Cutting the cord: Lifesaving telesurgery in the age of 5G

The 2024 landmark 5G-enabled telesurgery from Orlando to Dubai

The weekend of February 3-4, 2024, marked a historic moment in the annals of medical innovation and technology. More than 200 practicing surgeons, 10 sitting Presidents of Medical Societies, the White House, the FDA and NSF as well as telco and most robotic surgery companies sacrificed their weekend to be at the Nicholson Center in Orlando, Florida. We witnessed a pioneering achievement that could very well redefine the future of surgical procedures and healthcare delivery across the globe.

Notably, we showcased an unparalleled live telesurgery, connecting a surgeon over a staggering distance of more than 10,000 kilometers, from Orlando, Florida, to Dubai, United Arab Emirates, and thereafter from Orlando to Shanghai, China. This feat was made possible through the incredible skills of robotic surgeons; and the integration of advanced robotics with the cutting-edge capabilities of 5G technology.

Indeed, at the heart of this was the use of 5G technology, known for its ultra-low latency and high bandwidth. These features are critical in telesurgery, where outages can significantly impact the outcome of surgical procedures. The 5G network ensures near real-time communication between the surgical team and the robotic instruments, allowing the surgeon to perform intricate operations with precision akin to being present in the operating room.

I (Vipul) recall my initial thoughts on hosting a telesurgery conference, believing that it may not accepted well due to the infancy of the project. However, the attendees supported the vision of telesurgery as an avenue for healthcare equity, while acknowledging the significant hurdles ahead in terms of implementation, cybersecurity, credentialing, regulatory and cost/payment.

The live operation was thus not just a technical demonstration but a testament to international collaboration. Surgeons and medical professionals from different parts of the world joined forces, leveraging their expertise in a synchronized manner. This event illustrated the potential of telesurgery to break down geographical barriers, offering access to high-quality surgical care in remote or underserved regions.

Robotic surgery has been evolving over the past decades, but the integration of 5G technology represents a significant leap forward. Robotic systems, such as those developed by pioneers in the field, offer unparalleled precision, flexibility, and control. However, it is the advent of 5G with its capability to transmit large amounts of data at lightning speed that is now truly unlocking the potential for remote operations.

This synergy between robotics and 5G can lead to safer, more efficient surgical procedures and a reduction in recovery times for patients. The successful telesurgery from Orlando to Dubai and to Shanghai demonstrates the potential for advanced technologies to provide equitable access to healthcare services, regardless of geographical constraints. In regions where specialist surgical expertise is scarce, telesurgery could become a lifeline, enhancing patient outcomes and saving lives.

From concept to reality: The heroes behind 5G-enabled robotic telesurgery

The journey to the landmark event of live telesurgery is a story of vision, perseverance, and groundbreaking innovation. This narrative is not just about the technology itself but about the individuals and pivotal moments that have collectively paved the way for this medical and technological marvel.

At the forefront of this revolution stands our robotic surgical community, embodied by renown surgeons like Prokar Dasgupta, Nadine Hachach-Haram, myself (Vip Patel) and many others. Our vision and dedication have not only propelled the field forward but have also inspired a generation of surgeons to explore the potential of technology in enhancing patient care.

Before them, pioneers like Rick Savata, Fred Moll and Jacque Marescaux have each contributed chapters to the story of robotic surgery. Savata's initial concept of robotic surgery some 40 years ago emerged as a radical idea. Moll's commercialization efforts through Intuitive Surgical have been instrumental in proving commercial viability. And Marescaux's groundbreaking remote operation, the Lindbergh Operation, has been foundational in underpinning the concepts of remote interventions.

A decade later, the conceptional designs of 5G technology have been a game-changer to telesurgery. The notion of 5G-enabled surgery, first explored about a decade ago as part of an MWC proof of concept that embraced the broader vision of an Internet of Skills, has finally come to fruition. Today, 5G has shown how end-to-end slicing can address critical issues like performance and reliability.

The successful implementation of 5G-enabled telesurgery is also a story of collaboration. From the early support by academia and industry, to the involvement of global regulatory bodies and healthcare professionals, this achievement reflects a united effort. The partnerships formed between technologists, surgeons, and innovators across different fields have been instrumental in turning a once-distant dream into reality.

Healing the world by saving lives and bridging healthcare divides

There are many lifesaving applications of telesurgery. But one stands out: the necessity for robotic telesurgery is underscored by the stark statistics surrounding urgent neuro interventions for stroke victims. For instance, around 200,000 Americans find themselves in need of these life-saving procedures annually, yet a mere 7% receive the necessary care. This gap in treatment is not just a medical issue but a geographic and technological one, with only 2,000 primary care centers in the US equipped to diagnose, not treat, and half of the population living within driving distance to such facilities.

The implementation of telesurgery using a combination of fiber and 5G at these centers could significantly alter the landscape, offering timely interventions that could save lives and reduce disability. Collaboration with tech companies, regulatory adjustments, and innovations in mobile medical technology are pivotal for this transformation. By leveraging 5G's capabilities, the healthcare system can extend the reach of specialized surgical care, making it a reality for the many who currently face insurmountable barriers to treatment.

However, 5G-enabled telesurgery offers extensive benefits across other fronts: once operational at scale, patients in remote areas gain access to specialized care, thereby reducing healthcare disparities and ensuring more equitable healthcare distribution. This leads to improved patient outcomes in these areas through the precision and reduced invasiveness of robotic-assisted surgeries, which in turn facilitates quicker recoveries and fewer post-operative complications.

The flexibility afforded by robotic telesurgery could also lead to shorter waiting times for surgeries by enabling surgeons to operate on patients across different regions or even time zones more efficiently. In emergency situations, such as natural disasters or pandemics, it provides a crucial option for immediate surgical intervention when physical presence is impractical or unsafe.

From a cost perspective, while the initial investment in telesurgery infrastructure is notable, the long-term benefits include reduced travel and accommodation expenses for patients and the more efficient utilization of high-end surgical expertise. For surgeons, the technology can lessen physical fatigue and offer a better work-life balance, potentially reducing burnout rates.

Educationally, robotic telesurgery is a powerful tool for training and skill development, allowing medical students and professionals in less accessible areas to learn from global experts in real-time. This fosters a culture of continuous learning and global collaboration, where knowledge and expertise can be shared across borders to tackle complex surgical cases.

Moreover, the data generated from robotic telesurgery operations is invaluable for medical research, contributing to the continuous improvement of surgical techniques and the innovation of new procedures. This cycle of research and development further stimulates advancements in telemedicine and robotic technologies, promising even more sophisticated healthcare solutions in the future.

By overcoming geographical and socioeconomic barriers, 5G networks are pivotal in crafting a more equitable healthcare system. This leap forward not only promises stories of hope for those in underserved areas but also marks a significant step towards universal access to critical healthcare services.

The future is now: 5G's role in advancing telesurgery

A core proposition of 5G is low latency. A core requirement of telesurgery is low latency. Understanding both allows to understand how 5G is indeed a core enabler for robotic telesurgery. The sources of latency in haptic telesurgery systems are four-fold:

1. Network Latency: This is the time taken for data to travel across the network connecting the surgeon and patient across the robotic system. Factors like network type (fiber, 5G, etc.), bandwidth, and distance play a significant role.
2. Processing Latency: This involves the time required for the robotic system and the surgeon’s console to process the incoming and outgoing data. Advanced computational capabilities are essential to minimize this latency but there are fundamental limits due to cybersecurity and video compression.
3. Haptic Interface Latency: The delay in the haptic interface, which provides tactile feedback to the surgeon, is also crucial. It needs to be minimized to ensure that the surgeon feels an accurate representation of the surgical environment.
4. Surgeon’s Reaction Delay: Depending on the technology realization of the robotic system, each surgeon will react differently to the haptic and audiovisual signals – thus inducing an additional subjective latency which needs to be trained to be minimized.

Network Latency	Processing Latency	Haptic Interface Delay	Surgeon’s Reaction Time
10s-100s of ms	1-10s of ms	1-10s of ms	10s of ms

In terms of the surgeon’s requirements, a fairly detailed analysis showed that surgical performance deteriorates exponentially as latency increases. The delay impact on instrument manipulation is barely noticeable up to 100 ms, fairly mild at below 200 ms, then increases from small to large at 300-700 ms, and becomes very large at 800-1,000 ms. Latencies of ≤200 ms are considered ideal for telesurgery, with 300 ms also being suitable. Latencies of 400-500 ms may be acceptable but are tiring; note that this event’s trial between Orlando and Dubai experienced 500ms. Further, latencies of 600-700 ms are difficult and only acceptable for low-risk and simple procedures. At 800-1,000 ms, surgery becomes quite difficult, suggesting that telementoring would be a better option in such cases.

10,000 km separation between surgeon and patient (i.e. 20,000 km round-trip) translate to approximately 100 ms in fiber, assuming no other sources of latency. Indeed, in fiber, electromagnetic waves propagate up to 30% slower compared to free-space. In reality, however, many other latency sources need to be added, such as wireless scheduling latencies if a wireless last-mile connectivity is used, congestion, processing delays, etc.

Telesurgical trials around the world confirm that in a best-effort internet, the achieved latency is roughly 5x of the theoretically lower bound; and in an end-to-end managed system composed of managed fiber and 5G, this is only 2x – thus significantly more performant. 5G connectivity can be enabled in different forms:

1. 5G Network Slicing: 5G is being rolled out globally as of 2024. It comes in two forms, a transitionary implementation called 5G Non Stand-Alone (NSA) and the actual 5G solution called 5G Stand-Alone (SA). NSA uses 4G as an anchoring system and thus is not able to reap all the key benefits of 5G, whilst SA allows for very performant systems. A key feature of 5G SA is the ability to implement “slices” which is a logically separated, self-contained, independent and secured part of the network, targeting different services with different requirements on speed, latency and reliability. Network slice characteristics are for example low latency, high bandwidth and ultra-reliability for critical hospital use-cases like telesurgery.
2. 5G Fixed Wireless Access (FWA): FWA is a special subset of 5G use-cases where the end-point is not a mobile phone but rather a static customer premises equipment (CPE). The CPE can be mounted outdoors on the roof or wall; or indoors. The CPE provides connectivity to indoor devices via indoor fiber and/or an attached Wifi access point.
3. Private 5G Networks: Yet another method is to deploy a Private 5G network on the premises of the enterprise, e.g. a hospital. It allows implementing many different use-cases, such as serving all patients and medical staff with general internet, providing location services as well as critical connectivity services, etc.

Given the criticality of telesurgery, regulation will likely require a fallback network. One can thus envisage a future of fiber being complemented by an SLA-enabled 5G network. Latency, rate and reliability will not be the only decision factor: compared to Wifi and fiber, 5G addresses a much larger assurance issue accounting for end-to-end security and global identity management.

Navigating the hurdles to a connected-health future

The integration of novel technologies like remote robotic surgery in healthcare however also raises significant societal issues, primarily revolving around trust. Patients' anxiety may increase due to the absence of direct human interaction with the operating surgeon. Moreover, the general apprehension towards new technologies, especially in critical care, the fear of technological malfunctions, and concerns over cyber-security, including hacking risks, contribute to the skepticism surrounding robotic telesurgery.

Additionally, the perceived lack of control by patients over their surgical procedures, doubts about the surgeon's ability to manage unexpected complications remotely, and negative historical precedents or media portrayals can further compound trust issues. These fears are not unfounded but stem from a complex mix of personal experiences, societal attitudes towards technology and healthcare, and educational barriers that hinder a comprehensive understanding of the benefits and safety of robotic telesurgery.

To navigate these challenges, a multi-pronged strategy emphasizing patient education, transparent communication, and the implementation of stringent safety and security protocols is essential. Ensuring a human-centric approach in robotic telesurgery, where patient comfort and empathy remain at the forefront, can also play a crucial role in building societal acceptance. By addressing these concerns thoughtfully, the healthcare sector can foster a more trusting and receptive environment for the adoption of remote robotic surgery technologies.

Furthermore, the integration of remote robotic surgery into healthcare introduces regulatory challenges focusing on safety, efficiency, data privacy, and ethical administration. Addressing these concerns requires establishing comprehensive standards, managing liability, ensuring data security, and navigating the complexities of surgeon credentialing across healthcare providers and jurisdictions. Moreover, updating telemedicine laws, ensuring device approval, harmonizing international standards, and developing informed consent processes are critical. Collaborative efforts among stakeholders are thus essential to create a regulated environment that supports the safe, ethical implementation of this technology, fostering accessibility and quality assurance while addressing insurance and ethical considerations.

Charting the uncharted: A call to arms for the next-gen health pioneers

The convergence of cutting-edge technology with medical expertise opens up unprecedented possibilities for enhancing surgical precision, improving patient outcomes, and making healthcare more accessible. As we stand on the brink of this new frontier, we need a community of technologists, medical professionals, and policymakers who are not only skilled in their respective fields but are also deeply committed to working together to solve complex healthcare challenges.

The critical importance of cross-disciplinary collaboration cannot be overstated. The next months and years of healthcare depend on our ability to blend technological innovation with medical knowledge, ensuring that advancements are clinically effective, ethically sound and technically viable. This collaborative spirit is essential for navigating the complexities of modern healthcare, breaking down silos that have historically hindered progress, and fostering an environment where innovation can thrive.

Moreover, inspiring a collective commitment to innovation and inclusivity in surgery is about creating a healthcare ecosystem that is equitable, ensuring that the benefits of technological advancements are accessible to all, regardless of geographical location or socio-economic status. This vision for the future calls for a concerted effort to prioritize patient-centric solutions that address the needs of diverse populations, including the most vulnerable.

We will move forward. We will make this happen. We know now what immediate issues need to be overcome, from a tech, regulatory and perception point of view. If you want to be part of this and have ideas about solutions or challenges we need to overcome, get in touch with us.

Let’s walk this beautiful journey together!

Challenges	State of Today	Consensus Meeting CfA	Desired End-State
5G National Infrastructure	Sparse 5G Stand Alone limiting capabilities, especially in rural areas.	Make business case with operators to accelerate 5G-SA.	Comprehensive 5G-SA coverage, for latency, reliability, coverage.
Robotic Devices	Closed systems with locked consoles, preventing scalable telesurgery.	Have robotic surgery companies agree on openness and standards.	Open telesurgery console systems following standards and security practices.
System Security	Cybersecurity is a concern with rising threats to data transmitted over networks.	Request hospitals and robotic surgery companies to adopt ZTA.	Robust zero-trust architecture (ZTA) in place for safe data transmission.
Regulatory Compliance	Varying regional healthcare regulations complicating deployment.	Form WG with key regulators to accelerate regulatory clarity.	Unified, clear standards and regulations supporting nationwide telesurgery.
Underfunded Ecosystem	>20% of rural areas are underserved with broadband.	Apply with USAC/FCC & register w/ FCC Community Anchor Institution.	Broadband coverage for 100% of US health care providers.

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5G Network Slicing

Fixed Wireless Access

5G Private Networks

Mission Critical Services