Implementing the robotic platform Hugo™ RAS system for colorectal surgery seems feasible and safe, with adequate oncological and postoperative results for all patients in our group, who had extensive laparoscopic experience but were naive to robotic surgery.

To our knowledge, this is the longest published series of colorectal resections with the Hugo™ RAS system. Our coloproctology unit is accredited by the Spanish Association of Coloproctology (AECP) as an advanced unit in Spain that achieves quality standards in colorectal surgery [13]. Among them, the outcome standards for patients with colorectal cancer (surgical site infection < 12.5%; anastomotic leakage < 5%; mortality < 7%; readmission < 5%; reintervention < 6%; stay < 6 days) continue to be met in our series of procedures with this robotic platform. Therefore, our study confirms the good initial results of very few cases, [8, 14,15,16,17] who reported that the Hugo™ RAS system is safe and feasible for colorectal procedures.

To date, only two long series of cases in which major colorectal surgery were performed safely and effectively with Hugo RAS have been published. The first study by Romero et al. [9], with ten cases—five right colectomies, three sigmoid resections, one high rectal resection and one ventral mesh rectopexy—reported no cases of anastomotic dehiscence or conversion to laparoscopy, with a hospital stay of 3 days. The second study by Belyaev et al. [18] included 31 cases—11 sigmoid, nine rectal, eight right, one left cancers, and two Hartmann’s reversal—reported two conversions due to adhesions: one anastomosis leak, one paralytic ileus, two presacral hematomas, and one medical complication with a hospital stay of 8 days.

Studies on urogynecological procedures performed with this platform have also demonstrated its safety and effectiveness [3,4,5,6,7]. In fact, in robotic prostatectomy and nephrectomy, where there is greater experience with Hugo™ RAS than with colorectal surgery, comparisons with the Da Vinci system have yielded comparable results [19, 20].

The Hugo RAS robotic platform consists of four interchangeable modular arms and an open console, which are the main differentiating characteristics from the Da Vinci platform. The first great advantage of this robotic platform is the modularity of the different arms of the system, which allows configurations or setups that can be slightly adjusted depending on the patient's body features and the surgeon’s individual preferences [9, 14], just as it performs in laparoscopic surgery. This greater versatility compared with unimodular robotic platforms is especially relevant in surgeries of different quadrant areas since it allows a greater range of mobility and access to multiple quadrants without the need to insert new trocars or change the configuration. In our series, in only two patients due to the descent of the splenic flexure, we had to change the patient’s position (anti-Trendelenburg) by undocking and modifying the tilt and angles of the arms in a comfortable and fast way without moving the position of the arm carts. A right colectomy can be performed without modifying the initial patient’s configuration and position. It is really exciting and we were surprised from the first right colectomy by the ease of being able to approach the transverse colon and lymphadenectomy without having to change either the patient’s position (from Trendelenburg to anti-Trendelenburg) or the configuration of the arms. Without a doubt, a correct setup based on the patient’s characteristics and the different anatomical areas in which we will perform the surgery is essential. In the case of extended right colectomies, we recommend lateralizing the trocars to the left, somewhat further from the midline for access to the transverse colon. The modularity of the robot allows us to play with these aspects.

In contrast, owing to the need to bring four carts closer to the surgery table, even the initial docking times described with this platform are relatively quick—7 min in our experience, 14 min [9], 12 min [18], 5 min [14], and 8 min [8]—and easy to perform, which, together with the mobility of each robotic arm throughout the operating room, allows a change back to robotic surgery after laparoscopic surgery and vice versa without problems, such as emergent bleeding or some steps of difficult cases.

Even its multimodular feature grants it certain adaptability in operating rooms whose configuration is not recommended for installing unimodular robotic platforms owing to size and weight restrictions. In our hospital, a previous weight-bearing study indicated that the Da Vinci robotic platform could not be installed without floor reinforcement and that some hospitals could have problems due to insufficient height of the operating rooms. However, the Hugo™ RAS platform could be installed given the weight/m2 distributions of the different modular components of the robot. Furthermore, modularity allows for quick, safe, and easy transport of components within the operating room and even mobility between different operating rooms.

However, the separated placement of the four arms carts around the operating table takes up a lot of space and cause more spatial constraints in operating rooms than the Da Vinci platform. This fact limits the correct positioning of the assisting surgeon, which is especially relevant at this time in the absence of stapling devices and energy instruments integrated into the Hugo platform.

For the open console display system, the second major difference to the Da Vinci robotic platform is that vision is achieved through a 3D glasses system with eye tracking, providing a security blocking system. The vision is magnified by 10 × , which offers, in our opinion, the fact that we were users of 3D laparoscopic towers with the same Stroz system, a surprisingly better and spectacular vision compared with this system, which produces a truly immersive vision of the surgical field. Compared with closed immersive platforms, the open console significantly improved communication between the surgeon and the operating room team. This direct flow of communication potentially impacts complex intraoperative situations. The open console offers quick visualization of the patient’s position with the robotic arms during the procedure, which is vitally important during the learning curve and in cases with multiquadrant access. On the other hand, one of the most important aspects of a university hospital such as ours is that the open console facilitates the teaching system since it does not require an additional console to visualize the surgical field and movements, thus improving training and teaching during the same procedure. In addition, the open system is very comfortable and ergonomic for the surgeon since it enables a sitting position in a chair with a backrest and the possibility of more natural body movement. Improved ergonomics and comfort could mitigate occupational injuries and extend the longevity of surgeons’ careers [21, 22].

The Hugo™ RAS system incorporates the Touch Surgery™ DS1 Video solution, the first smart surgical video recorder on the market [18]. Equipped with real-time artificial intelligence (AI), the device can capture, anonymize, and upload sensitive surgical footage automatically to the cloud. This enables surgeons to monitor and review their performance and share footage securely with others in their field, supporting surgeon learning and improving patient outcomes. In addition, DS1 can incorporate an accessory module with an additional external camera for real-time streaming of OR, surgeon, and surgical videos to external users through their phones or tablets and personal computers with two-way interaction. This tool represents a milestone for the remote proctorization of users, teaching and training tasks, and the live broadcast of surgeries at events.

Although the Hugo™ RAS system is fully operational, it is under continuous development and integration into new surgical procedures. In terms of instrumentation, advanced bipolar energy systems such as LigaSure™□ or robotic Tri-Staple™□ and the integration of indocyanine green will soon be available for this platform. Hybrid surgery is necessary through an accessory port used by the assistant surgeon.

In conclusion, Hugo™ RAS is a valuable addition to robotic surgery, addressing Da Vinci robotic platform limitations with its open console, enhanced optics, and tetrameric structure. The new modular platforms are anticipated to provide increased versatility, eliminating the need for adapted operating rooms and allowing flexible placement of robotic arms around the patient. Incorporating open consoles and polarized glasses enhances the sense of freedom and ergonomics. However, it remains to be proven whether the advantages historically associated with the da Vinci system over conventional laparoscopic approaches persist when these emerging platforms are utilized. Further research is needed to validate and compare the performance of this new system in various surgical scenarios.