Single-incision plus one robot-assisted surgery (SIPORS) using the Hugo robotic-assisted surgery (RAS) system for rectal cancer

Yu Yoshida; Yoshiro Itatani; Takehito Yamamoto; Ryosuke Okamura; Koya Hida; Kazutaka Obama

doi:10.3393/ac.2025.00787.0112

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Technical Note Colorectal cancer Single-incision plus one robot-assisted surgery (SIPORS) using the Hugo robotic-assisted surgery (RAS) system for rectal cancer: Yu Yoshida, Yoshiro Itatani, Takehito Yamamoto, Ryosuke Okamura, Koya Hida, Kazutaka Obama; Annals of Coloproctology 2025;41(6):586-591.
DOI: https://doi.org/10.3393/ac.2025.00787.0112
Published online: December 24, 2025

Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan

Correspondence to: Yoshiro Itatani, MD, PhD, FACS Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan Email: itatani@kuhp.kyoto-u.ac.jp

• Received: June 25, 2025 • Revised: August 10, 2025 • Accepted: September 4, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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INTRODUCTION
TECHNIQUE
DISCUSSION
ARTICLE INFORMATION
Supplementary materials
REFERENCES

INTRODUCTION

Minimally invasive surgery has become the standard approach for colorectal cancer treatment, offering advantages such as reduced postoperative pain, shorter hospital stays, and improved oncological outcomes [1]. Single-incision laparoscopic surgery was developed to further minimize surgical trauma by reducing the number of incisions. However, it poses technical challenges, including restricted tissue manipulation and instrument clashing. These difficulties are especially pronounced in rectal surgery, which requires precise dissection within a confined pelvic space [2, 3].

The introduction of surgical robots has overcome many of the limitations of conventional laparoscopy by providing enhanced dexterity and visualization. The da Vinci single port (SP) system (Intuitive Surgical) was specifically designed for single-incision use, allowing single-site procedures to be performed with robotic precision [4, 5]. Nonetheless, in rectal surgery, an additional assistant trocar (plus one port) is still required for colorectal transection because robotic staplers are not yet available for this application.

The Hugo robot-assisted surgery (RAS) system (Medtronic) represents a new robotic platform with a modular design in which 4 robotic arms are mounted on individual carts. Although early clinical applications have shown encouraging results, its use in single-incision colorectal cancer surgery has not yet been reported. To our knowledge, this study provides the world’s first clinical experience with single-incision plus one robot-assisted surgery (SIPORS) using the Hugo RAS system for colorectal cancer. Here, we present our initial series of 4 cases, demonstrating the feasibility and safety of this novel approach.

TECHNIQUE

Ethics statement

This study was approved by the Institutional Review Board of Kyoto University (No. 01891). All patients provided written informed consent for publication of the research details and clinical images.

Surgical technique

Patients with primary colorectal cancer who underwent SIPORS using the Hugo RAS system between January and June 2025 were analyzed. Under general anesthesia, patients were placed in the lithotomy position with their arms tucked. A vertical skin incision of approximately 4 cm was made at the umbilicus, after which a wound-protecting device and surgical glove were applied. Through this setup, one 11-mm camera trocar and two 8-mm robotic trocars were inserted to create a triangular configuration. Port placement and cart layout are shown in Fig. 1. A 12-mm assistant trocar was inserted in the right lower quadrant (RLQ). An 8-mm robotic trocar, docked with a robotic arm, was then introduced through the assistant trocar using the port-in-port technique (Fig. 2A). The instruments used in SIPORS with the Hugo RAS system included a 30° oblique camera, monopolar curved shears for the right hand, bipolar fenestrated forceps for the left hand, and double-fenestrated forceps for the reserve arm. Docking angles, tilts, and the instruments of the robotic arms are summarized in Table 1. An assistant utilized the RLQ trocar for vessel ligation and rectal transection with laparoscopic clips and staplers. To optimize handling, the reserve and right arms were swapped with the operator’s right hand, allowing bilateral tissue manipulation and more effective control.

Supplementary videos present representative cases of low anterior resection for rectal cancer. Supplementary Video 1 demonstrates trocar insertion using a surgical glove, extracorporeal robotic arm movements, and bedside views, including the port-in-port technique. Initially, the right wall of the mesorectum was mobilized by elevating the superior rectal artery (SRA) pedicle with the reserve arm. Dissection began with incision of the mesorectal peritoneum on the right side at the sacral promontory. After the hypogastric nerves were identified, sparse connective tissue above the nerves was carefully dissected in both caudal and cranial directions. By straightening the inferior mesenteric artery (IMA) with the reserve arm, lymph nodes along the IMA were dissected, and the SRA was ligated immediately distal to the branching of the left colic artery (LCA), thereby performing LCA-preserving proximal-D3 lymphadenectomy (Supplementary Video 2). When vessels or lymphatic channels traversed the dissection plane, monopolar curved shears in soft coagulation mode were used to seal the structures before sharp division (“sealing shears” technique) (Supplementary Video 3).

Total mesorectal excision (TME) was then performed. For nerve-preserving TME, once the pelvic nerves were identified along the fascia propria recti, the anterior mesorectum was dissected to locate the proper plane above the mesorectum (Denonvilliers fascia). The peritoneal dissection was extended laterally, and both the white (nerve) and yellow (mesorectum) borders were separated (Supplementary Video 4). Following completion of the TME, the distal tumor was compressed with a gut clamp, irrigated with saline through the anus, and transected using laparoscopic linear staplers by the bedside surgeon (Supplementary Video 5).

The specimen was extracted through the umbilical incision via a small laparotomy, after which the mesocolon on the oral side of the tumor was dissected. Blood perfusion at the planned transection line was confirmed by intravenous injection of a 1-shot bolus of 1 mL indocyanine green (ICG), followed by a 20-mL saline flush. Perfusion was assessed using an external photodynamic eye device within 10 to 15 seconds of ICG administration.

Results

Four patients underwent SIPORS for rectal cancer using the Hugo RAS system between January and June 2025 at our institution. Patient characteristics and intraoperative outcomes are summarized in Table 2. In 1 patient with a neuroendocrine tumor of the lower rectum who underwent low anterior resection, a 2-team approach with a transanal procedure was performed. No intraoperative adverse events occurred, and there were no unexpected conversions to open, laparoscopic, or multiport robotic surgery. The mean operative time was 240 minutes (range, 172–322 minutes), and estimated blood loss was minimal in all cases, which was consistent with or better than previous reports [6]. When compared with conventional Hugo rectal surgery at our institute (mean, 335 minutes), no prolongation of operative time was observed [7].

Postoperative outcomes and clinicopathological findings are presented in Table 3. No postoperative complications of Clavien-Dindo classification grade ≥II were observed. Adequate tumor-free resection margins were achieved both proximally and distally, and the mean number of harvested lymph nodes was 16, which was considered satisfactory. At 3 months postoperatively, all patients demonstrated excellent cosmetic results (Fig. 2C).

DISCUSSION

This study demonstrated the feasibility and safety of SIPORS using the Hugo RAS system for rectal cancer procedures. To our knowledge, this represents the world’s first clinical experience with SIPORS using the Hugo RAS system for rectal cancer. By reducing the number of surgical wounds, SIPORS provides several advantages, including decreased pain, improved cosmetic outcomes, and faster postoperative recovery. Although the da Vinci SP was designed for single-port robotic surgery through a multichannel port requiring inline instrument operation, the Hugo RAS system offers a modular design with individually docked arms through separate ports, providing greater flexibility and wider arm movement. However, because Hugo was originally developed for multiport robotic surgery, SIPORS using the Hugo RAS system may be susceptible to arm-to-arm interference outside the patient.

To overcome this potential limitation, we introduced several technical innovations. The camera was positioned as a 30° oblique scope angled upward, and a contralateral reserve arm manipulation technique was employed. This technique enables bilateral tissue handling by alternating between the reserve arm and the RLQ arm [7]. Since the Hugo RAS system currently lacks robotic clip appliers and linear staplers, bedside assistance remains necessary. To address this, we applied a port-in-port technique by inserting an 8-mm robotic trocar through a 12-mm assistant trocar, which permitted assistant procedures without undocking the robotic trocar.

Our safety strategy emphasized several key principles. Energy devices were introduced through the 12-mm trocar, while the umbilical arms were dedicated to tissue manipulation, consistent with our standardized multiport protocols. In cases of unexpected complications, such as bleeding, the assistant could rapidly remove the shears and introduce laparoscopic instruments through the 12-mm trocar without disrupting the surgical field. Furthermore, if technical difficulties arose due to a narrow pelvis or tumor invasion, conversion to multiport robotic surgery with Hugo could be performed immediately, without changing the operating room layout or robotic devices—a robot-to-robot conversion to the standard configuration, as previously reported [7].

Limitations of this study include its retrospective design. Additionally, this study included a small number of cases, and lacked long-term oncological follow-up. Nevertheless, our mean operative time of 240 minutes and minimal blood loss were comparable to those reported in other robotic colorectal studies [7–12], supporting feasibility and demonstrating successful skill transfer despite this being an initial SIPORS experience. Larger prospective studies with extended follow-up are required to clarify the long-term oncological and functional outcomes and to establish the definitive role of SIPORS in colorectal cancer surgery.

In conclusion, this study shows that the Hugo RAS system represents a promising and innovative robotic platform for SIPORS in rectal cancer surgery. Our initial clinical experience with rectal resections confirms that SIPORS using the Hugo RAS system is both feasible and safe, producing acceptable operative outcomes with minimal complications. These findings highlight the potential of SIPORS to combine the precision of robotic surgery with improved cosmetic results and enhanced patient satisfaction.

ARTICLE INFORMATION

Conflict of interest

Kazutaka Obama, Koya Hida, and Yoshiro Itatani have received honoraria from Medtronic. No other potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: YI; Investigation: all authors; Methodology: YI; Visualization: YY, YI; Writing–original draft: YY, YI; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Supplementary materials

Supplementary Video 1.

Docking procedure and the port-in-port technique.

Supplementary Video 2.

Mesorectal dissection and inferior mesenteric artery division with left colic artery preservation (left colic artery–preserving proximal-D3 lymphadenectomy).

Supplementary Video 3.

Sealing shears method.

Supplementary Video 4.

Total mesorectal excision.

Supplementary Video 5.

Hybrid surgery with robot and laparoscopic assistant.

Supplementary materials are available from https://doi.org/10.3393/ac.2025.00787.0112. All supplementary videos are displayed at 1.5 times normal speed.

Fig. 1.

Port placement and surgical cart layout of single-incision plus one robot-assisted surgery (SIPORS) using the Hugo robotic-assisted surgery (RAS) system (Medtronic) for rectal cancer surgery. (A) Gray circles, robotic trocars. Gray double circles, the port-in-port technique with an 8-mm robotic trocar inserted through a 12-mm trocar in the right lower quadrant. Blue square, swapping between reserve arm and shears. R, trocars manipulated with the right hand. L, trocar manipulated with the left hand. Reserve arm trocar, trocar for reserve arm manipulated with the right hand. (B) Triangular trocar configuration through the umbilical incision showing the angular positioning of the 3 robotic trocars. (C) Arm cart placement and the position for other operating staff.

Fig. 2.

Abdominal wound. (A) Intraoperative photograph demonstrating the port-in-port technique in the right lower quadrant with an 8-mm Hugo robotic trocar inserted through a 12-mm trocar. (B) A triangular configuration of the 3 robotic arms inserted from the umbilical skin incision through a surgical glove. (C) Cosmetic results after single-incision plus one robot-assisted surgery (SIPORS) using the Hugo robotic-assisted surgery (RAS) system (Medtronic).

Table 1.

Docking angles and tilt settings for SIPORS with the Hugo RAS system (Medtronic)

Arm no.	Role	Instrument	Docking angle (°)	Tilt (°)
1	Reserve	Double-fenestrated forceps	90	5
2	Camera	30° Oblique (up)	135	–15
3	Left hand	Bipolar fenestrated forceps	310	30
4	Right hand	Monopolar curved shears	180	–30

SIPORS, single-incision plus one robot-assisted surgery; RAS, robotic-assisted surgery.

Table 2.

Characteristics of patients who underwent SIPORS with the Hugo RAS system (Medtronic)

Characteristic	Patient 1	Patient 2	Patient 3	Patient 4
Age (yr)	54	67	72	57
Sex	Male	Male	Female	Male
Body mass index (kg/m²)	23.9	24.0	22.4	27.9
ASA physical status	I	II	II	II
Underlying disease	None	Hyperlipidemia, BPH	None	None
Previous operation history	None	None	None	None
Neoadjuvant treatment	None	None	None	None
Combined operation	None	None	None	Combined with TAMIS
Incision site	Transumbilical	Transumbilical	Transumbilical	Pfannenstiel incision
Wound size (cm)	4	4	4	4
Tumor location	Rectosigmoid colon	Rectosigmoid colon	Upper rectum	Lower rectum
Surgical procedure	HAR	HAR	LAR	LAR
Anastomotic method	DST	DST	DST	SST
Estimated blood loss (mL)	0	0	0	0
Conversion	None	None	None	None
Reoperation	None	None	None	None
Operation time (min)	195	172	271	322
Docking time (min)	122	125	210	195

SIPORS, single-incision plus one robot-assisted surgery; RAS, robotic-assisted surgery; ASA, American Society of Anesthesiologists; BPH, benign prostatic hyperplasia; TAMIS, transanal minimally invasive surgery; HAR, high anterior resection; LAR, low anterior resection; DST, double-stapling technique; SST, single-stapling technique.

Table 3.

Clinicopathological and postoperative data of SIPORS with the Hugo RAS system (Medtronic)

Variable	Patient 1	Patient 2	Patient 3	Patient 4
Histologic type	ADC MD	ADC WD	ADC MD	NET
Tumor size (cm)	0.8	3.8	5.5	Post-ESD
Proximal margin (mm)	110	140	120	120
Distal margin (mm)	80	38	50	23
Circumferential resection margin	Negative	Negative	Negative	Negative
Total no. of harvested lymph node	20	22	11	11
Metastatic lymph node	0	0	0	0
Pathologic TNM	T1N0M0	T3N0M0	T3N0M0	T1N0M0
First bowel movement (postoperative day)	2	2	3	3
Hospital stay (day)	9	11	12	15
Complication (Clavien-Dindo grade II–IV)	No	No	No	No
30-Day readmission	No	No	No	No

SIPORS, single-incision plus one robot-assisted surgery; RAS, robotic-assisted surgery; ADC, adenocarcinoma; MD, moderately differentiated; WD, well differentiated; NET, neuroendocrine tumor; ESD, endoscopic submocosal dissection

REFERENCES

1. Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 2010;11:637–45. Article PubMed
2. Li FH, Zeng DX, Chen L, Xu CF, Tan L, Zhang P, et al. Comparison of clinical efficacy of single-incision and traditional laparoscopic surgery for colorectal cancer: a meta-analysis of randomized controlled trials and propensity-score matched studies. Front Oncol 2022;12:997894.Article PubMed PMC
3. Kong J, Wu MQ, Yan S, Zhao ZF, Yao H. Single-incision plus one-port laparoscopy surgery versus conventional multi-port laparoscopy surgery for colorectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2024;39:62.Article PubMed PMC PDF
4. Kim HS, Oh BY, Cheong C, Park MH, Chung SS, Lee RA, et al. Single-incision robotic colorectal surgery with the da Vinci SP® surgical system: initial results of 50 cases. Tech Coloproctol 2023;27:589–99. Article PubMed PDF
5. Picciariello A, Annicchiarico A, Gallo G, Dezi A, Grossi U. Evaluation of the da Vinci single-port system in colorectal cancer surgery: a scoping review. Updates Surg 2024;76:2515–20. Article PubMed PDF
6. Matsuyama T, Endo H, Yamamoto H, Takemasa I, Uehara K, Hanai T, et al. Outcomes of robot-assisted versus conventional laparoscopic low anterior resection in patients with rectal cancer: propensity-matched analysis of the National Clinical Database in Japan. BJS Open 2021;5:zrab083.Article PubMed PMC PDF
7. Itatani Y, Hida K, Okamura R, Maekawa H, Hoshino N, Kinoshita H, et al. Initial clinical experience of robot-assisted rectal surgery by using Hugo RAS system: horizontal line port placement with contralateral reserve arm manipulation. Asian J Endosc Surg 2025;18:e70099. Article PubMed
8. Farah E, Abreu AA, Rail B, Salgado J, Karagkounis G, Zeh HJ, et al. Perioperative outcomes of robotic and laparoscopic surgery for colorectal cancer: a propensity score-matched analysis. World J Surg Oncol 2023;21:272.Article PubMed PMC PDF
9. Brucchi F, Montroni I, Cirocchi R, Taffurelli G, Vitellaro M, Mascianà G, et al. A systematic review of the Da Vinci® single-port system (DVSP) in the context of colorectal surgery. Int J Colorectal Dis 2025;40:83.Article PubMed PMC PDF
10. Cho HJ, Kim WR. Early single-center experience of DaVinci® single-port (SP) robotic surgery in colorectal patients. J Clin Med 2024;13:2989.Article PubMed PMC
11. Rottoli M, Violante T, Calini G, Cardelli S, Novelli M, Poggioli G, et al. A multi-docking strategy for robotic lar and deep pelvic surgery with the Hugo RAS system: experience from a tertiary referral center. Int J Colorectal Dis 2024;39:154.Article PubMed PMC PDF
12. Belyaev O, Fahlbusch T, Slobodkin I, Uhl W. Major colorectal surgery with Hugo™ RAS: initial experience of a German center and a review of the literature. Updates Surg 2024;76:1705–14. Article PubMed PMC PDF

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Single-incision plus one robot-assisted surgery (SIPORS) using the Hugo robotic-assisted surgery (RAS) system for rectal cancer

Ann Coloproctol. 2025;41(6):586-591. Published online December 24, 2025

DOI: https://doi.org/10.3393/ac.2025.00787.0112

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Figure

Single-incision plus one robot-assisted surgery (SIPORS) using the Hugo robotic-assisted surgery (RAS) system for rectal cancer

Fig. 1. Port placement and surgical cart layout of single-incision plus one robot-assisted surgery (SIPORS) using the Hugo robotic-assisted surgery (RAS) system (Medtronic) for rectal cancer surgery. (A) Gray circles, robotic trocars. Gray double circles, the port-in-port technique with an 8-mm robotic trocar inserted through a 12-mm trocar in the right lower quadrant. Blue square, swapping between reserve arm and shears. R, trocars manipulated with the right hand. L, trocar manipulated with the left hand. Reserve arm trocar, trocar for reserve arm manipulated with the right hand. (B) Triangular trocar configuration through the umbilical incision showing the angular positioning of the 3 robotic trocars. (C) Arm cart placement and the position for other operating staff.

Fig. 2. Abdominal wound. (A) Intraoperative photograph demonstrating the port-in-port technique in the right lower quadrant with an 8-mm Hugo robotic trocar inserted through a 12-mm trocar. (B) A triangular configuration of the 3 robotic arms inserted from the umbilical skin incision through a surgical glove. (C) Cosmetic results after single-incision plus one robot-assisted surgery (SIPORS) using the Hugo robotic-assisted surgery (RAS) system (Medtronic).

Fig. 1.

Fig. 2.

Single-incision plus one robot-assisted surgery (SIPORS) using the Hugo robotic-assisted surgery (RAS) system for rectal cancer

Arm no.	Role	Instrument	Docking angle (°)	Tilt (°)
1	Reserve	Double-fenestrated forceps	90	5
2	Camera	30° Oblique (up)	135	–15
3	Left hand	Bipolar fenestrated forceps	310	30
4	Right hand	Monopolar curved shears	180	–30

Characteristic	Patient 1	Patient 2	Patient 3	Patient 4
Age (yr)	54	67	72	57
Sex	Male	Male	Female	Male
Body mass index (kg/m²)	23.9	24.0	22.4	27.9
ASA physical status	I	II	II	II
Underlying disease	None	Hyperlipidemia, BPH	None	None
Previous operation history	None	None	None	None
Neoadjuvant treatment	None	None	None	None
Combined operation	None	None	None	Combined with TAMIS
Incision site	Transumbilical	Transumbilical	Transumbilical	Pfannenstiel incision
Wound size (cm)	4	4	4	4
Tumor location	Rectosigmoid colon	Rectosigmoid colon	Upper rectum	Lower rectum
Surgical procedure	HAR	HAR	LAR	LAR
Anastomotic method	DST	DST	DST	SST
Estimated blood loss (mL)	0	0	0	0
Conversion	None	None	None	None
Reoperation	None	None	None	None
Operation time (min)	195	172	271	322
Docking time (min)	122	125	210	195

Variable	Patient 1	Patient 2	Patient 3	Patient 4
Histologic type	ADC MD	ADC WD	ADC MD	NET
Tumor size (cm)	0.8	3.8	5.5	Post-ESD
Proximal margin (mm)	110	140	120	120
Distal margin (mm)	80	38	50	23
Circumferential resection margin	Negative	Negative	Negative	Negative
Total no. of harvested lymph node	20	22	11	11
Metastatic lymph node	0	0	0	0
Pathologic TNM	T1N0M0	T3N0M0	T3N0M0	T1N0M0
First bowel movement (postoperative day)	2	2	3	3
Hospital stay (day)	9	11	12	15
Complication (Clavien-Dindo grade II–IV)	No	No	No	No
30-Day readmission	No	No	No	No

Table 1. Docking angles and tilt settings for SIPORS with the Hugo RAS system (Medtronic)

SIPORS, single-incision plus one robot-assisted surgery; RAS, robotic-assisted surgery.

Table 2. Characteristics of patients who underwent SIPORS with the Hugo RAS system (Medtronic)

Table 3. Clinicopathological and postoperative data of SIPORS with the Hugo RAS system (Medtronic)