New era of robotic surgery: first case in Spain of right hemicolectomy on Hugo RAS surgical platform
- Riccardo Caruso ,
- Emilio Vicente ,
- Yolanda Quijano and
- Valentina Ferri
- HM Sanchinarro University Hospital, Madrid, Maryland, Spain
- Correspondence to Dr Riccardo Caruso; ricaruso2@gmail.com
Abstract
We describe the first robot-assisted right hemicolectomy performed in Spain using the new Hugo RAS (robotic-assisted surgery) (Medtronic, Minneapolis, Minnesota, USA). No conversion was registered, and no intraoperative complications or technical failures of the system were recorded. The operative time was 200 min, the docking time was 5 min and the length of the hospital stay was 8 days. We conclude that a right hemicolectomy using the Hugo RAS system is safe and feasible. Our earlier experience provides important skills for those who are starting to use this new robotic system.
Background
In the last few years, the use of robotic systems for surgical procedures has increased markedly around the world. Robotic surgery is going through a significant transition as new robotic platforms are entering the market. The Hugo RAS (robotic-assisted surgery) system is the most recently introduced system and our hospital was the first in Spain to make it available. Our early experience provides a description of the new Hugo RAS system showing the docking settings for general surgical procedures (figures 1 and 2). The most important difference compared with other robotic systems is the open design of the surgical console and the modular system which uses four arms.
Port placement.
Docking configuration.
Case presentation
We introduce the case of a patient (body mass index 20 kg/m2), without previous medical history, who came to our outpatient clinic with digestive bleeding lasting approximately 2 months. After a colonoscopy study, he was diagnosed with right colon cancer. He denied allergies and previous surgical operations. A complete preoperative study was performed including a CT scan, PET-CT and blood analysis with tumour markers. The study confirmed the presence of right-sided colon cancer without lymph node involvement or metastases.
Treatment
The procedure began with the identification and ligation of the ileocolic vessels at their origins. We then dissected the right mesocolon along the Toldt’s line and completed the hepatic colic angle mobilisation. We completed the procedure realising an intra-abdominal mechanical ileocolic anastomosis and closed the enterotomy with a V-lock suture. The complete procedure is shown in the attached video.
Outcome and follow-up
No postoperative complications were registered. The operation time was 200 min without intraoperative blood transfusion. A liquid diet was restored on the first day postsurgery, and the postoperative hospital stay was 8 days. The patient returned to the outpatient’s department 15 days after surgery and maintains a regular follow-up programme.
Discussion
In the last year more robot-assisted right colectomy (RAC) has been described highlighting the advantages of the robotic approach due to a three-dimensional and magnified image with a stable camera, the eldest dexterity of instruments and the possibility for the surgeon to independently control the camera.1–8 These advantages improve postoperative outcomes, but the cost still remains a controversial issue that may restrict its application.9 In the previous years several studies have been published comparing RAC with the laparoscopic approach (LA) performing a cost-effectiveness analysis.3 10 The results from the experience published in the literature showed that the robotic approach for the RAC is a feasible and safe procedure compared with LA.9 Furthermore these studies concluded that RAC is well accepted in terms of cost-effectiveness in a healthcare panorama.10 The new era of robotic surgery with Hugo RAS system is becoming a big revolution in the world of the minimally invasive surgery.11 The main differences with the Da Vinci system compared with the latest robotic platforms are the independent robotic arms and open console design.2 Although the modular nature of Hugo RAS system adds important benefits, these do not always correspond to efficiency in the operation theatre. At the beginning, the biggest difficulty with this new system is the docking time. Indeed the docking with HUGO requires to do a docking for each independent arm. This is the real challenge in the first part of the learning curve. However, this process should become more straightforward in line with the learning curve for such systems.9 During the last procedures Hugo RAS appears to offer more flexibility compared with other systems.12 13 We believe that the open console of the HUGO system can help improve the learning curve compared with closed console. The open sitting provides an excellent ergonomics to the surgeon at the console. The possibility to sit and see the screen using 3D glasses provides the surgeon to feel comfortable and with a freedom of movement. Moreover the open console allows team communication and at the same time multiple observers using 3D vision. We believe that this feature can help the proctor’s function.14 HUGO RAS allows different movements between the abdominal quadrants. The system allows independent movement of individual arms to change the view of the surgical field. In the video we present, the high image quality provided by Hugo screen HD-3D display allows clear identification of the various anatomical planes. In the video we present, the surgical time was 200 min, including the docking time. The new concept of HUGO RAS requires adjustments in the operating room in order to obtain the best management of available space. The console and the system tower should be positioned in the corner and at the foot of the operating table, respectively. The presence of these new elements requires a change in the positioning of the instrument table, the nurse, the anaesthesiologist and the bedside assistant. In the modular design of this system, the arm location and the trocar placement are fundamental steps. They require getting the best robotic setup in order to avoid external collisions or movement restrictions.5 To better understand the system and its greatest features, it is critical to attend the preliminary technical training with a focus on a description of the basic device and docking setup.15 16 In our preliminary use of HUGO RAS, we have experienced the limitations of this robotic system. Currently the biggest limitation is certainly the lack of advanced coagulation systems. Nowadays we have the possibility to use only a bipolar Maryland dissector and monopolar scissors as coagulation energy. In these first procedures, we use an auxiliary laparoscopic troc for using devices, such as electrothermal bipolar-activated devices (LigaSure (LS)) or ultrasonic systems (Harmonic scalpel (HS).
Learning points
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Robotic surgery is the new era of minimally invasive surgery.
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Modular design of HUGO RAS is a good innovation for the docking step.
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The open console improves ergonomics and communication within the operating room.
Ethics statements
Patient consent for publication
Footnotes
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Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms and critical revision for important intellectual content: Dr VF and Dr RC wrote the draft, Dr YQ and EV edited the video and figures. The following authors gave final approval of the manuscript: Dr YQ and EV.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.
References
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