Surgery 4.0: From the Smart Operating Room to the Learning Operating Room

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 Académie 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 "surgical world model" 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.