Ultra-remote robot-assisted right upper lobectomy between the Shanghai and Kashi Prefectures: a case report

Introduction

With the development of high-definition, three-dimensional, and amplified operation fields, and highly flexible robotic arms, robot-assisted surgical systems can be used by operators to perform surgeries conveniently and accurately. Several studies have reported that robot-assisted thoracic surgery has a higher operation quality and results in better perioperative outcomes than conventional video-assisted surgery or thoracotomy for lung cancer patients (1-3). Recently, progress in mobile communication technology and surgical robotic devices in China has boosted the use of remote surgery (also known as telesurgery) (4,5). To date, there have been no reports of remote surgery being performed to treat pulmonary diseases; however, the safety and feasibility of remote surgery were preliminarily proven in animal experiments.

As a developing country, China faces challenges related to the scarcity and inequitable distribution of medical resources. The development of advanced models of medical cooperation, such as tele-surgery, which make use of computerisation and remote capabilities, could provide new solutions to support medical development in border regions and promote the equitable distribution of medical resources.

In this article, we describe a case in which a middle-aged female patient with a tumor in the right upper lobe underwent ultra-remote robot-assisted minimally invasive lobectomy and lymph node dissection. The patient was hospitalized in Kashi, and the surgeon operated the surgical robot from over 5,000 kilometers away in Shanghai. We present this case in accordance with the CARE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1605/rc).

Case presentation

A 53-year-old female was admitted with a pulmonary lesion detected through computed tomography (CT). Chest CT revealed a partly solid lesion in the central right upper lobe with a maximum diameter of 2.3 cm; no enlarged hilar or mediastinal lymph nodes were observed. Further comparison with previous CT scans showed that the size and solid component of the lesion had both increased significantly (Figure 1). The patient had a medical history of undergoing myomectomy, cholecystectomy, and thyroidectomy, but denied any history of smoking or any relevant family history.

Figure 1 A comparison of chest computed tomography scans from August, 2022 (A) and July, 2024 (B) revealed an increase in the size and solid component of the lesion.

A multidisciplinary team consultation was organized between the hospitals in Shanghai and Kashi, which included members of the thoracic surgery, oncology, radiology, and anesthesiology departments. According to the consultation opinion, early-stage lung cancer (cT1cN0M0) was highly suspected. Considering the location and size of the lesion, elective right upper lobectomy using a minimally invasive approach was the preferred treatment option. Relevant examinations were completed for which the results were normal. The patient was deemed a suitable candidate for this remote robot-assisted surgery project, which was approved by Institutional Review Boards of Shanghai Chest Hospital and Kashi Prefecture Second People’s Hospital, and had been verified as feasible in previous experimental animal operations. After thoroughly informing the patient about the risks of the procedure, the patient consented and signed the informed consent form for the surgical procedure and use of anonymized clinical data and images for potential publication. To address potential complications, including important bleeding during the remote surgery, an experienced thoracic surgical team including a thoracic surgeon and two assistants was stationed in the local operating room. Continuous real-time communication between the remote and local teams was established to facilitate swift decision-making and coordination in the event of unexpected complications. To mitigate the risk of signal loss during the surgery, a dedicated 5G network with multiple redundant connections was utilized to ensure stable communication. In the event of signal loss, the thoracic surgeon of on-site team was prepared to take over the backup console or perform a manual conversion, ensuring the continuity and safety of the procedure.

On July 13, 2024, the ultra-remote robot-assisted right upper lobectomy was performed. The patient was hospitalized at the Kashi Second People’s Hospital, while the surgeon operated the surgical robot from over 5,000 kilometers away in Shanghai (Figure 2). Dedicated engineering teams at both sides continuously monitored real-time latency and packet loss metrics. The patient was intubated with a double-lumen endotracheal tube for contralateral single-lung ventilation and placed in the left-lateral decubitus position under general anesthesia. The operation was performed using the Toumai^® endoscopic surgical robot system (MicroPort, Shanghai, China), and the entire process was performed via communication and data transmission facilitated by China Telecom’s dedicated network and 5G technology.

Figure 2 Pattern diagram of remote robot-assisted surgery between Shanghai and Kashi.

The surgical procedure was similar to that described in our previous study (Video 1) (6). The trocar for observation was placed in the 7th intercostal space (ICS) in the posterior axillary line, and the other two trocars for the robotic arms were placed in the 6th ICS in the mid-axillary line, and the 8th ICS in the infrascapular line, respectively. A 4-cm utility incision was made in the 4th ICS in the anterior axillary line (Figure 3). Cadiere forceps were operated by the left arm, and an ultrasonic knife, bipolar coagulation forceps, and a cautery hook were controlled by the right arm. The procedure commenced with the dissection of the posterior mediastinal pleura and the opening of the interlobar fissure, and the interlobar lymph nodes were then dissected to expose branches of the pulmonary arteries further. First, posterior segment artery (A2) and anterior segment artery (A3) were thoroughly dissected and sectioned using a mechanical stapler. Next, the lung was tucked ventrally to dissect and transect the bronchus. The lobe was then tucked dorsally, and the apical segment artery (A1) and right upper pulmonary vein were transected together with the remaining fissure. All the staplers were introduced via a utility incision by the assistant.

Figure 3 The incision and trocar port placement. ICS, intercostal space.

The entire surgery lasted 1 hour and 50 minutes, with approximately 80 minutes dedicated to the main operation time. Intraoperative blood loss was less than 10 mL. The real-time transmission of the robotic control signals, images, and audio remained stable. The packet loss rate was 0.012%, with a maximum delay of 121 ms and an average network delay of 100 ms. No connection interruptions or accidents related to the robotic system occurred during the procedure. Intraoperative frozen section pathology indicated invasive mucinous adenocarcinoma, with no tumor involvement observed in the dissected 7# and 11R# lymph nodes. Postoperative pathology and immunohistochemistry further confirmed the diagnosis of lung mucinous adenocarcinoma, which was classified as T1aN0M0 (Figure 4). The patient’s drainage volume within 24 hours of surgery was 200 mL, and a chest X-ray showed good lung re-expansion (Figure 5). On the fifth postoperative day, after the chest tube had been clamped for 24 hours, a CT scan was performed, and the drainage tube was subsequently removed.

Figure 4 Pathological results for the resected tumor. (A) Hematoxylin and eosin staining showed tall columnar cell morphology with abundant intracellular mucus. Immunohistochemistry and special staining showed positive staining for (B) MUC1, (C) CK-7, (D) and TTF1.

Figure 5 Postoperative imaging review. (A) Chest radiograph 12 hours after surgery. (B) Chest computed tomography on the fifth day after surgery.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Patient’s perspective

The patient stated, “I was really anxious when I found out that my lung nodule had grown and needed surgery. During my visit, the medical team told me about the remote robotic surgery project. I was pretty nervous and had some doubts about trying this new treatment. But thanks to Dr. Chen and the other team members for their patience and care, I decided to go for it. I’m also very thankful to the expert team in Shanghai and our country’s fast-growing technology, which allows us in remote areas access the most advanced medical resources.”

International Multidisciplinary Team (iMDT) discussion

Discussion among physicians from Shanghai Chest Hospital and Kashi Prefecture Second People’s Hospital

Following the trend of minimally invasive surgery, remote surgery represents another major surgical innovation. Since the groundbreaking Lindberg operation in 2001 (7), numerous studies on remote surgery have been conducted. With advances in China’s independently developed surgical robots and 5G communication technology, advances are also being made in remote surgery. Multiple centers in China have made significant advances in remote robotic surgery research. In 2020, Li et al. and Zheng et al. successfully conducted a 5G ultra-remote laparoscopic animal experiment, and subsequently carried out extensive clinical trials to complete dozens of 5G remote robot-assisted kidney surgeries (5,8). Recently, Zhang led his group and completed an intercontinental prostate cancer surgery between Beijing and Rome. Our group first began to explore remote robotic lung surgery in 2023. Since then, we have successfully performed remote robot-assisted lobectomy animal experiments in Shanghai, and between Shanghai and Kashi, accumulating a wealth of experience for the present surgery (9). Nonetheless, treating a real patient required not only managing technical aspects but also developing detailed contingency plans to address potential complications, including signal loss, excessive latency, or major bleeding—scenarios that cannot be fully simulated in experiments. This successful surgery demonstrates the feasibility of overcoming such challenges and provides valuable experience for planning future prospective studies, further bridging the gap between experimental and clinical applications of remote surgery. To the best of our knowledge, this case is the first reported instance in which a remote robot-assisted lobectomy has been applied in clinical practice.

This remote surgery was led by an experienced chief surgeon and a team that has collectively completed over 3,000 robotic lung surgeries. During the procedure, network records indicated an average network latency of 100 ms, which was imperceptible for most surgical steps during this procedure. However, the peak latency of 121 ms necessitated heightened caution during critical steps such as vascular dissection and stapler placement. To mitigate potential risks, the lead surgeon slightly slowed the pace of these maneuvers, ensuring precise control despite the latency. This experience highlights the importance of maintaining latency within acceptable thresholds, particularly for complex and high-risk steps in remote surgeries. According to a previous study by Li et al., a latency of ≤200 ms is sufficient for the application of remote surgery in urology (5). Xu et al. used a simulator to examine the effects of latency on surgical performance and concluded that latencies ≤200 ms were ideal for telesurgery (10). Previous experiments involving intra-city remote surgeries demonstrated that latencies exceeding 200 ms caused noticeable operational delays, even over shorter distances. Thus, we proposed that network quality and communication technology could play a more significant role than geographical distance in maintaining smooth remote surgical performance. Given the unique anatomical characteristics of the thoracic cavity, we believe that maintaining a network latency <100 ms is essential to ensure the safety of remote thoracic surgeries.

While this report demonstrates the preliminary feasibility of remote robot-assisted lobectomy, there are several limitations to consider. First, the current approach may not be suitable for complex or emergency thoracic cases. Procedures involving extensive vascular reconstruction, emergency interventions, or unpredictable complications require an on-site team with immediate access to additional resources and expertise. For such cases, advanced training for on-site teams, and robust communication protocols are critical. Second, scaling up remote surgeries to other hospitals or countries presents logistical and technical challenges. These include variations in network infrastructure, regulatory and ethical considerations, and the high cost of robotic systems. To address these issues, pilot programs should focus on establishing hub-and-spoke models where centralized surgical hubs can support multiple peripheral hospitals.

Cybersecurity is also a paramount concern in remote surgery due to the involvement of sensitive patient data and the critical nature of real-time robotic control systems. The risks include unauthorized access, data breaches, and potential sabotage of the surgical process. To mitigate these threats, the network used in this case was secured with end-to-end encryption, multi-factor authentication, and continuous monitoring for anomalies. Engineering teams were on-site to provide immediate responses to any detected threats or disruptions. Furthermore, the importance of robust cybersecurity frameworks will grow as remote surgery expands, requiring the integration of advanced measures such as AI-based threat detection, blockchain technology for data security, and international cybersecurity standards. Expanding these safeguards is essential to protect patient safety and maintain trust in remote surgical technologies.

As unequal distribution of medical resources is becoming a pressing issue worldwide, and particularly affects patients in remote or economically underdeveloped regions who lack access to optimal medical care. Telesurgery offers a potential solution to this problem (11). By allowing skilled surgeons to perform operations remotely and fostering sustainable collaborative relationships, this approach can promote equity of health care and facilitate the transfer of medical resources from developed areas to underserved regions. Further, as the remote intraoperative frozen pathology consultation showed in this case, with continuous improvements in telesurgery platforms, experts from various fields can collaborate in real-time to treat the same patient.

Several questions arise in relation to the diagnosis and treatment of this patient:

Question 1: How can we ensure the safety of patients undergoing remote surgery? Beyond the inherent risks of the surgery itself, do concerns related to cybersecurity also arise?

Expert opinion 1: Dr. Yoshikane Yamauchi

To ensure safety, there must be one or two doctors on standby who can perform emergency thoracotomy in the local operating room. There are also of course cyber security issues, and it is necessary to have measures in place if remote surgery cannot continue due to some kind of network problem. Furthermore, the issue of latency is also important. The paper cited states that delays ≤200 ms are sufficient, but that paper is based on simulator results, and moreover, the target is not moving. In lung resections, on the other hand, the position of the vessels constantly moves slightly with the beating of the heart and ventilation of the contralateral lung. In this context, the operation is performed to dissect the pulmonary artery or vein, and the delay should be minimised as much as possible, as it can lead to serious complications such as vascular injury.

Expert opinion 2: Dr. Raja M. Flores

Remote surgery is made safe by having an experienced surgeon at the bedside in case an intraoperative emergency like bleeding arises. One definitely needs to be able to ensure cybersecurity to protect patient privacy or a potential sabotage to hurt the patient receiving surgery.

Question 2: Remote robotic-assisted surgery was considered a viable option for the patient in this case. In upcoming clinical trials, under what scenarios and for which types of patients would remote surgery be appropriate?

Expert opinion 1: Dr. Yoshikane Yamauchi

When conducted as a clinical trial, the plan should include measures to ensure safety as described above. It is desirable to conduct the trial between facilities that have multiple spare lines for remote surgery. Although the ultimate goal would be to carry out surgery over very long distances, such as in the case presented here, I do not think the distance between facilities is very important for these clinical trials.

Expert opinion 2: Dr. Raja M. Flores

To remove different surgeon biases from the field a study may use a single surgeon to perform all the cases in multiple institutions to remove surgeon experience from the variable list.

Question 3: Current remote surgeries primarily rely on robotic surgical systems. What are the future prospects for the development of new surgical systems or platforms that could enhance remote surgery?

Expert opinion 1: Dr. Yoshikane Yamauchi

Of course, robotic surgical systems play a major role in these operations. I believe that safety would be enhanced if the robot system were augmented with a surgical support system, such as a virtual reality system that displays the anatomical location of the vascular, nerve, and bronchus.

Expert opinion 2: Dr. Raja M. Flores

As long as safety is the priority new advanced technology could lend itself to remote surgery.

Question 4: In terms of training surgeons and surgical teams, which aspects should be emphasized to better prepare them for the demands of remote surgery?

Expert opinion 1: Dr. Yoshikane Yamauchi

In the Society of Thoracic Surgeons database study, emergency conversions occurred more frequently in robotic lobectomy versus VATS lobectomy and emergency conversion was associated with an increase in hospital mortality compared with elective conversions (5.5% vs. 1.9%; P<0.001) (12). From this perspective, surgeons must make every effort to avoid emergency conversions as much as possible. The main difference between ordinary robotic surgery and telerobotic surgery is that the surgeon is not present in the operating room. Communication between the surgeon and the assistant is by voice (plus video), which is very different from face-to-face communication. In a team performing remote surgery, it is desirable to prepare for elective conversion by creating many conversion scenarios in advance and repeatedly practicing these scenarios, so that you can perform elective conversion before a disastrous situation arises in an actual case.

Expert opinion 2: Dr. Raja M. Flores

Well-trained surgeon will need experience in open, VATS, and robotic technologies to be a complete surgeon. Experience is the single greatest teacher.

Conclusions

In summary, we reported the first clinical application of remote robot-assisted lobectomy, and showed the preliminary feasibility and safety of performing remote robotic thoracic surgery using 5G technology. We also outlined the corresponding surgical procedures, thereby laying the groundwork for future remote thoracic surgeries. Larger-scale cohorts or clinical studies need to be conducted to further clarify the guidelines and promote the application of remote surgery.

Acknowledgments

Funding: This study was supported by the Shanghai Hospital Development Center (No. SHDC2022CRTO24) and the Shanghai Innovative Medical Device Application Demonstration Project (No. 23SHS04000-05).

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1605/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1605/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1605/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. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

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/.

References

1. Jin R, Zhang Z, Zheng Y, et al. Health-Related Quality of Life Following Robotic-Assisted or Video-Assisted Lobectomy in Patients With Non-Small Cell Lung Cancer: Results From the RVlob Randomized Clinical Trial. Chest 2023;163:1576-88. [Crossref] [PubMed]
2. Pan H, Zhu H, Tian Y, et al. Quality of lymph node dissection and early recurrence in robotic versus thoracoscopic lobectomy for stage N1-2 non-small cell lung cancer: Eleven-year real-world data from a high-volume center. Eur J Surg Oncol 2024;50:108496. [Crossref] [PubMed]
3. Huang J, Tian Y, Li C, et al. Robotic-assisted thoracic surgery reduces perioperative complications and achieves a similar long-term survival profile as posterolateral thoracotomy in clinical N2 stage non-small cell lung cancer patients: a multicenter, randomized, controlled trial. Transl Lung Cancer Res 2021;10:4281-92. [Crossref] [PubMed]
4. Tian W, Fan M, Zeng C, et al. Telerobotic Spinal Surgery Based on 5G Network: The First 12 Cases. Neurospine 2020;17:114-20. [Crossref] [PubMed]
5. Li J, Yang X, Chu G, et al. Application of Improved Robot-assisted Laparoscopic Telesurgery with 5G Technology in Urology. Eur Urol 2023;83:41-4. [Crossref] [PubMed]
6. Huang J, Tian Y, Zhou QJ, et al. Comparison of perioperative outcomes of robotic-assisted versus video-assisted thoracoscopic right upper lobectomy in non-small cell lung cancer. Transl Lung Cancer Res 2021;10:4549-57. [Crossref] [PubMed]
7. Marescaux J, Leroy J, Gagner M, et al. Transatlantic robot-assisted telesurgery. Nature 2001;413:379-80. [Crossref] [PubMed]
8. Zheng J, Wang Y, Zhang J, et al. 5G ultra-remote robot-assisted laparoscopic surgery in China. Surg Endosc 2020;34:5172-80. [Crossref] [PubMed]
9. Tian Y, Huang J, Li J. Animal experimental study of 5G remote robot-assisted thoracoscopic lobectomy. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery 2023;30:1112-5.
10. Xu S, Perez M, Yang K, et al. Determination of the latency effects on surgical performance and the acceptable latency levels in telesurgery using the dV-Trainer(®) simulator. Surg Endosc 2014;28:2569-76. [Crossref] [PubMed]
11. Patel V, Marescaux J, Covas Moschovas M. The Humanitarian Impact of Telesurgery and Remote Surgery in Global Medicine. Eur Urol 2024;86:88-9. [Crossref] [PubMed]
12. Servais EL, Miller DL, Thibault D, et al. Conversion to Thoracotomy During Thoracoscopic vs Robotic Lobectomy: Predictors and Outcomes. Ann Thorac Surg 2022;114:409-17. [Crossref] [PubMed]