Surgery without distance: will 5G-based robot-assisted telesurgery redefine modern surgery?

Introduction

The journey of surgical techniques is a testament to the relentless pursuit of medical excellence, marked by extraordinary milestones that have significantly improved patient outcomes. Entering the late 20th and early 21st centuries, minimally invasive surgery, exemplified by laparoscopic techniques, transformed surgical practice by reducing recovery times and minimizing surgical trauma. In an era marked by a growing demand for surgical precision and minimal invasion, the robot-assisted surgery has gradually assumed an influential role in modern surgical ecology, with the da Vinci Surgical System becoming a cornerstone in various surgical specialties (1). An increasing body of research has demonstrated the advantages of robot-assisted surgery, including reduced perioperative complications, less intraoperative bleeding, and improved long-term survival rates for patients (2,3).

The advancement of surgical techniques is inextricably linked to the progress of cutting-edge technologies. 5G mobile technology is engineered to address the complexities of large-scale network connections, offering ultra-low latency, high capacity, and faster data transmission via higher-frequency millimeter waves compared to current networks (4). 5G networks promise an end-to-end latency (refers to the total time taken for a data packet to travel from the surgeon’s console to the robotic system and back) of less than 5 ms and over-the-air latency (refers to the measured time required for wireless signal transmission between devices) of less than 1 ms—ten times faster than 4G networks. Furthermore, 5G supports Ultra-High-Definition multimedia streaming, facilitating the seamless transfer of high-resolution images (5). The arrival of 5G technology may have a significant impact on healthcare, potentially helping to overcome partial traditional constraints of time and space. Practical medical applications of 5G include remote robot-assisted telesurgery, remote examinations and diagnosis via high-speed networks, rapid deployment of remote medical assistance in disaster relief scenarios, efficient delivery of hospital materials, etc. (6). These advancements underscore the potential of 5G technology to revolutionize healthcare practices, making high-quality medical care more accessible and efficient on a global scale.

Among these advancements, robot-assisted telesurgery has emerged as one of the most technically challenging and valuable innovations. Surgical robots exemplify the novel integration of multiple disciplines, leading to the field of medical device innovation by integrating artificial intelligence (AI), informatization, and program control. Compared with conventional surgical robots, doctors can perform surgery using a console through a 5G network, while the robots execute the operations at the patient’s side, far from the surgeon.

Applications and innovations of 5G-based telemedicine and remote robotic surgery

In the 5G epoch, remote healthcare has undergone a significant transformation, introducing numerous applications that enhance medical service delivery and accessibility. One major advancement is the development of remote diagnosis systems, which enable patients to access advanced medical care without extensive travel. This is particularly beneficial for elderly patients in rural areas, where an aging population and uneven distribution of healthcare professionals pose significant challenges. These systems facilitate early diagnosis and timely intervention, thereby reducing the economic burden of patients and enhancing health outcomes. During the coronavirus disease 2019 (COVID-19) pandemic, the advantages of 5G technology in remote healthcare became even more apparent. Elderly patients could avoid hospital visits and the associated risk of exposure by receiving remote diagnostic services. In China, for example, COVID-19 patients underwent ultrasonography using a 5G-based remote system, linking temporary hospitals with specialists located 700 km away (7). This approach ensured quality care while minimizing the risk of infection. Thus, the integration of 5G technology into remote robot-assisted surgery is expected to contribute to the evolution of modern surgical practices, offering new possibilities for patient care. The core advantage of 5G lies in its high-speed, low-latency network, which allows for near-instantaneous transmission of data between the surgeon and the robotic system even far away from each other, enabling real-time adjustments and responses that are critical during surgery. The robust communication capabilities of 5G technology enable transmission of high-definition 4K and stereoscopic 3D video in real time, facilitating diagnosis and treatment through advanced imaging modalities like magnetic resonance imaging (MRI), computed tomography (CT) scans, and ultrasound examinations. This unprecedented clarity and detail enhance surgeons’ ability to interpret complex anatomical structures in real time, thereby improving the overall success rate of surgeries. Moreover, the dual and even multiple console operations, a key benefit of 5G-based robot-assisted surgery, exemplify the potential for global multifocal collaboration. By enabling experts in different locations to simultaneously operate in collaboration and oversee surgeries, 5G technology facilitates real-time insights and interventions. Importantly, this capability reduces risks associated with ultra-remote surgeries, which is particularly beneficial for complex cases requiring a multidisciplinary approach or in emergencies where time is critical. Dual-console telesurgery, leveraging both 5G and wired networks, has been successfully validated in both animal models and clinical trials. The system demonstrated high reliability, with data packet loss below 1% and an average latency of 271 ms (8).

However, the expansion of doctors’ catchment areas through the telemedicine system may increase the workload on specialists. To address this, AI-based deep learning is expected to help reduce the burden on healthcare providers. Integrating 5G technology with AI-powered diagnostic imaging in a remote support system can create a more efficient healthcare model, benefiting both providers and patients (9). Preoperatively, natural language processing can extract data from electronic medical records which optimizes treatment modality selection through case-based learning (10). Intraoperatively, computer vision can conduct enhancement of image and video quality and real time identification (e.g., vital signs, imaging), realizing lesion segmentation and accurate anatomical localization for optimized surgical decision-making (11,12). Although robotic 3D visualization enhances precision, absent haptic feedback risks tissue damage from force miscalibration during dissection or knot-tying, compromising surgical safety. A meta-analysis demonstrated that haptic feedback in robotic surgery reduced intraoperative force and duration while enhancing accuracy and success rates compared to systems lacking tactile sensory integration (13). In addition, predictive video analysis for adverse intraoperative events is extremely important to improve surgical safety. Rahbar et al. performed an entropy-based algorithm that detects abrupt surgical tool movements via texture uniformity, achieving 88% accuracy, 90% precision, and 0.66 s mean warning time, enabling proactive robotic attenuation to prevent vascular injury (14). Postoperatively, AI-powered systems enable data-driven prediction of surgical complications, facilitating personalized postoperative care protocols and rehabilitation guidance to improve prognosis (15).

The revolution history of telesurgery

The first-ever robot-assisted experiment was conducted on July 7, 1993, between Milan, Italy and Pasadena, USA. An Italian surgeon remotely operated an Italian robot in the USA, which performed a biopsy on a pig organ model, initiating the chapter of remote telesurgery. The procedure was transmitted via a dual satellite link, connecting three stations in Italy, New York, and Pasadena, with signals traveling 150,000 km each way. This pioneering experiment, spanning 14,000 km, showcases the potential of remote robotic surgery facilitated by advanced satellite communication, while the delay time reported was 1.1 s (16). In 2001, Marescaux et al. pioneered the field of robot-assisted telesurgery by reporting the world’s first trans-Atlantic robot-assisted laparoscopic cholecystectomy, a procedure commemorated as the “Lindbergh Operation” (17). The surgeon and the ZEUS robotic system were linked through a high-speed terrestrial optical fiber network (France Telecom/Equant), achieving a reported latency of just 155 ms. The surgery, spanning a round-trip distance of more than 14,000 km, was completed in 54 minutes without any complications. On February 28, 2003, Anvari et al. established the world’s first remote robotic surgery service, connecting a teaching hospital with a community hospital more than 400 km away. By 2005, the team had completed 21 robotic telesurgeries, aiming to deliver advanced laparoscopic surgical care to patients in this rural community more effectively (18). In 2006, a remote laparoscopic cholecystectomy was successfully performed on a pig using a minimally invasive surgical system, linking Japan and Korea via an optical submarine cable network. The procedure was conducted across a distance of 540 km, with a response delay of 540 ms and an image delay of 871 ms (19). Recently, the first-in-human trial of tele-remote robot-assisted percutaneous coronary intervention (tele-R-PCI) has been performed with the operator 20 miles away from the patient. Five patients with type A coronary lesions were treated by telesurgery with a mean delay of 53 ms, demonstrating that remote R-PCI is feasible with good internet connectivity and local catheterization facilities. This approach could provide standard care for patients in remote or underserved areas (20). A comprehensive summary of pioneering cases in robot-assisted telesurgery as well as an in-depth examination of the technological requirements has been conducted (Table 1) (17,18,20-33).

With the revolution brought about by 5G technology, remote surgery has achieved higher precision and safety. In 2020, Tian et al. successfully performed the world’s first 12 cases of robotic spinal telesurgery based on a 5G network (23). Acemoglu and colleagues executed a laser microsurgical procedure on a cadaver using an innovative surgical robot connected to a 5G network, observing a maximum round-trip latency of 280 ms over a 15 km distance (34).

Recently, Professor Vipul Patel and his team completed the groundbreaking intercontinental 5G remote surgery, performing a procedure from Orlando to Dubai, over 12,400 km. Subsequently, Dr. Moschovas and Dr. Breda conducted a transcontinental 5G remote animal surgery, performing a right kidney ureterectomy from Orlando to Shanghai, nearly 13,000 km apart. These groundbreaking achievements mark significant milestones in remote surgery, laying a strong foundation for future global, real-time surgical operations (35). In Greece, Moustris et al. conducted a remote robotic surgery training 300 km away. The system achieved 18 ms motion latency and 350 ms video delay, enabling tasks like cutting, dissection, and transfer, which provided the surgeon with positive feedback on the system’s usability and video quality, highlighting the feasibility of 5G in clinical adoption (36). In ophthalmology, where extreme surgical precision is critical, 5G robot-assisted telesurgery represents a promising advancement for ophthalmologic surgery. Alessio et al. pioneered the first 5G remote topography-guided transepithelial photorefractive combined with phototherapeutic keratectomy telesurgery via the iRes®2 excimer laser for epithelial basement membrane dystrophy, achieving 20/20 postoperative visual acuity and validating the precision of robotic corneal microsurgery (33).

In addition, a series of pioneering surgeries based on the 5G network were successfully performed by multiple centers in China. A pioneering 5G-enabled ultra-remote robot-assisted right upper lung lobectomy with lymph node dissection was performed by our team, lasting 80 minutes of main surgery. Blood loss was minimal (<10 mL), and real-time transmission of robotic control signals, images, and audio remained stable. The packet loss rate was 0.012% (means that out of 10,000 data packets transmitted, fewer than 2 packets are lost, ensuring seamless communication), with a maximum delay of 121 ms and an average delay of 100 ms, confirming the feasibility of 5G-based telesurgery (22). Yang et al. conducted ultra-remote robot-assisted laparoscopic radical cystectomy with nearly 3,000 km of communication distance and a mean delay of 254 ms, highlighting the safety and robustness of 5G telesurgery (25). Five ultra-remote robot-assisted hepatobiliary and pancreatic surgeries were conducted between Hangzhou and Alaer, China, spanning 4,670.2 km by Fan et al. The surgeries had an average network delay of 73 ms, with a median operation time of 39 minutes and minimal blood loss (2 mL) (21). The surgeries proceeded without network disruptions or major complications, and a two-month follow-up confirmed the safety and feasibility of 5G-enabled remote robot-assisted surgery. In conclusion, the safety and feasibility of 5G-based remote surgery have been extensively validated, paving the way for the broader adoption of remote surgical technologies.

Challenge in the application of 5G remote robotic surgery

Despite its advancements, 5G technology remains vulnerable to environmental factors, particularly in transoceanic communications, where ensuring continuous, high-quality transmission is challenging, highlighting the need for ongoing research to optimize signal reliability. 6G system represents a new paradigm in wireless communication, driven by the Intelligence Internet of Things for more efficient data storage and processing (37). Supported comprehensively by AI, 6G offers enhanced system capacity, faster data rates, lower latency, increased security, and superior quality of service compared to 5G (38). This technological leap is poised not only to advance remote surgery but also to drive patient-centered intelligent services integration and revolutionize the entire healthcare value chain (39,40). Notably, ensuring the security of patient’s medical data and protecting networks from cyberattacks are vital for safeguarding privacy and maintaining the integrity of medical procedures (41,42).

However, the widespread adoption of robot-assisted remote surgeries is hindered by the necessity for highly experienced surgeons and advanced medical centers. Based on the experience of our team, we believe that, whether during the initial or mature stages of remote surgical technology, the surgical teams at remote sites (those located near patients) must possess sufficient expertise and technical proficiency to address any complex intraoperative issues that may arise within a short time. The solution to this challenge is to establish specialized remote surgical teams at these remote sites, ensuring they undergo systematic training and assessment to equip them with the capability to take over surgeries in case of emergencies, thereby safeguarding the quality of the surgery and the patient’s safety. We conceive a feasible solution by integrating high-quality local medical resources and centralizing experienced medical personnel to create small-scale, specialized robotic surgery centers in regional areas. Firstly, this approach would alleviate the financial burden of acquiring robotic surgical equipment in remote or even harsh regions, thereby improving the accessibility of robotic surgeries and fulfilling the initial goal of redistributing quality healthcare resources through remote surgeries. Secondly, the establishment of robotic surgery centers that integrate regional medical resources serves as a technical safeguard for the success of remote surgeries. More importantly, we envision that as these regional robotic surgery centers mature, they could enable fully autonomous robotic surgeries in the local areas, significantly improving local healthcare standards and fundamentally addressing the issue of unequal distribution of quality medical resources. Once a patient is identified as needing specialized surgical intervention, they will be referred to the appropriate specialist via teleconsultation. The specialist will then evaluate the case and authorize the surgery, directing the patient to the nearest robotic surgery centers for the procedure.

Robotic telesurgery raises critical legal and ethical concerns. One of the primary ethical concerns is patient autonomy and informed consent. Given the complexity and novelty of remote surgeries, patients may not fully comprehend the potential risks associated with a procedure conducted by a distant surgeon. Ensuring robust, interactive consent procedures, involving video consultations and digital tutorials, can address this concern and enhance understanding of the technology and its limitations. Another ethical issue is the surgeon-patient relationship, as the absence of direct, in-person interaction could impact trust. To mitigate this, clear communication protocols and the involvement of local healthcare teams can ensure that patients feel supported throughout the process. Taken together, forming specialized ethical committees to regularly assess the practices in remote robotic surgery and ensure patient safety is necessary (43).

From a medicolegal standpoint, the question of liability and accountability is paramount. In cases of surgical mishaps, determining who is responsible—the surgeon, the equipment provider, the healthcare institution, or the AI—remains a grey area, particularly in cross-border remote surgeries with different jurisdictional issues. Currently, as global remote surgery remains in its exploratory phase, the lack of standardized protocols for operational procedures and guidelines also increases the potential for unforeseen risks during surgical interventions. Learning from the experience of Europe in assigning legal responsibility to AI (44), the EU proposes to recognize “electronic persons” (refers to the legal consideration of artificial entities such as robots and AI) for addressing liability ambiguities in human-AI interactions. However, this concept faces criticism regarding potential moral hazards and the dilution of preventive measures against irresponsible behavior. AI-integrated robotic surgical systems operate with limited autonomy and function primarily as decision-support tools for healthcare professionals. In these cases, medical practitioners as the ultimate decision-makers, may shoulder a portion of the associated liability. Therefore, international legal frameworks should be updated to define the roles and responsibilities of all parties involved, while providing a clear path for malpractice claims. Although the notion of electronic personhood offers a promising solution, its implementation must be meticulously balanced to ensure fairness and prevent misuse. A critical balance must be struck between fostering technological advancement through limited liability protections and enforcing strict liability protocols for high-risk medical AI systems. Such calibrated governance could incentivize safety-driven innovation while ensuring patient protection through mandatory transparency requirements and developer accountability.

Furthermore, cross-border interoperability of data governance frameworks emerges as a prerequisite for globalized AI healthcare applications. The EU’s General Data Protection Regulation exemplifies high-standard data protection through its mandates on algorithmic transparency and user consent, serving as a potential blueprint for international harmonization (45). This framework enhances transparency and builds trust among users. Achieving global interoperability, however, remains challenging due to varying regulatory standards across jurisdictions. In India, frameworks like the Information Technology Act provide indirect applicability for addressing AI liability (46). This underscores the need for countries to adopt similar strategies to align their data privacy regulations with international standards, thereby fostering a more cohesive global approach to AI governance. Harmonizing these standards through international agreements or mutual recognition frameworks could facilitate smoother cross-border data flows, accelerating innovation while maintaining privacy protections. Such efforts would also support the ethical deployment of AI in healthcare by ensuring that data subjects’ rights are universally respected.

Also, the mutual recognition of regulatory approvals and risk-based classifications plays a pivotal role in fostering innovation within the healthcare sector. The EU’s risk-based approach, as outlined in the AI Act, categorizes AI systems based on their potential impact on fundamental rights and safety. High-risk AI systems undergo rigorous conformity assessments to ensure they meet essential health and safety requirements. This tiered regulatory framework enables efficient oversight while promoting responsible innovation. Nonetheless, achieving mutual recognition of these approvals internationally and identical risk tolerance thresholds poses significant challenges. A WHO-led consensus on evidence standards for AI validation may facilitate mutual recognition of regulatory approvals. Establishing common criteria for risk assessment and harmonizing approval processes could mitigate these barriers, allowing for broader adoption of AI technologies in healthcare settings worldwide. In conclusion, while the integration of robotics and AI in healthcare holds immense promise, it necessitates a nuanced approach to liability, data privacy, and regulatory coherence. By leveraging insights from the European experience, stakeholders can develop comprehensive strategies that address these multifaceted challenges, ultimately enhancing patient outcomes and fostering ethical innovation. Future research should focus on refining these frameworks to better accommodate emerging technologies and evolving societal expectations. Finally, acceptance by patients and society may take time for the concept and practice of remote robotic surgery.

Conclusions

The integration of 5G technology into telemedicine offers a transformative potential to redefine a more interconnected and efficient healthcare ecosystem. By overcoming barriers concerning distance, latency, and access, telesurgery has the potential to realize improving effects, reducing disparities, and more global in patient management and surgical interventions. However, its successful implementation requires addressing challenges related to network stability, security, and the development of global protocols. Legal and regulatory frameworks must also evolve to ensure patient safety and provider protection. In addition, its widespread adoption depends on advancements in infrastructure, medical equipment, and training. Regional robotic surgery centers utilizing 5G could bridge gaps between advanced and resource-limited areas. AI and machine learning could further improve remote surgery precision, aiding in better surgical decisions. As these technologies continue to mature, the future of surgery will likely be defined by seamless integration, real-time collaboration, and enhanced patient experiences, all underpinned by the transformative power of 5G and even beyond the 5G network.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-16/prf

Funding: This study was supported by the National Natural Science Foundation of China (Grant No. 82272679), the Shanghai Oriental Talent Youth Project, the Shanghai Talent Development Fund (Grant No. 2019073).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-16/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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