{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T12:31:20Z","timestamp":1787056280469,"version":"build-2736575974"},"reference-count":12,"publisher":"MDPI AG","issue":"16","license":[{"start":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T00:00:00Z","timestamp":1787011200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"COMPASS-AI project","award":["101233553"],"award-info":[{"award-number":["101233553"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>The connected operating room captures, transmits, and displays data, but it does not learn. This perspective presents Chirurgie 4.0 (C40), a French-led initiative born within the Commission Innovation of the Acad\u00e9mie nationale de chirurgie, which proposes not only a concept but a method for the safe adoption of artificial intelligence (AI) in surgery. At its core is the C40 Maturity Model of the Operating Room, a human-governed \u201csurgical world model\u201d describing the transition from the Smart OR to the Learning OR across six levels, from the conventional operating room to a sovereign, federated network of surgical world models. We situate surgical autonomy on an explicit six-level scale, show that autonomous devices are already an accepted clinical reality in fields such as interventional cardiology, ophthalmology, neuro- and orthopedic surgery, and argue that governance must be native rather than retrofitted, through a Cognitive Governance Layer resting on human oversight, explainability, auditability and agent governance. We describe the economic and sovereignty stakes specific to intelligent surgical technologies and set out the design of the 2026 C40 field survey, whose results will feed a Livre Blanc for public decision-makers. C40 offers five steps that can genuinely be climbed, and a method for climbing them safely, with the surgeon retaining final clinical authority at every step.<\/jats:p>","DOI":"10.3390\/jcm15166384","type":"journal-article","created":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T12:09:32Z","timestamp":1787054972000},"page":"6384","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Surgery 4.0: From the Smart Operating Room to the Learning Operating Room"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7044-5318","authenticated-orcid":false,"given":"Andrew A.","family":"Gumbs","sequence":"first","affiliation":[{"name":"Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany"},{"name":"Service de Chirurgie Digestive Minimale Invasive, H\u00f4pital Antoine B\u00e9cl\u00e8re, Assistance Publique-H\u00f4pitaux de Paris, 157 Rue de la Porte de Trivaux, 92140 Clamart, France"},{"name":"Commission Innovation, Acad\u00e9mie Nationale de Chirurgie, Les Cordeliers, 15 Rue de l\u2019\u00c9cole de M\u00e9decine, 75006 Paris, France"},{"name":"Do Tank Chirurgie 4.0\u2014\u201cLa Fabrique de la Chirurgie Num\u00e9rique\u201d, 75017 Paris, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6248-7086","authenticated-orcid":false,"given":"Roland","family":"Croner","sequence":"additional","affiliation":[{"name":"Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, 39120 Magdeburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean-Claude","family":"Couffinhal","sequence":"additional","affiliation":[{"name":"Commission Innovation, Acad\u00e9mie Nationale de Chirurgie, Les Cordeliers, 15 Rue de l\u2019\u00c9cole de M\u00e9decine, 75006 Paris, France"},{"name":"Do Tank Chirurgie 4.0\u2014\u201cLa Fabrique de la Chirurgie Num\u00e9rique\u201d, 75017 Paris, France"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,18]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"znaf298","DOI":"10.1093\/bjs\/znaf298","article-title":"Why the European Union urgently needs guidelines for the safe implementation of artificial intelligence in surgery","volume":"113","author":"Gumbs","year":"2026","journal-title":"Br. J. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"180","DOI":"10.20517\/ais.2023.24","article-title":"Surgomics and the artificial intelligence, radiomics, genomics, oncopathomics and surgomics (AiRGOS) project","volume":"3","author":"Gumbs","year":"2023","journal-title":"Artif. Intell. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"znaf217","DOI":"10.1093\/bjs\/znaf217","article-title":"Bridging the gap: Exposing the hidden challenges towards adoption of artificial intelligence in surgery","volume":"112","author":"Snoek","year":"2025","journal-title":"Br. J. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1751","DOI":"10.1001\/jama.2026.5483","article-title":"A licensure framework for autonomous clinical AI","volume":"335","author":"Bergman","year":"2026","journal-title":"JAMA"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1186\/s13244-025-01913-x","article-title":"Empowering cancer research in Europe: The EUCAIM cancer imaging infrastructure","volume":"16","author":"Blanquer","year":"2025","journal-title":"Insights Imaging"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"znaf121","DOI":"10.1093\/bjs\/znaf121","article-title":"A multicentre randomized controlled trial exploring the clinical usefulness of an artificial intelligence-based anatomical navigation system","volume":"112","author":"Kitaguchi","year":"2025","journal-title":"Br. J. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"znae248","DOI":"10.1093\/bjs\/znae248","article-title":"The integration of artificial intelligence with robotic instruments in surgical practice","volume":"111","author":"Tejedor","year":"2024","journal-title":"Br. J. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Gumbs, A.A., Frigerio, I., Spolverato, G., Croner, R., Illanes, A., Chouillard, E., and Elyan, E. (2021). Artificial intelligence surgery: How do we get to autonomous actions in surgery?. Sensors, 21.","DOI":"10.3390\/s21165526"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"65","DOI":"10.20517\/ais.2024.101","article-title":"Announcement of consensus conference on definitions of artificial intelligence for the next generation of surgeons","volume":"5","author":"Gumbs","year":"2025","journal-title":"Artif. Intell. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1007\/s11701-026-03301-z","article-title":"Wisdom, balance, and action: An ancient Anatolian perspective on leadership in AI-enabled surgery-a narrative mini-review","volume":"20","author":"Ozmen","year":"2026","journal-title":"J. Robot. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"502","DOI":"10.1016\/j.hpb.2024.12.016","article-title":"Ethics and trustworthiness of artificial intelligence in hepato-pancreato-biliary surgery: A snapshot of insights from the E-AHPBA survey","volume":"27","author":"Rashidian","year":"2025","journal-title":"HPB"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"znae062","DOI":"10.1093\/bjs\/znae062","article-title":"Artificial intelligence in surgery: A global balancing act","volume":"111","author":"Kewalramani","year":"2024","journal-title":"Br. J. 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