Telesurgery and surgical robotics. It’s real

Telesurgery remote robotics

Introduction

So let me be totally transparent here to start with. About five years ago I was still in the camp of thinking that the idea of telesurgery was technically feasible but totally irrelevant. I could see that idea of controlling a robot over 5G etc was technically possible . But I just keep coming back to the “why?”

I was struggling to understand why a super busy surgeon would want, or have capacity to do remote surgery. How would they get paid? How would regulatory work, and operating rights? Legal ownership? Lawsuits?

It all felt just too messy to become more than a strange curiosity for demo purposes.

Roll forwards to 2025 - and well my mind is in a totally different place. Physical scar tissue of trying to launch a robot globally, use cases that have come up, different formats of robots and sites of care - all the things that have totally changed my mind. So let me explain more.

I think that everyone harking on to the Lindbergh Operation is one of the key issues that gets in the way of modern thinking about telesurgery - remote surgery. As a reminder - this was a 45 minute cholecystectomy performed remote by Jacques Marescaux and the team from IRCAD. The patient was in Strasbourg and the operator (using  ZEUS by computer motion) was in New York.

And this is where referring to this procedure starts to create issue in many people’s minds. Firstly an operation from New York to Strasbourg for a simple cholecystectomy sounds silly. It is often met with snarky remarks and noses in the air. But we must remember this is 24 years ago and it was a pure demonstration. It was only ever meant to be a demonstration.

Lindbergh Operation 2001

So the next issue - 24 years later and we still don’t have telesurgery as mainstream… then clearly  it must have no value. (I hear this a lot.) If it was valuable it would be diffuse - right?

The other thing people refer to (which is not exactly accurate) is that they say a dedicated fibre optic was laid between New York and Strasbourg. Well not actually. But it did require the dedication of a fibre network for the case with the coordination of several telecoms companies and that “pipe” was not available for standard customers coms - so it was in effect very dedicated and expensive. And unfortunately that - even today - sticks in people’s minds. You need dedicated informatics infrastructure and that makes it prohibitive.

It was estimated (all in) to have cost about $1 million in the day ($1.81 million equivalent). So some people still have in their heads that telesurgery is an expensive fools errand.

I would all ask that we acknowledge that pioneering case - but understand it was a quarter century ago and the entire world has moved on. Nearly everyone is steaming HD and 4K movies all the time - all day. That wasn’t happening in 2001. Technology has taken massive leaps and bounds with connectivity since 2001. And the hardware and software behind it all is light years ahead. I think we should all doff our caps to that pioneering work but consign it to history.

Current uses of telesurgery

Okay - roll forwards to today. With modern communications infrastructure and protocols like 5G we can shift vast amounts of data across standard lines in a super stable and secure way.

We also have nearly 25 years of experience of gaming, lag, latency compensation, and building redundancies into systems. Chips and software inside the robots are so far ahead of what they were back in 2001 - nothing is comparable.

The one thing that is in common with the Lindbergh Operation is that like the team from IRCAD, the advances and push for tele-robotics is coming from outside the USA. China, India and Japan are absolutely leading the way in telerobotics - having completed thousands of cases and many firsts.

That is not to say that a few - very few - US companies are not also doing some pioneering work there - like Virtual Incision and Sovato. But the surprise to everyone might be that Intuitive has not been at the forefront of this. (Update: they are coming.)

I will go into details later of why that is the case, and why China and India are the clear front runners in this new way of delivering robotic surgical care.

I first need to turn to China - where Edge Medical with the MP1000, Harbin Sagebot with Kanduo, Microport Medbot with Toumai (to name a few) have built their systems from the ground up with telesurgery in mind. They knew that China was in need of telesurgery.

Edge Medical has been demonstrating multiple surgeons in Europe operating remotely in China - via distances of over 8000km; with little to no lag or issues. They have repeated this from many countries including Italy. And this has been a “nice demo” of capability - but they are actually using this daily within China to perform remote cases. And later I will explain why China and India are particularly in need of remote telesurgery.

Edge Medical Telesurgery

Sagebot and Kanduo have been doing some very interesting cases of telesurgery. Their system is capable of not just a single surgeon doing telesurgery. But you can hook up two or three surgeons from different continents - and stick the patient in yet another location. An impressive demo was shown at SRS 2024 with Dr Vip Patel participating in a three location surgery. Where two consoles worked independently controlling two arms each - (so 4 arms at once independently) and a third surgeon was supervising (big use case coming) that could jump in and take over any of the arms as needed for the “specialist” parts of the operation. 3 surgeons - and multiple arms. Wild.

Then you have Microport Medbot Toumai that are again demonstrating their prowess with global procedures via the 5G networks. In fact a recent 12,000km record procedure between china and north Africa was completed over standard broadband. This is what is changing things. A standard broadband in 2025 is way more capable than a dedicated fiberoptic in 2001. (Technical people may be rolling their eyes.)

We have these companies also using dedicated satellite communications to do procedures across the country. Using the Apstar- 6D broadband comms satellite surgeons performed across mountainous regions of China where there was no physical landline connection. This was done using the Toumai. Each week they are pushing the boundaries of what they can do with remote telesurgery.

Now the idea of using satellites to relay data to remote control a robot is strangely the original DARPA concept for what become da Vinci.

Original DARPA battlefield surgery

The key is that Medbot has been working hard on the way it uses infrastructure to do this and ensure low latency and “issue” management if they should get lag - or delay - or loss of comms. Having fast switching to the local control and the ability to quickly stop the surgery is critical. And well they have that all worked out.

They have also been working with many of the world’s top network providers to ensure they can easily work across global networks. (More later.)

Now let’s cross briefly to Japan where the homegrown robot that is Hinotori by Medicaroid is performing remote 5G surgeries day in and day out across Japan. If you understand the geography of Japan, you understand why having the capability to have expertise from Tokyo telesurgery into a remote system on an island a few thousand kilometres away makes sense.

In fact this should start to give you a clue as to why China, India, Japan are pioneering this and why South East Asia will also be a hotspot for this technology. And why we see more and more news articles on Indonesia and other countries. They are laying down the base work for telesurgery in these rapidly modernising and growing healthcare systems. Systems that have large geographies and spread out populations. (Sounds a lot like. Brazil;… hmmmm. Hows Medbot doing in Brazil?)

A trip across now to India and SS Innovations with the Mantra 3. They too have been demonstrating remote tele surgical robotics - but just last week they went one step further. You see general surgery is up there for most of the systems. But Sudhir Srivastava performed remote cardiac surgery. Yes - doing IMA takedowns and anatamosis in a Cardica bypass procedure. This is not demonstrating on a cholecystectomy - it is on a beating heart. (I know there are big risks in every surgery but you know exactly what I mean.)

SS Innovations remote cardiac telesurgery - Mantra 3

The Asian companies are pushing the boundaries - and this is real - here and now and accelerating. And what this case showed is that for critical steps - the LIMA LAD anastomosis is massively user skill dependent - an expert can be brought in (especially during learning curves) to do the hard technical  parts of the procedure - the important parts. So we start to see another use case of telerobotics that I will dive into deeper.

Now I do want to make one honourable mention about Virtual Incision. As they have probably done one of the most extreme demos of remote telesurgery capabilities by having surgeons in Nebraska operate Space MIRA - their ultra compact RAS - while it was orbiting the earth on the International Space Station. Firstly that shows the distance, the complexity of doing that. But you have to understand that the link to the ISS is not that high of a bandwidth. So they demonstrated lag and latency are just not an issue. (No patients were used - just to be clear.)

I have personally driven that system over a standard local broadband network from their HQ to a lab. It works and it feels like “you’re there.”

What I’m trying to say is that telesurgery is here and now. It’s being used within countries, across borders, using 5G networks, standard broadband, 12,000km - round the globe, multi users. It’s being used to do demonstrations and is even being used every single day for procedures on humans.

I think it will be utterly unforgivable for any new system to come to market that does not have a well thought out telesurgery capability. If your company and system does not have this - I feel that for a growing number of countries, governments, providers this will be a mandatory tick box on tenders, for training, for proctoring or rather precepting, and for networks that want to now deploy hub and spoke robotics across their networks.

In simplest terms: Proctor: oversees / Precptor: Hands on

The uses of telesurgery

I’ve started eluding here to the potential real world uses of the telerobotic remote  abilities of systems. Well outside of interesting demos of course.

One of the major things that drives the need for remote telesurgery is scarcity. And by that I don’t necessarily mean the scarcity of robots - but that does in some cases factor in. Because if we had a surgical robot in every single OR on the planet, and everyone was equally good and well trained - then you wouldn’t need to use remote surgery. (Well some weird corner cases.)

As I’ve watched the number of systems multiply, the number of hospitals wanting robots grow - there is one common scarcity around training. To ideally get a new team, new surgeon to adopt robotic surgery: for the next ten years at least we will be heavily reliant on proctors and preceptors. Now there is no substitute for having a trainer sit in the same room and observe not only what happens console side but also bed side.

(Okay let me pen something in a decade where the AI assistant proctor and preceptor comes in and helps)

However, surgeons are becoming more scarce and flying halfway around the world to observe and assist in training of a new user is becoming less practical. Hospitals don’t want their surgeons out of their own ORs. They don’t want them away for a week. Also scheduling to get enough cases to make that one trip work gets harder. The education and learning curve can take months - you can’t keep flying people.

Companies cannot afford to keep sending people and paying flights, and hotels and down time fees and training fees.

This is a bottleneck for the entire industry. But if we can augment that training and proctoring with remote support precepting - with the ability to actually jump in - intervene and demonstrate!!! Then we start to help reduce that issue in the world of robotics.  We reduce costs and open up the possibility that proctors / preceptors will be used more willingly - not bound by cost constraints or scheduling challenges. I believe strongly that telesurgery can increase the amount of proctored case support - whilst reducing the complexity and cost of that case support. It is a phenomenal use case - and I’m seeing it used more and more.

If you go slightly parallel to that - you can alter the learning curve and remove some of the risk of conversion for the learning curve. How?

Well, it allows more complex cases to be scheduled earlier on. Cases a lone trainee mayn’t think to attempt without a safety net. A novice surgeon can go into a more complex case  knowing they have their “phone a friend” on line right next to them. The novice can go as far as they feel comfortable - but for say some difficult steps such as a complex anastamosis - there can be handoff to the expert - and a much better learning experience. Slowly, slowly there can be less hand holding as the novice goes up the learning curve. And none of that support requires months of scheduling and flights and time out.

Extend that further. An expert robotic surgeon does 99% of their procedures with no issues. But they have a rather unusual / complex case where having a world expert (that focuses on that) can come in and join… if not do the entire case. It allows hyper specialists to support difficult cases on those rare occasions without having to travel across state, country or borders.

Another case is emergency rescue. In surgery shit happens. Often a urologist is called in to fix a cut ureter. Well what if you could dial in the urologist from up state, or next door and have them just jump in and repair that issue without even having to step across to the OR. Bring in world experts when the going gets tough and you need a rescue. Better for patients, better for surgeons, better for the hospitals and better for the payers.

There are cases where a robot may be taken out to a remote hospital- purposefully for a day to do two or three hyper specialist cases - to save the patients having to travel six hours and stay away from home. It could allow a real hub and spoke system where a robot can be shipped for a few days - do the cases and then ship it back. The “roaming robot” as seen with Toumai can be a shared asset across a network without the need for the surgeon to “follow it” physically. Less disruption for their cases - better use of specialised knowledge - better use across a health network of resources. And multiple specialities can do those remote dial in days to be have more efficient use of the roaming robot.

Hub and spoke and multi location can absolutely benefit from remote surgery. I see more and more surgeons that split across say public and private. Or across multiple locations in a day. They can end up with a one hour travel each way - that’s two hours when they are not operating. Remote surgery can allow them to be “in two places at once.” That is a huge efficiency gain if they are not losing to windshield time (and finding parking.)

Remote telesurgery precepting or surgery

It can also mean that robots that are in place can be used more. If you had a spoke based robot that was bought just for prostates on a Tuesday and Thursday. Well now that robot might do a case on a Monday or a Friday as the Gyn team remote in - and do a case in the afternoon. It can lead to way better resource utilisation and even reduce the total number of robots needed, help scheduling and increase operating loads. That in itself can lead to a loss of case leakage from Hopsital networks (I won’t go into deep details now.)

And then of course there just is simply doing more cases by being able to do it remotely on patients at a distance. So if you’re a surgeon with not enough case load - you can get more case load. Maybe more in the private sector than the over stretched public sectors around the world.

And it maybe that you as a patient just want your prostate or your bypass or whatever done by “The number 1 surgeon in the world.”

(This could even be one of the catalysis’s to super hyper procedure specialisation. A surgeon does every ventral hernia in every location across a network. They can now be the ventral hernia guru - with enough case load of ventrals. And that means better outcomes - as more cases generally means better outcomes. It could allow network so go hyper specialist. One location driving the cases.) ** yes I know pre op and post op care also counts - but I’m dreaming a little here. I have a list of who I’d like to do my ailments surgically if I had them. I know who’s doing my prostate, or hernia, or gallbladder or Lima LAD. And if that means they could do it on me near my home without me travelling…. Hey why not !!

There are other corner cases I will not go into now - space surgery for Mars missions (I know I know) - battlefield support (I will not cover the reality of that now.) But there are some corner cases that may be interesting - including a roving “missionary” robot that goes to rural areas and yet allows world experts to all contribute on rotation without having to all fly there.

There are more I’m sure.

Why India and China are at the forefront

I was asked this just last week. And as I’ve been digging into this for some time, it has become more obvious to me. So let me dive in.

Both India and China have several problems that are identical. Massive populations, disparity in wealth and health in different regions. They both have massive geographies. They both have low ratios of expert surgeons per 1000 population. They both have massively upward moving economies and classes and a huge demand for healthcare. They both still have vast rural populations. They have strong socialised and private health. They both have governments pushing the agenda of improving healthcare. They both have all of this under one single country, regulatory policy, health policy, credentialing policy.

China Population density

That last one will come up in the barriers to telesurgery for most other places. But for China, India Japan that is not an issue. It’s a benefit.

So when you look at the macro situation - several things start to stand out as to where you might be able to spread expertise across a geography to meet the demands of that large population that have growing expectations of better health. It is the democratisation of surgery much talked about by Verb and surgery 4.0.

The ability for surgeons to have operating rights and get paid to do procedures with little to no hassle means there are not those barriers to a surgeon in Beijing doing a prostate in a remote rural area between Qiemo and Hotan.

If you look at it - China, India and to many extents Japan (long island nation) are almost pushing for the spread of robotics capabilities via remote surgery. In fact - it starts to become clear that “you can’t really do that with lap or open surgery” so robotic surgery becomes an almost mandatory route to delivering decentralised expert surgery to the masses. There is no “just popping from Shanghai to Kashi to support a few cases for a morning. Remote telerobotic surgery just makes sense to them.

Same for India - to travel across India requires a lot of travel - and even short distances can be a nightmare in traffic. Popping across Mumbai for a quick case is easier said than often done. So being able to remote in - do a case and then continue what you were doing is exactly what SSi are demonstrating so eloquently.

India population density

It shows the opposite of why in Europe it just makes no sense. You have small self contained geographies - multiple regulatory approvals - operating rights - and languages. You can easily hop  on a plane or train and be at the other end of the country in an hour or so (okay 4). The density of health care makes little to no sense for major use of telesurgery in Europe. Is that why none of the systems coming out of Europe have that capability? And do correct me if I'm wrong.

UK population density

Scale difference UK and China

Likewise in the USA - to date it has not felt a need. Plus it has been complex to operate across state borders - and more importantly in the USA - who gets paid and how. But I do think that will change as more hospitals become part of bigger networks and the hub and spoke model even here starts to make sense.

But it is clear why even Intuitive did not focus hard on telesurgery. Again I think that is about to change. Late addition: More information coming out that Intuitive does have the capability and there rumours of a switch on of that feature in the da Vinci system.

UK to USA size comparison

The Challenges of telesurgery

If it was easy the, everyone would be doing it … right?

There are multiple challenges to telesurgery - and one of the biggest is the mental barrier of “Why?”. But once we get past that we then come across the real world challenges of being able to operate - via a robot - across the network - safely - effectively and legally… it can make sense.

The first barrier is if the robot itself is really designed from the ground up to be a telerobotic system. Halt !! But aren’t most robots teleoperated with a console - wires and arms?Yes and no. It is true that for many of the “classic” surgical robots the operator is acting on the arms remotely. But it goes beyond that a little - as you need to get power to the arms - and comms to the arms. You need 3D video flowing and getting to the console. I’m not going hyper technical now - but some systems are built from the ground up to make sure that the boom or arms and imaging can work independently and over long distances from the console.

They have comms protocols that deal with the increased lag in signals. They have redundancies and back ups and software that kicks in if a connections dropped. They have their own power supply.

What you can’t have is an operator 1000km away seeing their grasper in free space as it was a few seconds ago - while in real time it’s actually tearing open a major vein. You need to build the systems right, and from the ground up, to be able to cope with the physical and temporal differences. Not all robots are equal.

Next is the network. If you have ever been on a Zoom call or a teams call, or played an online videoi game (I’m a COD fan) - or even watched Netflix at home and the quality of the line drops - it is super frustrating. A pixelated video on Netflix that buffers. A lag in a game and you can’t hit the target. Missing information or video in a zoom call - or it hangs - or disconnects.

To be able to do remote surgery you generally need good quality - high stability networks like 5G.

But those networks also have to be secure and hack proof. What you don’t want is a third party getting into your connection and taking control of a robot as it’s doing a procedure.

Next is regulatory. Both around the security of the teleoperated systems - lag - latency and cyber security. But there is still a lot of work to do around the regulations of use. You see if a system is cleared in Europe but not in the USA - and the surgeon operated from the console in the USA but does the procedure in Europe - is that system being used off label in the USA?

The subtle technicalities by region and country add a deep layer of complexity. And I’m still thinking “grey area” for some of the live surgery demos I’ve seen last year.

And that complexity then expands to operating rights. Is the surgeon in the United States qualified and allowed to operate in the country in Europe - where technically the procedure is taking place. Does a US surgeon in Florida have operating rights in California if they did interstate telerobotics.

Is the surgeon credentialed to even work at other facilities remotely?

It starts to get into a horrible legal and regulatory nightmare - and if that “working it out” is left to the individuals then missteps could be made. Or it’s just too complex to contemplate.

But you go one further - and let’s say we worked out all the paperwork to get it done - for a demo case at a congress then there may be no payments involved. Proctoring / precepting - that is usually paid by the companies deploying the robots. But when the buzz dies down and we get into regular day to day use - the money must flow.

How does a surgeon in London get paid for operating on a patient in Dubai?

How does a surgeon in Texas get paid if they operate on a patient in France?

Does the surgeon’s contract allow this kind of “moonlighting?”

And who’s paying for the infrastructure and payments for any infrastructure? What if the system requires some dedicated secure lines in a certain country? Or satellite time and bandwidth? Small as money may be - all of that needs working out.

And then it needs all the contracts putting in place - because we all know how much we all love our paperwork. So will that contract be in French for a Texas surgeon under French law? Will the insurance companies cover it? Where is the paper trail to make all of this happen? Even down to the consents. (That may be easier as the host surgeon may say they are the surgeon taking consent for their patient.) But it needs working out and formalising.

It will all be “okay” right until that lawsuit comes from NewYork state to a surgeon in Berlin… and it gets real messy - real quick.

For me - I think the technicalities of the infrastructure are the easy part. I think the bigger challenges will be the paperwork, regulations and payments around this.

Who is dealing with this infrastructure?

Let me first point to the companies that are creating the technical capabilities to do this. There are many examples - but one of the companies leading the infrastructure is Microport Medbot.

Medbot has already passed the 1st generation infrastructure to the 2nd generation. In 1st gen you required dedicated optical lines, point to point connectivity and were reliant upon partner carriers to carry the whole signal and help work it out during a case (give dedicated traffic). It was bespoke and expensive

Medbot old vs new telesurgery architecture

2nd Generation is about simplification and ease. It is about becoming less reliant on bespoke infrastructure but working with carriers to set up a shared network effect. It also then requires some smarts in the system and the network handling capabilities. One such thing is the ability for signals to pass over 5G, 4G, dedicated lines, satellite, WIFI all fluidity under interchangeable protocols. In what they call a network fusion - so that signals can be handed off and used across multiple network platforms to be able to span the globe.

This makes the signal transmission independent of a fixed network provider and allows hand off across networks that “simply works” and that is truly global. Also much of that ability has come in the way they try to reduce the data loads and the bandwidth needed. <200ms latency with only 1.25Mbps bandwidth - which can be handled by most modern networks.

Toumai telesurgery architecture

That all gets combined with their Toumai system software that is built from the ground up on how it does real time switching, uses security protocols (to allow it go over public networks) and the built in safety protocols that can rapidly handle problems if they arise.  Such as disconnects or latency.

Toumai switching architecture

It’s not just Medbot doing this. You also have technical solutions that get around some of the other more logistical issues. Most mainframes will need a big bedside unit (boom) and a tower and a second local console. That is a lot of big and heavy hardware to ship around. It might require dedicated transport like Toumai.

Instead companies like Virtual incision have taken a different approach - as was seen with SpaceMIRA. And now being worked out back on earth.

Space MIRA Virtual Incision

They think that sending out full systems with huge hardware out to a remote location to allow shared services will be challenging with da Vinci like form factors. So their system is quite unique in that you ship the small bedside cart and a MIRA in a box. No console needed. That breaks own one of the major logistics issues when we think hub and spoke. As now you can literally UPS a sterile system straight to the spoke hospital - and the van driver can walk in the bedside unit and the actual robot along with other hospital supplies. Simple.

The operating surgeon can work over standard internet connections (I know I did it in Nebraska) and that simplified remote hardware and compactness is one way they are overcoming the logistical and technical issues around real everyday telesurgery options. Don’t underestimate logistics in wandering systems.

But all of the companies working out all of the technical solutions (and there’s lots) are only really solving the tech side… and not diving into the reality of the administrative side. Which I think is the bigger elephant in the room.

Step in Sovato and Yulun Wang.

Sovato Yulun Wang Architecture

Sovato is taking an affiliated network approach to trying to solve many of the technical (providing a backbone infrastructure) but more importantly starting to work on the logistics, regulations and the administrative side of the issue.

It’s early days, but by using an affiliation network - they help to get the regulations, paperwork, payments, scheduling, patient slection (help) etc - all pre wired in. Their service is to make doing telesurgery easier and “done right.”

What Sovato Delivers

They want to be that bridge between the healthcare providers and robot industry to make it quick and simple to get into their pre worked out network. Of course there will be a lot of up from screening  paperwork - forms - and getting everything set up. But once into such an affiliation program (a network) it should all then just become plug and play each time you want to do a surgery. Even down to scheduling the patients and surgeries so that the two remote sites sync up operating schedules to drive efficiency. And of course they ant to make the payments simple - and “work.” — because in the real world Dif the economics don’t work - no surgery is being done.

They are wanting to bring a blend of administration tools, networking back bone and some supportive technologies such as audio visual support systems that go beyond just relying on the operative image, and a tele proctoring system if you have one. They know the dance in the OR is a team sport and that there needs to be a more comprehensive team approach to remote telesurgery.

They also know that (especially in some countries) there will be very deep scrutiny around the secure and reliable network connections. Again they are looking into all of that.

They are making a comprehensive system that is as plug and play as possible to allow tams to deliver telesurgery.

I think that the solution will work very well for local networks of hospitals - will get a little more challenging when you try to go interstate (but all doable) and will become a whole lot more complex if we want to do this between countries.

However - besides language and local regulations / laws that need navigating - we do have many -say- US hospitals and networks that now have satellite hospitals of their own network in other countries. Not difficult to see HCA operating USA to London or Dubai to maximise the use of their facilities. Maximise income for the hospital and the surgeons, and offer more choice to the private patients world wide. Social medicine systems and Sovato may be a little further off between countries, with a lot more work to do.

But I could see the NHS (with its crippling waiting lists) maybe (with a big M) be able to improve efficiencies in some cases with a remote surgery NHS network. Sovato like systems applied across the NHS could be intriguing.

I know for sure places like Tuscany in Italy are doing huge amounts of work on hub and spoke deployment of robotic surgery. The want to allow a standardised level of care and equal access to all patients independent of if they are in Florence or a more remote town. So I could see (good luck Sovato trying to navigate the Italian paper work mountains) this being applied in regional levels - even across Europe. I actually think there will be a lot of local solutions coming up for this. Maybe not as polished but effective.

What about the future?

Today I’m not going to go into the future of things like remote stroke telesurgery with companies like X-Cath. That for me is another whole post.

What I do think is that immediate future will be a scramble of all systems (including da Vinci) to work out how to get their system to do telesurgery and catch up with the leaders. In part because it will become a commercial tick box on tenders and contracting spec sheets. If you don’t have it (even if they never use it ) you will get market down. So all systems will need it. (Well those that use teleoperation - the DistalMotion or Moon Surgical doesn’t make sense.)

I think there will be a rush of firsts - as we are living now. SSi first cardiac tele surgeries, Medbot first satellite, Edge first Italian, Virtual Incision flirts Space demo etc etc etc. So I think we will see 12 months of exciting and interesting “what can be done”. I do think that within 12 to 18 months we will see the first hospital network set up a well orchestrated telesurgery roadmap.

I do think the “phone a friend” rescue of a case - “erm can you help me put the ureter together… can you help with this really weird anatomy…” etc will be a very good use case. And we will see more of this. That won;’t be so reliant on “payments” so could happen faster.

But beyond that we will see the real world cases start to bubble to the surface. I think one of the first is really genuine assistive teleproctoring / teleprecepting - where the teacher can actually demonstrate and not just telestrate. I think this will greatly impact learning curves and allow learners to schedule the more difficult cases - even early on - as they have assistance of they get in trouble. I think this “hyper selection” of easier cases has been an issue of dragging out robotic adoption and learning curves for some time. I hope telesurgical proctoring and precepting support with remote capabilities will speed up learning curves through opening up early case selection.

I think the teleprecepted remote surgery will also reduce costs - and improve access to preceptors - which again will help with getting faster adoption of teams into robotic programs. We see this already with North Africa and Toumai - where that remote teleproctoring is enabling them to get the world’s best proctors to help and teach. Opening up markets that were maybe less inclined to have systems deployed in the past.

I think the work horse of telesurgery in the near future will be within hospital networks were they want to maximise robotic surgery access - maximise assets used in facilities - improve scheduling - and deploy their network of experts across their network of robots to remote locations. This for me will be an easy win - and will be “easier” to deploy as well as have an economic driver benefit.

And the use of in country democratisation of surgery - where language - payments and regulations are easier to deal with will simplify things. China, India and Japan being those markets out of the gate. Then some regional hub and spoke uses like Tuscany. And of course in the USA within the hospital networks.

I think we will still have the odd transcontinental case now and again - and  few islands of “remote health tourism” if you like. But this won’t be a mainstay. I think inter country regulations - payments and opening rights will just be painful enough to keep this off mainstream.

Hey - but I was totally wrong about any form of telesurgery being used just 18 months ago. So I could be wrong here as well.

Exciting times.

These are just opinions of the author for educational purposes. All trademarks and rights remain with the owning companies. This information is speculative and can be wrong.