10 min, is comparable to the figures reported in the literature [6, 10].

One of the theoretical advantage of the Hugo RAS™ platform is the flexibility in terms of setup and the possibility to use only three arms according to the surgical procedure or to perform just predefined step with a hybrid laparoscopic/robotic approach. Though we are conceptually in favor of full-robotic procedures to maximize the benefit of the platform and the procedures performed to date were full-robotic, these technical features must be taken into account. Moreover, though cost analysis and cost-effectiveness are outside the scope of this study, the proposal of different charging models as “procedural kits” and competition in the market may potentially reduce costs of robotic-assisted surgery in the near future. Implementation of the available instrumentation is needed in terms of advanced energy devices, staplers and integrated fluorescence imaging systems, together with refinements in robotic arm shape and length to reduce external conflicts among different arms and with the bedside assistant.

Further experience and clinical data are needed to standardize robotic right and left colectomy with Hugo RAS™ surgical platform. Refinements and adjustments about port placement, docking and tilt angles will be probably required with increasing clinical experience and ongoing practice (especially for multiquadrant procedures such as colorectal resections and different patients’ body habitus) with the platform in order to facilitate diffusion and integration of the system into robotic general surgery and colorectal programs.