First reported robotic pancreaticoduodenectomy using the Hugo™ RAS system: feasibility and safety

First reported robotic pancreaticoduodenectomy using the Hugo™ RAS system: feasibility and safety | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report First reported robotic pancreaticoduodenectomy using the Hugo™ RAS system: feasibility and safety Isabel Mesquita, Teresa Correia, Mario Marcos, Jorge Santos, Paulo Soares This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7553174/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Pancreaticoduodenectomy (Whipple procedure) is among the most demanding operations in HPB surgery. Early diagnosis and meticulous perioperative optimization, combined with recent technical advances, especially robotic platforms, are key contributors to improved postoperative outcomes. Robotic pancreaticoduodenectomy (RPD) may enhance dexterity and ergonomics in complex HPB procedures. The Hugo™ Robotic-Assisted Surgery (RAS) system has recently entered clinical practice, yet RPD on this platform has not been reported. Methods: We describe a single-center, first reported case of RPD using the Hugo™ RAS system. Preoperative evaluation, OR layout, port mapping, arm configuration, instruments, docking strategy, and stepwise operative workflow are detailed. Primary endpoints were technical feasibility and intra/perioperative safety. Secondary endpoints included operative time, estimated blood loss (EBL), conversion, 30-day complications (Clavien–Dindo), length of stay, and pathology concerning oncological principles. Results: The procedure was completed robotically without conversion. Docking time was 4 min 35 s and console time 5 hours 14 min, EBL 200 mL. No high-priority system alarms or device-related adverse events occurred. Final pathology showed pT1 Duodenal Gastro-Intestinal Stroma Tumour (GIST), tumor size 1,8*1,4*1,4 cm, R0 resection, and 10 lymph nodes retrieved. Postoperative course was notable. Hospital discharge on postoperative day 7 with no postoperative pancreatic fistula (ISGPS), no delayed gastric emptying (ISGPS), and no readmission within 30 days. Conclusion: RPD using the Hugo™ RAS system was feasible and safe in this first reported case, with a reproducible setup and workflow. These findings support further prospective evaluation and standardization of RPD on this platform. Robotic pancreaticoduodenectomy Whipple Hugo RAS feasibility safety HPB surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Pancreaticoduodenectomy (PD) remains one of the most technically demanding abdominal procedures. Despite advances in perioperative care and system‐level centralization, contemporary series still report substantial major morbidity and non-trivial mortality; for example, in a nationwide very-high-risk (ISGPS-D) cohort, in-hospital mortality reached 4.1% with 45.9% major complications, and clinically relevant postoperative pancreatic fistula (POPF) is the principal driver of adverse outcomes [1,3]. Accordingly, best practice emphasizes comprehensive preoperative optimization, standardized Enhanced Recovery After Surgery (ERAS) pathways, and delivery in high-volume centers, while leveraging enabling technologies (e.g., minimally invasive/robotic approaches and intraoperative adjuncts) to improve precision, recovery and failure to rescue [2,4]. In gastrointestinal stromal tumors (GIST), including duodenal GIST, the surgical objective is complete macroscopic excision with negative microscopic margins (R0). Wide anatomic resections and routine lymphadenectomy are not required for oncologic adequacy [5–7]. However, the proximity of duodenal tumors to the ampulla, pancreatic head and major mesenteric vessels often renders limited resections unsafe or unfeasible; in such scenarios, PD may be required to achieve an R0 resection [8,9]. When a mutilating resection would otherwise be necessary, neoadjuvant imatinib can downsize mutation-sensitive tumors and facilitate margin-negative, organ-sparing surgery [6,10–12]. In this article, to our knowledge, we describe the first report of RPD using Hugo™ RAS, with safety and reproducibility and without registered morbimortality. Technical aspects The Hugo™ robotic-assisted surgery (RAS) system received the Conformité Européenne (CE) mark for general surgery in October 2022. At our institution, we started using Hugo™ in March 2023 and account more than 800 cases overall. To date, our General Surgery Upper GI team has completed nearly 200 procedures on the Medtronic platform, predominantly bariatric and upper gastrointestinal cases. In parallel with our robotic experience, the lead surgeon has extensive expertise in open and laparoscopic hepatobiliary surgery. Building on this combined expertise and on the progressive adoption of increasingly complex procedures with proven feasibility and favorable outcomes, we set out to perform the first worldwide case of pancreatoduodenectomy (PD) using the Hugo™ RAS system. In an initial case, we elected a hybrid approach to PD: laparoscopic resection followed by robot-assisted reconstruction. Given the feasibility and validation of this strategy, we subsequently proposed a fully robotic PD to a patient with a duodenal gastrointestinal stromal tumor (GIST). Below, we present the clinical case, operating-room layout, arm configuration, instruments, docking strategy, and stepwise operative workflow. We also report secondary outcomes including operative time, estimated blood loss (EBL), conversion, 30-day complications (Clavien–Dindo), length of stay, and pathology with respect to oncologic principles. Clinical case description A 38-year-old, functionally independent patient. Past medical history notable for Transthyretin Familial Amyloid Polyneuropathy (on Tafamidis ® ) and gastroesophageal reflux disease (GERD). Due to worsening GERD related symptoms, the patient underwent esophagogastroduodenoscopy, which identified a tumor lesion measuring just over 2 cm in the second portion of the duodenum (D2). Subsequent endoscopic ultrasound characterized the lesion as arising from the fourth duodenal wall layer; it was situated on the pancreatic aspect, involving the major papilla and apparently abutting the uncinate process (Figure 1). No lymphadenopathy was detected, and contrast-enhanced CT of the chest, abdomen, and pelvis showed no distant disease. Fine-needle aspiration (FNA) cytology supported the clinical suspicion. The case was discussed at a multidisciplinary tumor board, and surgical treatment was recommended: pancreaticoduodenectomy (Whipple). The procedure was performed on March 5, 2025, via a robotic approach, as described below. Platform Hugo™ RAS Hugo™ RAS is a modular system composed of an open 3DHD surgeon console, a system tower, and four independent arm carts. The open-console design aims to enhance situational awareness and ergonomics for the primary surgeon, while the independent arm carts permit flexible operating-room layouts as shown in Figure 2. The robotic instruments included the camera, monopolar curved shears, bipolar Cadiere forceps, and Cadiere forceps. The instruments for the assistant port included Signia™ stapling system, insufflation and smoke evacuation and filtration device, Hem-o-lock endoscopic applicator and metallic clips. No advanced energy device was used. The platform also integrates the Touch Surgery™ Enterprise ecosystem to enable digital video capture and analytics performance. Surgical Procedure Patient positioning on the operating table and trocar placement followed the configuration shown in Figure 3. This setup was developed by our team based on cumulative experience and is currently used for all upper abdominal procedures (bariatric and upper GI) Figure 4. The operation was performed entirely via a robotic approach using the Hugo™ RAS platform. Patient positioning, port placement, and system configuration remained unchanged throughout. Docking time was 4 min 35 s; console time was 5 h 14 min; total operative time was 5 h 40 min. The resection phase took 2 h 45 min and reconstruction approximately 2 h 29 min. Both the gastrojejunostomy and the biliary–enteric anastomosis were fashioned in a Roux-en-Y configuration. The pancreatic anastomosis (pancreatojejunostomy) was constructed to a normal-caliber main pancreatic duct (Wirsung), performed over a 22-gauge angiocatheter, facilitated by the platform’s high-definition optical system. Key operative steps are shown in the video. The estimated blood loss was 200 mL. Two drains were left in situ: one adjacent to the biliary–enteric anastomosis and one near the pancreatojejunostomy. No intraoperative transfusion was required, and no vasopressor support was needed. No high-priority system alarms or device-related technical events occurred. Postoperative Course The patient was extubated at the end of the procedure and observed for 2 days in an Intermediate Care Unit without adverse events. On the ward, oral diet was initiated on postoperative day (POD) 4. The patient was discharged on POD 7 with no postoperative pancreatic fistula (ISGPS), no delayed gastric emptying (ISGPS), no readmission within 30 days. Histopathological Findings Gross examination: well-circumscribed, nodular, solid, whitish-gray lesion measuring 1.8 × 1.4 × 1.4 cm. The tumor bulged toward/expanded into the adjacent pancreatic parenchyma without microscopic invasion of it. Margins (measured distances): 0.2 cm from the posterior margin (superior mesenteric artery margin); ≥3 cm from the mesenteric vein aspect/groove; ≥3 cm from the pancreatic transection margin; 8 cm from the common hepatic duct transection margin. Microscopy: Gastrointestinal stromal tumor (GIST), mixed type - predominantly spindle with focal epithelioid areas, G1, mitotic index ≤5 per 5 mm². Pathological stage and resection status: pT1 N0 (0/10) R0. Discussion Minimally invasive pancreatoduodenectomy has progressed from the exploratory phase to routine use in selected patients at experienced centers. Accumulating comparative data suggest that robotic pancreatoduodenectomy (RPD) achieves at least comparable safety and oncologic adequacy to open surgery, suggesting reduced blood loss and shorter length of stay, albeit at the cost of longer operative times [13–15]. When compared with laparoscopy, several analyses indicate that the robotic approach may bring technical advantages and improved short-term outcomes for pancreatic and periampullary disease [16]. Successful implementation of RPD hinges on structured training, standardized workflows, experienced surgical teams and institutional volume. In contemporary series, proficiency often emerges after 30–40 cases, with measurable improvements in operative efficiency thereafter [13,17-18]. In our case, a mature robotic team, already standardized for upper-abdominal procedures, translated that experience to a complex HPB operation, maintaining a constant port configuration and system setup throughout the case. The observed metrics (EBL ~200 mL, no transfusion/vasopressors, no major device alarms, POD-7 discharge without POPF or DGE) align with outcomes reported by high-volume programs [13,15]. Platform choice is pertinent. Published clinical experience with the Hugo™ RAS system in general surgery has expanded over the last two years, with feasibility demonstrated across multiple procedures and early comparative data emerging [20–23]; however, peer-reviewed HPB reports remain limited. In our case, high-definition 3D visualization and wristed instrumentation supported fine suturing tasks (e.g., duct-to-mucosa pancreatojejunostomy over a 22-g angiocatheter), consistent with experimental data showing performance benefits of 3D vision with articulated instruments on this platform [21–23]. Oncologically, the indication for pancreatoduodenectomy in this patient was a duodenal GIST in D2, abutting the papilla and uncinate. For D-GISTs involving or closely approximating the ampulla/pancreatic head, formal pancreatoduodenectomy is an accepted strategy to achieve an R0 resection; nodal metastasis is rare, and lymphadenectomy is not routinely required [24–27]. Our specimen achieved negative margins (R0) with pT1N0 disease, consistent with the biology of low-risk GIST [24–26]. Overall, our perioperative pathway (early extubation, step-down monitoring, oral intake from POD-4, discharge POD-7) mirrors ERAS elements associated with enhanced recovery after PD and is consistent with favorable short-term outcomes reported in contemporary RPD series [15, 14]. Conclusion Robotic surgery is becoming the natural evolution of modern surgical practice, reflecting major technological advances which bring surgeons enhanced dexterity, precision and vision. In line with experience on other robotic platform, early use of the Hugo™ RAS system across surgical domains has demonstrated feasibility, safety, and reproducibility. In our case, a robotic pancreatoduodenectomy using Hugo™ RAS was completed safely with low blood loss, no major intraoperative events and an uncomplicated postoperative course with discharge on postoperative day 7, achieving an R0 resection for a periampullary duodenal GIST. This early experience supports the feasibility of pancreatoduodenectomy on this platform when undertaken by a highly experienced, standardized team with cumulative robotic expertise. As adoption of Hugo™ RAS in HPB surgery expands, outcomes should be reported within structured training pathways and prospective registries to validate reproducibility, account for learning-curve effects, and benchmark performance against established platforms. In parallel, we aim to show that our setup model offers notable versatility and flexibility, underscoring that platforms should adapt to the surgeon rather than the other way around. Declarations Ethics The procedure complied with institutional and national ethics standards. Consent Written informed consent for the procedure and for publication of anonymized images/video were obtained. Conflicts/Funding Mesquita I. and Soares P., are clinical proctors for Hugo™ RAS and have collaborated on several Medtronic Advisory Boards for Robotic Surgery. Correia T., Marcos M. and Santos J. have no conflicts of interest or financial ties to disclose. Author Contributions Mesquita I, Soares P, conceptualized the work; Soares P, was the main surgeon; Mesquita I, wrote the main manuscript text and prepared the figures and video. All authors reviewed and approved the final version of the manuscript. References Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery. 2017;161(3):584-591. doi:10.1016/j.surg.2016.11.014 Melloul E, Lassen K, Roulin D, et al. Guidelines for Perioperative Care for Pancreatoduodenectomy: ERAS Recommendations 2019. World J Surg. 2020;44(7):2056-2084. doi:10.1007/s00268-020-05462-w Theijse RT, Suurmeijer AJH, van Hilst J, et al. Nationwide outcome after pancreatoduodenectomy in patients at very high risk (ISGPS-D) for postoperative pancreatic fistula. Ann Surg. 2025 Perri G, van Hilst J. Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care. BJS Open. 2023;7(5) doi:10.1093/bjsopen/zrad081 Casali PG, Blay JY, Abecassis N, et al. Gastrointestinal stromal tumours: ESMO-EURACAN-GENTURIS Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2022;33(1):20-33. doi:10.1016/j.annonc.2021.09.005 National Cancer Institute. Gastrointestinal Stromal Tumors Treatment (PDQ®). Updated Dec 13, 2024. Accessed Aug 11, 2025 Vassos N, Perrakis A, Hohenberger W, Croner RS. Surgical approaches and oncological outcomes in the management of duodenal GIST. J Clin Med. 2021;10(19):4459. doi:10.3390/jcm10194459 Shen Z, Chen P, Yin Y, et al. Pancreaticoduodenectomy versus limited resection for duodenal GIST: a systematic review and meta-analysis. BMC Surg. 2019;19:158 Johnston FM, Kneuertz PJ, Cameron JL, et al. Presentation and management of GIST of the duodenum: a multi-institutional analysis. Ann Surg Oncol. 2012;19(11):3351-3360. (cited in [8,7]) Renberg S, Bränström R, Engström C, et al. The role of neoadjuvant imatinib in GIST—a long-term, retrospective study. Cancer Med. 2022;11(20):3696-3708 Jakob J, Mussi C, Ronellenfitsch U, et al. Neoadjuvant therapy to downstage the extent of surgery in locally advanced GIST: a narrative review. Cancers (Basel). 2018;10(12):386 Liu Z, Gao S, Li X, et al. Comparison of prognosis between neoadjuvant imatinib plus surgery and upfront surgery in GIST: meta-analysis. Front Pharmacol. 2022;13:966486 Liu R, et al. International consensus guidelines on robotic pancreatic surgery in 2023. Hepatobiliary Surg Nutr. 2024; Published Jan 18, 2024. doi:10.21037/hbsn-23-132 Asbun HJ, et al. The Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection. Ann Surg. 2020;271(1):1-14 Tang G, et al. Comparison of short-term outcomes of robotic versus open pancreaticoduodenectomy: meta-analysis of RCTs and PSM studies. Int J Surg. 2025;111(1):1214-1230 Tang G, et al. Robotic versus laparoscopic pancreaticoduodenectomy: meta-analysis. Front Oncol. 2024;14:1486504 Wei ZG, et al. Learning curve for robotic pancreatoduodenectomy. World J Gastrointest Surg. 2022;14(5):523-538 Boone BA, et al. Quality outcomes for RPD: influence of learning curve. JAMA Surg. 2015;150(5):416-422 Conroy PC, et al. Determining hospital volume threshold for safety of minimally invasive PD: contemporary cut-point analysis. Ann Surg Oncol. 2022;29(3):1566-1574 Belyaev O, et al. Use of HUGO™ RAS in general surgery: first 70 cases & systematic review. J Clin Med. 2024;13(13):3678 Østdal TB, et al. 3D monitors improve performance on the HUGO™ RAS system: randomized trial (simulation). Surg Endosc. 2024;38:7165–7171 Romero-Marcos JM, et al. Application of the HUGO™ RAS system in general surgery: a scoping review. Updates Surg. 2025;77(3) Calini G, et al. Colorectal cancer outcomes using HUGO™ RAS: prospective cohort. J Clin Med. 2025;14(14) Lim KT, et al. Current surgical management of duodenal GIST. Ann Gastroenterol Surg. 2021;5(6):780-792 Popivanov G, et al. Surgical treatment of duodenal GISTs: review. J BUON. 2018;23(6) Zhou Y, et al. Surgery for duodenal GIST: systematic review comparing PD vs limited resection. Asian J Surg. 2020;43(1):15-23 Abera SA, et al. Duodenal GIST: lymphadenectomy usually not required. Clin Case Rep. 2024;12: e8796 Additional Declarations No competing interests reported. Supplementary Files RDPHugoRAS.mp4 Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Dec, 2025 Reviews received at journal 11 Nov, 2025 Reviewers agreed at journal 03 Nov, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers invited by journal 09 Sep, 2025 Editor assigned by journal 08 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 06 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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the most technically demanding abdominal procedures. Despite advances in perioperative care and system‐level centralization, contemporary series still report substantial major morbidity and non-trivial mortality; for example, in a nationwide very-high-risk (ISGPS-D) cohort, in-hospital mortality reached 4.1% with 45.9% major complications, and clinically relevant postoperative pancreatic fistula (POPF) is the principal driver of adverse outcomes [1,3]. Accordingly, best practice emphasizes comprehensive preoperative optimization, standardized Enhanced Recovery After Surgery (ERAS) pathways, and delivery in high-volume centers, while leveraging enabling technologies (e.g., minimally invasive/robotic approaches and intraoperative adjuncts) to improve precision, recovery and failure to rescue [2,4].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn gastrointestinal stromal tumors (GIST), including duodenal GIST, the surgical objective is complete macroscopic excision with negative microscopic margins (R0). Wide anatomic resections and routine lymphadenectomy are not required for oncologic adequacy [5–7]. However, the proximity of duodenal tumors to the ampulla, pancreatic head and major mesenteric vessels often renders limited resections unsafe or unfeasible; in such scenarios, PD may be required to achieve an R0 resection [8,9]. When a mutilating resection would otherwise be necessary, neoadjuvant imatinib can downsize mutation-sensitive tumors and facilitate margin-negative, organ-sparing surgery [6,10–12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this article, to our knowledge, we describe the first report of RPD using Hugo™ RAS, with safety and reproducibility and without registered morbimortality.\u003c/p\u003e\n\u003cp\u003eTechnical aspects\u003c/p\u003e\n\u003cp\u003eThe Hugo™ robotic-assisted surgery (RAS) system received the Conformité Européenne (CE) mark for general surgery in October 2022. At our institution, we started using Hugo™ in March 2023 and account more than 800 cases overall. To date, our General Surgery Upper GI team has completed nearly 200 procedures on the Medtronic platform, predominantly bariatric and upper gastrointestinal cases. In parallel with our robotic experience, the lead surgeon has extensive expertise in open and laparoscopic hepatobiliary surgery.\u003c/p\u003e\n\u003cp\u003eBuilding on this combined expertise and on the progressive adoption of increasingly complex procedures with proven feasibility and favorable outcomes, we set out to perform the first worldwide case of pancreatoduodenectomy (PD) using the Hugo™ RAS system. In an initial case, we elected a hybrid approach to PD: laparoscopic resection followed by robot-assisted reconstruction. Given the feasibility and validation of this strategy, we subsequently proposed a fully robotic PD to a patient with a duodenal gastrointestinal stromal tumor (GIST).\u003c/p\u003e\n\u003cp\u003eBelow, we present the clinical case, operating-room layout, arm configuration, instruments, docking strategy, and stepwise operative workflow. We also report secondary outcomes including operative time, estimated blood loss (EBL), conversion, 30-day complications (Clavien–Dindo), length of stay, and pathology with respect to oncologic principles.\u003c/p\u003e\n\n"},{"header":"Clinical case description ","content":"\u003cp\u003eA 38-year-old, functionally independent patient. Past medical history notable for Transthyretin Familial Amyloid Polyneuropathy (on Tafamidis\u003csup\u003e®\u003c/sup\u003e) and gastroesophageal reflux disease (GERD). Due to worsening GERD related symptoms, the patient underwent esophagogastroduodenoscopy, which identified a tumor lesion measuring just over 2 cm in the second portion of the duodenum (D2). Subsequent endoscopic ultrasound characterized the lesion as arising from the fourth duodenal wall layer; it was situated on the pancreatic aspect, involving the major papilla and apparently abutting the uncinate process (Figure 1). No lymphadenopathy was detected, and contrast-enhanced CT of the chest, abdomen, and pelvis showed no distant disease. Fine-needle aspiration (FNA) cytology supported the clinical suspicion.\u003c/p\u003e\u003cp\u003eThe case was discussed at a multidisciplinary tumor board, and surgical treatment was recommended: pancreaticoduodenectomy (Whipple).\u003c/p\u003e\u003cp\u003eThe procedure was performed on March 5, 2025, via a robotic approach, as described below.\u003c/p\u003e\u003cp\u003ePlatform Hugo™ RAS\u003c/p\u003e\u003cp\u003eHugo™ RAS is a modular system composed of an open 3DHD surgeon console, a system tower, and four independent arm carts. The open-console design aims to enhance situational awareness and ergonomics for the primary surgeon, while the independent arm carts permit flexible operating-room layouts as shown in Figure 2.\u003c/p\u003e\u003cp\u003eThe robotic instruments included the camera, monopolar curved shears, bipolar Cadiere forceps, and Cadiere forceps. The instruments for the assistant port included Signia™ stapling system, insufflation and smoke evacuation and filtration device, Hem-o-lock endoscopic applicator and metallic clips. No advanced energy device was used.\u003c/p\u003e\u003cp\u003eThe platform also integrates the Touch Surgery™ Enterprise ecosystem to enable digital video capture and analytics performance.\u003c/p\u003e\u003cp\u003eSurgical Procedure\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u0026nbsp;Patient positioning on the operating table and trocar placement followed the configuration shown in Figure 3. This setup was developed by our team based on cumulative experience and is currently used for all upper abdominal procedures (bariatric and upper GI) Figure 4.\u003cbr\u003e\u0026nbsp;The operation was performed entirely via a robotic approach using the Hugo™ RAS platform. Patient positioning, port placement, and system configuration remained unchanged throughout. Docking time was 4 min 35 s; console time was 5 h 14 min; total operative time was 5 h 40 min. The resection phase took 2 h 45 min and reconstruction approximately 2 h 29 min.\u003cbr\u003e\u0026nbsp;Both the gastrojejunostomy and the biliary–enteric anastomosis were fashioned in a Roux-en-Y configuration. The pancreatic anastomosis (pancreatojejunostomy) was constructed to a normal-caliber main pancreatic duct (Wirsung), performed over a 22-gauge angiocatheter, facilitated by the platform’s high-definition optical system. Key operative steps are shown in the video.\u003c/p\u003e\u003cp\u003eThe estimated blood loss was 200 mL. Two drains were left in situ: one adjacent to the biliary–enteric anastomosis and one near the pancreatojejunostomy. No intraoperative transfusion was required, and no vasopressor support was needed. No high-priority system alarms or device-related technical events occurred.\u003c/p\u003e\u003cp\u003ePostoperative Course\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003eThe patient was extubated at the end of the procedure and observed for 2 days in an Intermediate Care Unit without adverse events. On the ward, oral diet was initiated on postoperative day (POD) 4. The patient was discharged on POD 7 with no postoperative pancreatic fistula (ISGPS), no delayed gastric emptying (ISGPS), no readmission within 30 days.\u003c/p\u003e\u003cp\u003eHistopathological Findings\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\u003cp\u003eGross examination: well-circumscribed, nodular, solid, whitish-gray lesion measuring 1.8 × 1.4 × 1.4 cm. The tumor bulged toward/expanded into the adjacent pancreatic parenchyma without microscopic invasion of it.\u003c/p\u003e\u003cp\u003eMargins (measured distances): 0.2 cm from the posterior margin (superior mesenteric artery margin); ≥3 cm from the mesenteric vein aspect/groove; ≥3 cm from the pancreatic transection margin; 8 cm from the common hepatic duct transection margin. Microscopy: Gastrointestinal stromal tumor (GIST), mixed type - predominantly spindle with focal epithelioid areas, G1, mitotic index ≤5 per 5 mm². Pathological stage and resection status: pT1 N0 (0/10) R0.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMinimally invasive pancreatoduodenectomy has progressed from the exploratory phase to routine use in selected patients at experienced centers. Accumulating comparative data suggest that robotic pancreatoduodenectomy (RPD) achieves at least comparable safety and oncologic adequacy to open surgery, suggesting reduced blood loss and shorter length of stay, albeit at the cost of longer operative times [13–15]. When compared with laparoscopy, several analyses indicate that the robotic approach may bring technical advantages and improved short-term outcomes for pancreatic and periampullary disease [16].\u0026nbsp;\u003c/p\u003e\u003cp\u003eSuccessful implementation of RPD hinges on structured training, standardized workflows, experienced surgical teams and institutional volume. In contemporary series, proficiency often emerges after 30–40 cases, with measurable improvements in operative efficiency thereafter [13,17-18]. In our case, a mature robotic team, already standardized for upper-abdominal procedures, translated that experience to a complex HPB operation, maintaining a constant port configuration and system setup throughout the case. The observed metrics (EBL ~200 mL, no transfusion/vasopressors, no major device alarms, POD-7 discharge without POPF or DGE) align with outcomes reported by high-volume programs [13,15].\u003c/p\u003e\u003cp\u003ePlatform choice is pertinent. Published clinical experience with the Hugo™ RAS system in general surgery has expanded over the last two years, with feasibility demonstrated across multiple procedures and early comparative data emerging [20–23]; however, peer-reviewed HPB reports remain limited. In our case, high-definition 3D visualization and wristed instrumentation supported fine suturing tasks (e.g., duct-to-mucosa pancreatojejunostomy over a 22-g angiocatheter), consistent with experimental data showing performance benefits of 3D vision with articulated instruments on this platform [21–23].\u0026nbsp;\u003c/p\u003e\u003cp\u003eOncologically, the indication for pancreatoduodenectomy in this patient was a duodenal GIST in D2, abutting the papilla and uncinate. For D-GISTs involving or closely approximating the ampulla/pancreatic head, formal pancreatoduodenectomy is an accepted strategy to achieve an R0 resection; nodal metastasis is rare, and lymphadenectomy is not routinely required [24–27]. Our specimen achieved negative margins (R0) with pT1N0 disease, consistent with the biology of low-risk GIST [24–26].\u0026nbsp;\u003c/p\u003e\u003cp\u003eOverall, our perioperative pathway (early extubation, step-down monitoring, oral intake from POD-4, discharge POD-7) mirrors ERAS elements associated with enhanced recovery after PD and is consistent with favorable short-term outcomes reported in contemporary RPD series [15, 14].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRobotic surgery is becoming the natural evolution of modern surgical practice, reflecting major technological advances which bring surgeons enhanced dexterity, precision and vision. In line with experience on other robotic platform, early use of the Hugo™ RAS system across surgical domains has demonstrated feasibility, safety, and reproducibility. In our case, a robotic pancreatoduodenectomy using Hugo™ RAS was completed safely with low blood loss, no major intraoperative events and an uncomplicated postoperative course with discharge on postoperative day 7, achieving an R0 resection for a periampullary duodenal GIST. This early experience supports the feasibility of pancreatoduodenectomy on this platform when undertaken by a highly experienced, standardized team with cumulative robotic expertise. As adoption of Hugo™ RAS in HPB surgery expands, outcomes should be reported within structured training pathways and prospective registries to validate reproducibility, account for learning-curve effects, and benchmark performance against established platforms.\u003c/p\u003e\u003cp\u003eIn parallel, we aim to show that our setup model offers notable versatility and flexibility, underscoring that platforms should adapt to the surgeon rather than the other way around.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe procedure complied with institutional and national ethics standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for the procedure and for publication of anonymized\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eimages/video were obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts/Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMesquita I. and Soares P., are clinical proctors for Hugo\u0026trade; RAS and have collaborated on several Medtronic Advisory Boards for Robotic Surgery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCorreia T., Marcos M. and Santos J. have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMesquita I, Soares P, conceptualized the work; Soares P, was the main surgeon; Mesquita I, wrote the main manuscript text and prepared the figures and video. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. \u003cem\u003eSurgery.\u003c/em\u003e 2017;161(3):584-591. doi:10.1016/j.surg.2016.11.014\u003c/li\u003e\n\u003cli\u003eMelloul E, Lassen K, Roulin D, et al. Guidelines for Perioperative Care for Pancreatoduodenectomy: ERAS Recommendations 2019. \u003cem\u003eWorld J Surg.\u003c/em\u003e 2020;44(7):2056-2084. doi:10.1007/s00268-020-05462-w\u003c/li\u003e\n\u003cli\u003eTheijse RT, Suurmeijer AJH, van Hilst J, et al. Nationwide outcome after pancreatoduodenectomy in patients at very high risk (ISGPS-D) for postoperative pancreatic fistula. \u003cem\u003eAnn Surg.\u003c/em\u003e 2025\u003c/li\u003e\n\u003cli\u003ePerri G, van Hilst J. Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care. \u003cem\u003eBJS Open.\u003c/em\u003e 2023;7(5) doi:10.1093/bjsopen/zrad081\u003c/li\u003e\n\u003cli\u003eCasali PG, Blay JY, Abecassis N, et al. Gastrointestinal stromal tumours: ESMO-EURACAN-GENTURIS Clinical Practice Guidelines for diagnosis, treatment and follow-up. \u003cem\u003eAnn Oncol.\u003c/em\u003e 2022;33(1):20-33. doi:10.1016/j.annonc.2021.09.005\u003c/li\u003e\n\u003cli\u003eNational Cancer Institute. \u003cem\u003eGastrointestinal Stromal Tumors Treatment (PDQ\u0026reg;).\u003c/em\u003e Updated Dec 13, 2024. Accessed Aug 11, 2025\u003c/li\u003e\n\u003cli\u003eVassos N, Perrakis A, Hohenberger W, Croner RS. Surgical approaches and oncological outcomes in the management of duodenal GIST. \u003cem\u003eJ Clin Med.\u003c/em\u003e 2021;10(19):4459. doi:10.3390/jcm10194459\u003c/li\u003e\n\u003cli\u003eShen Z, Chen P, Yin Y, et al. Pancreaticoduodenectomy versus limited resection for duodenal GIST: a systematic review and meta-analysis. \u003cem\u003eBMC Surg.\u003c/em\u003e 2019;19:158\u003c/li\u003e\n\u003cli\u003eJohnston FM, Kneuertz PJ, Cameron JL, et al. Presentation and management of GIST of the duodenum: a multi-institutional analysis. \u003cem\u003eAnn Surg Oncol.\u003c/em\u003e 2012;19(11):3351-3360. (cited in [8,7]) \u003c/li\u003e\n\u003cli\u003eRenberg S, Br\u0026auml;nstr\u0026ouml;m R, Engstr\u0026ouml;m C, et al. The role of neoadjuvant imatinib in GIST\u0026mdash;a long-term, retrospective study. \u003cem\u003eCancer Med.\u003c/em\u003e 2022;11(20):3696-3708\u003c/li\u003e\n\u003cli\u003eJakob J, Mussi C, Ronellenfitsch U, et al. Neoadjuvant therapy to downstage the extent of surgery in locally advanced GIST: a narrative review. \u003cem\u003eCancers (Basel).\u003c/em\u003e 2018;10(12):386\u003c/li\u003e\n\u003cli\u003eLiu Z, Gao S, Li X, et al. Comparison of prognosis between neoadjuvant imatinib plus surgery and upfront surgery in GIST: meta-analysis. \u003cem\u003eFront Pharmacol.\u003c/em\u003e 2022;13:966486\u003c/li\u003e\n\u003cli\u003eLiu R, et al. International consensus guidelines on robotic pancreatic surgery in 2023. \u003cem\u003eHepatobiliary Surg Nutr.\u003c/em\u003e 2024; Published Jan 18, 2024. doi:10.21037/hbsn-23-132\u003c/li\u003e\n\u003cli\u003eAsbun HJ, et al. The Miami International Evidence-Based Guidelines on Minimally Invasive Pancreas Resection. \u003cem\u003eAnn Surg.\u003c/em\u003e 2020;271(1):1-14\u003c/li\u003e\n\u003cli\u003eTang G, et al. Comparison of short-term outcomes of robotic versus open pancreaticoduodenectomy: meta-analysis of RCTs and PSM studies. Int J Surg. 2025;111(1):1214-1230\u003c/li\u003e\n\u003cli\u003eTang G, et al. Robotic versus laparoscopic pancreaticoduodenectomy: meta-analysis. \u003cem\u003eFront Oncol.\u003c/em\u003e 2024;14:1486504\u003c/li\u003e\n\u003cli\u003eWei ZG, et al. Learning curve for robotic pancreatoduodenectomy. \u003cem\u003eWorld J Gastrointest Surg.\u003c/em\u003e 2022;14(5):523-538\u003c/li\u003e\n\u003cli\u003eBoone BA, et al. Quality outcomes for RPD: influence of learning curve. \u003cem\u003eJAMA Surg.\u003c/em\u003e 2015;150(5):416-422\u003c/li\u003e\n\u003cli\u003eConroy PC, et al. Determining hospital volume threshold for safety of minimally invasive PD: contemporary cut-point analysis. \u003cem\u003eAnn Surg Oncol.\u003c/em\u003e 2022;29(3):1566-1574\u003c/li\u003e\n\u003cli\u003eBelyaev O, et al. Use of HUGO\u0026trade; RAS in general surgery: first 70 cases \u0026amp; systematic review. \u003cem\u003eJ Clin Med.\u003c/em\u003e 2024;13(13):3678\u003c/li\u003e\n\u003cli\u003e\u0026Oslash;stdal TB, et al. 3D monitors improve performance on the HUGO\u0026trade; RAS system: randomized trial (simulation). \u003cem\u003eSurg Endosc.\u003c/em\u003e 2024;38:7165\u0026ndash;7171\u003c/li\u003e\n\u003cli\u003eRomero-Marcos JM, et al. Application of the HUGO\u0026trade; RAS system in general surgery: a scoping review. \u003cem\u003eUpdates Surg.\u003c/em\u003e 2025;77(3)\u003c/li\u003e\n\u003cli\u003eCalini G, et al. Colorectal cancer outcomes using HUGO\u0026trade; RAS: prospective cohort. \u003cem\u003eJ Clin Med.\u003c/em\u003e 2025;14(14)\u003c/li\u003e\n\u003cli\u003eLim KT, et al. Current surgical management of duodenal GIST. \u003cem\u003eAnn Gastroenterol Surg.\u003c/em\u003e 2021;5(6):780-792\u003c/li\u003e\n\u003cli\u003ePopivanov G, et al. Surgical treatment of duodenal GISTs: review. \u003cem\u003eJ BUON.\u003c/em\u003e 2018;23(6)\u003c/li\u003e\n\u003cli\u003eZhou Y, et al. Surgery for duodenal GIST: systematic review comparing PD vs limited resection. \u003cem\u003eAsian J Surg.\u003c/em\u003e 2020;43(1):15-23\u003c/li\u003e\n\u003cli\u003eAbera SA, et al. Duodenal GIST: lymphadenectomy usually not required. \u003cem\u003eClin Case Rep.\u003c/em\u003e 2024;12: e8796\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"innovative-surgical-trends","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Innovative Surgical Trends](https://link.springer.com/journal/44414)","snPcode":"44414","submissionUrl":"https://submission.springernature.com/new-submission/44414/3?","title":"Innovative Surgical Trends","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Robotic pancreaticoduodenectomy, Whipple, Hugo RAS, feasibility, safety, HPB surgery","lastPublishedDoi":"10.21203/rs.3.rs-7553174/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7553174/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Pancreaticoduodenectomy (Whipple procedure) is among the most demanding operations in HPB surgery. Early diagnosis and meticulous perioperative optimization, combined with recent technical advances, especially robotic platforms, are key contributors to improved postoperative outcomes. Robotic pancreaticoduodenectomy (RPD) may enhance dexterity and ergonomics in complex HPB procedures. The Hugo™ Robotic-Assisted Surgery (RAS) system has recently entered clinical practice, yet RPD on this platform has not been reported.\u003cbr\u003e\n\u003cstrong\u003eMethods:\u003c/strong\u003e We describe a single-center, first reported case of RPD using the Hugo™ RAS system. Preoperative evaluation, OR layout, port mapping, arm configuration, instruments, docking strategy, and stepwise operative workflow are detailed. Primary endpoints were technical feasibility and intra/perioperative safety. Secondary endpoints included operative time, estimated blood loss (EBL), conversion, 30-day complications (Clavien–Dindo), length of stay, and pathology concerning oncological principles.\u003cbr\u003e\n\u003cstrong\u003eResults:\u003c/strong\u003e The procedure was completed robotically without conversion. Docking time was 4 min 35 s and console time 5 hours 14 min, EBL 200 mL. No high-priority system alarms or device-related adverse events occurred. Final pathology showed pT1 Duodenal Gastro-Intestinal Stroma Tumour (GIST), tumor size 1,8*1,4*1,4 cm, R0 resection, and 10 lymph nodes retrieved. Postoperative course was notable. Hospital discharge on postoperative day 7 with no postoperative pancreatic fistula (ISGPS), no delayed gastric emptying (ISGPS), and no readmission within 30 days.\u003cbr\u003e\n\u003cstrong\u003eConclusion:\u003c/strong\u003e RPD using the Hugo™ RAS system was feasible and safe in this first reported case, with a reproducible setup and workflow. These findings support further prospective evaluation and standardization of RPD on this platform.\u003c/p\u003e","manuscriptTitle":"First reported robotic pancreaticoduodenectomy using the Hugo™ RAS system: feasibility and safety","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-17 08:44:12","doi":"10.21203/rs.3.rs-7553174/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-08T14:06:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T09:05:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262576314931057563410647825965004166398","date":"2025-11-03T13:31:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318289361807805143543098201564515870196","date":"2025-10-16T12:51:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-09T14:47:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-08T06:27:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-08T06:27:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Innovative Surgical Trends","date":"2025-09-06T22:24:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"innovative-surgical-trends","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Innovative Surgical Trends](https://link.springer.com/journal/44414)","snPcode":"44414","submissionUrl":"https://submission.springernature.com/new-submission/44414/3?","title":"Innovative Surgical Trends","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f252852-8652-4533-9a04-ef167ff09aba","owner":[],"postedDate":"September 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T08:24:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-17 08:44:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7553174","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7553174","identity":"rs-7553174","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}