Technical and ethical considerations in telesurgery

Feasibility and Initial Outcomes of Telesurgery in Urology: a Systematic Review of the Literature

INTRODUCTION

Telesurgery allows the procedures to be carried out over long distances, however due to lack of data, its feasibility has not been consolidated yet. Since it is a promising modality, it is important to illustrate the current scenario on this subject.

OBJECTIVE

To review the literature aiming at the surgical success rate as a primary objective, and secondly, the most important patient outcomes and the network system.

MATERIALS AND METHODS

In June 2024, we followed PRISMA guidelines to research trials on urological robotic surgery in humans. We used as exclusion criteria: editorials, specialist's opinions, tele-mentoring, tele-training, small procedures, non-remote surgeries, absence of interest outcomes, telesurgeries in non-humans or in cadaver.

RESULTS

Five hundred and ninety eight studies were identified with peer review and a third reviewer for divergencies, both directed by previously established inclusion and exclusion criteria, selecting 6 studies after the exclusions. We found 54 patients who underwent urological telesurgeries; all of them were accomplished with no complications or need for conversion to open surgery. Almost all the procedures were carried out in China (98.14%) and the most used robotic model was MicroHand S (83.33%). Nephrectomy was the procedure of choice (57%). Mean surgical time was 66.2 (IQR) 56.6 minutes. Intraoperative bleeding time was 68.6 ± 76.7 milliliters. Hospital stay was 5.5 (IQR) 5 days. The distance between main surgeon and the patient was between 2,581.5 (IQR) 2,871 kilometers. 5G network was used the most (98.14%). The total network latency time was 176 (IQR) 10.9 milliseconds.

CONCLUSION

Despite its limitations, there was evidence demonstrating that robotic surgery in the genitourinary system is safe and feasible, however it is a subject that must be well discussed, and further studies must be carried out.

Global trends and insights of telesurgery research: a bibliometric analysis of publications since the 21st century

BACKGROUND

In recent years, telesurgery has shown a rapid development trend as an innovative surgical technique, and been applied to the clinical treatment of various tumor diseases. However, the current research on telesurgery is still relatively fragmented, lacking a systematic summary of its development and future directions. Addressing these limitations is crucial for advancing the application of this novel surgical technology.

METHODS

This bibliometric study of publications related to telesurgery that were indexed in the Web of Science Core Collection from 2000 to 2024. VOSviewer, CiteSpace, and Bibliometrix were used to analyze and visually represent the gathered data, and the relevant content was presented according to the BIBLIO guidelines.

RESULTS

We researched 565 publications across 269 journals authored by 2422 individuals affiliated with 917 institutions spanning 62 countries. Notably, the United States leads in the number of publications, with China also making noteworthy contributions. Kyushu University and the University of Washington emerge as prominent institutions in terms of research output within this domain. Analysis of document co-occurrence and co-citation reveals that Jacques Marescaux from France holds the top position globally among authors and wields significant influence in this field. Keyword analysis indicates that key future research directions in this area include mitigating latency issues in telesurgery, integrating advanced network communication technologies, and enhancing the performance of telesurgical robots. Furthermore, ethical and legal issues associated with telesurgery may emerge as critical challenges to be addressed for its further expansion and application.

CONCLUSION

This research provides an overview of telesurgery research findings, encompassing the evolution of research priorities in telesurgery. The study anticipates that the secure implementation and broader adoption of telesurgery will bring more benefits to patients on a global scale.

Telesurgery: current status and strategies for latency reduction

Telesurgery is a rapidly evolving field in robotic assisted surgery that allows surgeons to operate on patients remotely with the help of robotic systems. This has allowed increased access to specialized care reducing geographic barriers and improving overall surgical outcomes in remote locations. An important challenge that hinders its widespread adoption is latency period which is primarily a delay that exists in data transmission between the surgeon and the robotic system. It is essential to determine strategies that can reduce it to ensure greater precision, dexterity, and patient safety. A literature review was conducted using PubMed, Embase, Google Scholar, and Cochrane Library. After screening the articles for relevance, data were synthesized to present a narrative review on the current challenges and emerging solutions in latency reduction. Those articles were included that discussed telesurgery with latency periods, network infrastructure, AI driven latency compensation, and cybersecurity. After removing 8 duplicates, a total of 238 articles were identified in the literature search out of which 175 articles were excluded after title and abstract screening done by two independent reviewers. 63 full text articles were assessed for eligibility. Latency period greatly impacts telesurgical performance with an ideal value being less than 200 ms. This threshold is essential for effective surgical precision, and safety. The adoption of ultra-low latency 6G wireless networks, quantum computing, and artificial intelligence can enhance telesurgical performance. Ethical, legal, and cybersecurity challenges must be addressed for widespread adoption of telesurgery. Latency in telesurgery arise due to a multitude of factors, including network infrastructure, geographic barriers, cybersecurity protocols, hardware, and software limitations. AI-based algorithms, edge computing, advancements in 5G technology, along with optimum haptic feedback mechanisms are promising solutions in reducing latency.

The era of telesurgery: insights from ultra-long-distance Asia to Middle East human telesurgery robotic assisted radical prostatectomy

To show the feasibility of performing human telesurgery robotic-assisted radical prostatectomy (RARP) between two countries using low-latency ultra-long-distance connectivity. This study described the outcomes of performing RARP on a man in his 60's with localized intermediate-risk prostatic adenocarcinoma located in Kuwait City while the surgeon (SA) was approximately 7000 kilometers (Km) away at Toumai robotic surgical system (TRSS) headquarters in Shanghai. Operative and connectivity details were reported. RARP was performed in December 2024. There were no major clinical or technical problems encountered during the procedure. The average round-trip latency (RTL) was 181.4 milliseconds (ms) using fiber optic broadband network with 5G network as back-up. On the Shanghai end two wired broadband networks were employed as back-up to ensure patient safety. There was an experienced fellowship-trained robotic surgeon (AA) in the operating room in Kuwait capable of taking over in case of clinical or connectivity issues. There were no reported complications. The patient was discharged on postoperative day (POD) 2. Final pathology described Gleason score 7(3 + 4), ISUP 2, and negative surgical margins (pT2Nx). The catheter was removed on POD 9, and the patient was continent a week later. His serum prostate specific antigen (PSA) was undetectable seven weeks post-operatively. This study described the feasibility of human RARP telesurgery between two countries using low-latency, long-distance fiber optic broadband network with 5G network as back-up with successful clinical outcomes. There is a need to establish robust legal and regulatory framework to allow wider international expansion of telesurgery.

Robotic-assisted surgery in the Arab world: are we there yet?

Robotic-assisted surgery (RAS) has revolutionized surgical practice worldwide, with urology leading its adoption. Despite its global expansion, significant disparities exist in regional implementation, particularly in the Arab world. This study evaluates the current landscape of robotic surgery in the Arab world, highlighting advancements, challenges, and future directions. A literature review was conducted using PubMed, focusing on robotic procedures across multiple specialties in Arab countries. Data on installed robotic systems were obtained from industry reports and local distributors. A total of 56 relevant publications were identified. The highest volume of RAS publications originated from Saudi Arabia, Qatar, and the United Arab Emirates. Emerging trends include a rise in multidisciplinary robotic procedures, innovative telesurgical applications, and increased research output. However, high-quality, large-scale studies remain limited. The Arab world has made notable strides in RAS adoption, with key centers advancing research and clinical practice. Although full integration remains a work in progress, the foundation for widespread robotic surgical adoption in the Arab world is firmly in place.

Telesurgery and the importance of context

Telesurgery has the potential to overcome geographical barriers in surgical care, encouraging its deployment in areas with sparse surgical expertise. Despite successful in-human experiments and substantial technological progress, the adoption of telesurgery remains slow. In this Review, we analyze the reasons for this slow adoption. First, we identify various contexts for telesurgery and highlight the vastly different requirements for their realization. We then discuss why procedures with high urgency and skill sparsity are particularly suitable for telesurgery. Last, we summarize key research areas essential for further progress. The goal of this Review is to provide the reader with a comprehensive analysis of the current state of telesurgery research and to provide guidance for faster adoption of this exciting technology.

Ethical and legal aspects concerning robotic surgery in Brazil

Robotic surgery is a technological milestone that directly impacts the provision of healthcare services. Procedures that utilize robotics are continuously being developed. In this context, it is important to analyze the distribution of ethical and civil liability among doctors, hospitals, and suppliers of surgical equipment in cases of alleged medical errors or adverse events that may harm patients. This review aims to examine the civil and ethical liability of the parties involved in robotic surgeries, as well as possible means to avoid legal complications related to these procedures concerning the Medical Councils and the judicial system.

Expanding Surgical Frontiers Across the Pacific Ocean: Insights from the First Telesurgery Procedures Connecting Orlando with Shanghai in Animal Models

BACKGROUND AND OBJECTIVE

Telesurgery is as a promising solution to support and deliver advanced health care services to underserved areas. The primary endpoint of our study was to prove the concept of low-latency long-distance connectivity and to describe the feasibility of remote surgery.

METHODS

A prospective study was conducted from February 29 to March 1, 2024, in live animal models (porcine) connecting surgeons from Orlando (USA) to the animal laboratory in Shanghai (China) using 5G and Wi-Fi connections, in combination with continental and transpacific fiber. We performed ten radical nephrectomies and two partial nephrectomies in five animals using the MicroPort MedBot robotic platform. Intraoperative and telesurgery connection variables were reported with a descriptive statistical analysis.

KEY FINDINGS AND LIMITATIONS

No complications or conversions were reported. The mean animal weight was 38.2 (35-40) kg, the mean operative time was 32.7 (21-45) min, and the mean blood loss was 23.3 (20-30) ml. The mean latency was 296 (±50) ms. Findings from animal studies may not always translate directly to human outcomes.

CONCLUSIONS AND CLINICAL IMPLICATIONS

We described the feasibility of transpacific low-latency telesurgery in live porcine models with no intraoperative complications. Achieving optimal low-latency connectivity via telecommunication networks was essential for effectively performing the surgical procedures. However, we still need further investigation to achieve even lower latencies for human trials. We found that long-distance telesurgery is safe and feasible in animal models. However, it is a complex practice, and we still need further studies before translating these results to human trials.

PATIENT SUMMARY

Our research has demonstrated the feasibility of low-latency long-distance telesurgery in live animal models. However, this type of telesurgery is a complex procedure, and further work is needed to translate these results to human trials.

Feasibility of long-range telesurgical robotic radical gastrectomy in a live porcine model

BACKGROUND

Telesurgery has been made increasingly possible with the advancements in robotic surgical platforms and network connectivity. However, long-distance transnational complex robotic surgeries such as gastrectomy have yet to be attempted.

METHODS

Multiple transnational network connections by Science Innovation Network (SINET), Japan Gigabit Network (JGN), and Arterial Research and Education Network in Asia-Pacific (ARENA-PAC) were established and tested by multiple surgeons in a dry box model. Surgeons' perceptions of the different networks were recorded. Three robotic radical D2 gastrectomies in live porcine models were performed at a hospital in Toyoake, Japan, by a surgical team in a hospital in Singapore ~5000 km away, using the hinotori Surgical Robot System (Medicaroid Corporation).

RESULTS

The live porcine robotic gastrectomies were all completed in under 205 min with no intraoperative complications. From the different networks that were tested, the differences in latency ranged from 107 to 132 ms and did not translate to any significant differences in surgeon timings and perceptions.

CONCLUSIONS

Transnational telesurgical radical D2 gastrectomy is feasible in a porcine model. There is no appreciable difference between surgeon performance and perception with network latencies of 107-132 ms. Long-range telesurgery as clinical practice may become possible in the future.

Remote-Controlled and Teleoperated Systems: Taking Robotic Image Guided Interventions to the Next Stage

Remote-controlled and teleoperated robotic systems mark transformative advancements in interventional radiology (IR), with the potential to enhance precision, reduce radiation exposure, and expand access to care. By integrating robotic devices with imaging guidance, these systems enable precise instrument placement and navigation, thereby improving the efficacy and safety of minimally invasive procedures. Remote-controlled and teleoperated robotic systems-operated by clinicians using control interfaces from within or adjacent to the procedure room-are being adopted for both percutaneous and endovascular interventions. In contrast, although their application is still experimental, teleoperation over long distances hold promise for extending IR services to medically underserved areas by enabling remote procedures. This review details the definitions and components of remote-controlled and teleoperated robotic systems in IR, examines their clinical applications in percutaneous and endovascular interventions, and discusses relevant challenges and future directions for their incorporation into IR practices.

First impressions of Telesurgery robotic-assisted radical prostatectomy using the Edge medical robotic platform

PURPOSE

We reported, as a referral center in prostate cancer, our perspectives and experience performing Telesurgery using robotic surgery and 5G network.

MATERIAL AND METHODS

We described and illustrated the Telesurgery applications and outcomes to treat a patient with prostate cancer located 1300 kilometers away from the surgeon (Beijing-Harbin) in China. We used the Edge Medical Robot (MP1000) in November 2023 in a 71-year-old patient with Gleason 6 (ISUP 1) in 8 cores from 13, PSA of 14 ng/dL, and clinical stage cT2a. MRI described a PIRADS 5 nodule on the left peripheral zone at the base, and 20gr prostate. We described details about the connection between centers, perioperative outcomes, and our perspectives as a referral center in prostate cancer.

RESULTS

We had no delays, or problems with network connection between the centers. The procedure was performed in 60 minutes, with no intra- or postoperative complications. Estimated blood loss was 100 mL. The patient was ambulating soon after anesthesia recovery. Final pathology described a Gleason 6 (ISUP 1) involving the left base and left seminal vesicle, negative surgical margins, and no lymph node involvement (pT3bN0). The patient was continent soon after catheter removal (7 days).

CONCLUSION

As technological progress introduced novel robotic platforms and high-speed networks, the concept of Telesurgery became a tangible reality while 5G technology solved latency and transmission concerns. However, with these advancements, ethical considerations and regulatory frameworks should underline the importance of transparency and patient safety with responsible innovation in the field.

Ethical considerations in surgical research conducted in African LMICs: a comprehensive narrative review

Introduction

Surgical research has revolutionized healthcare by improving the efficacy, safety, and efficiency of surgical interventions. This research has the potential to significantly impact healthcare delivery in Africa, where surgical diseases pose a major public health burden. Studies suggest surgery alone could reduce the global disease burden by 11%, with a substantial portion stemming from conditions prevalent in sub-Saharan Africa like traumatic injuries, childbirth complications, and surgical infections. However, conducting surgical research in Africa presents unique ethical challenges. The continent's diverse socio-economic environments and rich cultural contexts necessitate careful consideration of ethical principles. Traditional research models often don't translate well to African settings, raising concerns about informed consent, community engagement, and benefit-sharing.

Aim

This review aims to shed light on various ethical dilemmas posed within surgical research, conducted in African countries. Further, standard practices and recommendations that involve a multi-pronged approach to mitigate said issues were explored.

Materials and methods

A meticulous analysis of the existing literature pertaining to the ethical issues proffered in Africa was performed. Databases employed comprised PubMed/MEDLINE, Embase, Scopus, and EBSCOhost. Pertinent case studies were also reviewed to comprehend said issues, providing comprehensive recommendations.

Results

In addressing the ethical challenges in the research, the importance of resource limitation, sociocultural factors, informed consent barriers, technological obsolescence, training deficits, power dynamics, vulnerable populations, regulatory oversight, and compliance was highlighted. The proposed approaches include conducting focused research lectures and practical workshops on surgery, organizing surgical boot camps for medical students, interns, and residents, promoting research in related fields such as anesthesia, radiology, and pathology, ensuring the presence of on-site surgeons as needed, and arranging outreach surgical and educational camps for patients.

Conclusion

Promoting community engagement and training local researchers and surgeons are crucial for navigating the unique ethical landscape in Africa. By prioritizing ethical considerations, surgical research can contribute to improved healthcare outcomes and a more equitable healthcare system across the continent.

Triple-console robotic telesurgery: first impressions and future impact

Telesurgery has been recently gaining momentum as a natural evolution of robotic surgery. Besides providing expert surgical care to patients who cannot geographically access it, telesurgery can also facilitate surgical collaboration between surgeons who might need urgent assistance or coaching experts. The idea of having two consoles, with one remote and one local, has been the ideal setup for such ecosystems. However collaborations can take on many forms and might require more than one remote surgeon, depending on procedure complexity and surgeon availability. The objective of the study was to describe our perspectives and experience performing telesurgery on one patient, using three surgeon consoles for three surgeons, operating from three separate cities. In November 2023, a triple-console, robot-assisted radical prostatectomy (RARP) was performed in a collaborative effort among three surgeons in three separate locations employing telesurgery using the Kangduo Endosopic Surgical Robot (KD-SR-01, Sagebot Medical). The furthest distance between participants was approximately 2600 km between Beijing and Hainan. We described and illustrated the applications and outcomes of this procedure to treat a single patient with prostate cancer. The local surgeon, along with the operating room team, and the patient were in Hainan, while the other two surgeons were in Beijing and Hunan Telesurgery command centers. The procedure lasted approximately 120 min and there were no intra- or postoperative complications. Estimated blood loss was 100 ml. The patient was ambulating 4 h after surgery and remained in the hospital for 2 days secondary to the postoperative care protocol followed by the local team taking care of the patient. The Foley catheter was removed on postoperative day 7 without complication. The final pathology was ISUP Grade Group 4 (Gleason score 4 + 4 = 8) T2cN0 with negative surgical margins. Our experience shows that telesurgery involving multiple surgeons at multiple remote locations is possible and can be completed safely with low-latency connections via available telecommunication networks.

The Humanitarian Impact of Telesurgery and Remote Surgery in Global Medicine

Telesurgery is a natural evolution of robotic surgery and has potential to address health care deficiencies in underserved areas of the globe. The same expert can reach more patients on the same day via telesurgery, and emergency procedures for neurovascular and cardiac events could be performed at the appropriate time, reducing deaths and disabilities.

Insights from telesurgery expert conference on recent clinical experience and current status of remote surgery

Remote surgery provides opportunity for enhanced surgical capabilities, wider healthcare reach, and potentially improved patient outcomes. The network reliability is the foundation of successful implementation of telesurgery. It relies on a robust, high-speed communication network, with ultra-low latency. Significant lag has been shown to endanger precision and safety. Furthermore, the full-fledged adoption of telerobotics demands careful consideration of ethical challenges too. A deep insight into these issues has been investigated during the first Telesurgery Consensus Conference that took place in Orlando, Florida, USA, on the 3rd and 4th of February, 2024. During the Conference, the state of the art of remote surgery has been reported from robotic systems displaying telesurgery potential. The Hinotori, a robotic-assisted surgery platform developed by Medicaroid, experienced remote surgery as pre-clinical testing only; the Edge Medical Company, Shenzen, China, reported more than one hundred animal and 30 live human surgeries; the KanGuo reported human telesurgical cases performed with distances more than 3000 km; the Microport, China, collected more than 100 human operations at a distance up to 5000 km. Though, several issues-cybersecurity, data privacy, technical malfunctions - are yet to be addressed before a successful telesurgery implementation. Expanding the discussion to encompass ethical, financial, regulatory, and legal considerations is essential too. The Telesurgery collaborative community is working together to address and establish the best practices in the field.