Remote Robotic Surgery and Virtual Education Platforms: How Advanced Surgical Technologies Can Increase Access to Surgical Care in Resource-Limited Settings

Abstract

Advanced surgical technologies consist of remote and virtual platforms that facilitate surgical care and education. It also includes the infrastructure necessary to utilize these platforms (e.g., internet access, robotic systems, and simulators). Given that 5 billion people lack access to safe and timely surgical care, the appeal of these technologies to the field of global surgery lies primarily in its ability to eliminate geographical barriers and address surgeon shortages. This article discusses the use of virtual and remote technologies in resource-limited settings, the potential applications of these technologies, the possible barriers to their integration, and the impact these technologies may have on access to surgical care and education. Specifically, it will explore how robotic surgery, telesurgery, virtual education platforms, and simulations have the potential to be instrumental in enhancing worldwide access to safe surgical care.

The Intersection of Global Surgery and Surgical Technology

Global surgery consists of the provision of safe, timely, and affordable surgical care to marginalized populations in resource-limited settings through collaboration, education, and diplomacy. ¹ A global surgeon has been defined as an individual who spends at least a portion of his or her time in person or virtually on activities aimed to improve surgical access in resource-limited settings. These efforts may include the delivery of surgical care, development of surgical capacity, and education of local trainees. Global surgery efforts are transitioning from short-term “mission trip”–based models to paradigms that prioritize the development and enhancement of surgical systems in resource-limited settings. ² Additionally, advanced surgical technologies are now being integrated into the design and development of surgical delivery systems in resource-limited settings. Advanced surgical technologies consist, in part, of remote and virtual platforms that facilitate surgical care and surgical education. It also includes the infrastructure necessary to utilize these platforms (e.g., internet access, robotic systems, and simulators).

The increased emphasis on incorporating advanced surgical technologies in resource-limited settings occurs in a broader context in which the field of medicine itself has seen a significant expansion in the use of remote and virtual technologies. Since the COVID-19 pandemic, the use of telemedicine (clinical services that prioritize diagnosis and monitoring) and telehealth (clinical services that emphasize preventative and curative care) has rapidly expanded. The benefits of virtual health care have included easier access to specialty care, improved efficiency, decreased wait times, increased patient satisfaction, and comparable patient care. ³ Additionally, more options for virtual surgical education have become available including virtual didactics, mentorship, robotic and laparoscopic skills training, team training, rounds, and in-clinic teaching. ⁴ Virtual platforms have been shown to reduce the cost of and increase access to surgical education while removing barriers related to time and space. ⁵ Moreover, multiple global surgery efforts are now being directed toward building virtual libraries with recorded lectures, cases, and procedures. These efforts have also included the establishment of virtual conferences, distribution of portable surgical simulators, and creation of open-source texts. ⁶

As the use of advanced surgical technologies becomes progressively normalized, these resources will become more accessible and easier to adopt and implement. It is, therefore, incumbent upon the global surgeon to begin considering the incorporation of advanced surgical technologies into capacity building efforts. This article discusses the use of virtual and remote technologies in resource-limited settings, the potential applications of these technologies, the possible barriers to their integration, and the impact they may have on access to surgical care and education. Specifically, it will explore how robotic surgery, telesurgery, virtual education platforms, and simulations have the potential to be instrumental in enhancing worldwide access to safe surgical care.

Advanced Surgical Technologies and Their Role in Patient Care

Telesurgery, Robotic Surgery, and the Surgical Patient

Telesurgery is the concept of performing an operation on a patient who is physically separated from the surgeon via virtual and remote platforms. Virtual surgical care can also include the initial clinical assessment, preoperative workup and risk stratification, postoperative monitoring, expert consultation, and long-term surveillance. Given that 5 billion people lack access to safe and timely surgical care, the appeal of telesurgery to global surgery lies primarily in its ability to eliminate geographic barriers and address surgeon shortages. The ability to virtually assess a patient and perform a surgical intervention from a remote site allows for the possibility of decreasing the worldwide surgical disease burden and reducing disability-adjusted life years.

Telesurgery has only become a possibility with the advent of robotic surgery platforms. Robotic surgical systems were initially developed in the 1980s and employed in clinical practice to assist in the performance of minimally invasive procedures during the early 2000s. Robotic surgery was intended to address the limitations of laparoscopy, which include two-dimensional visualization and limited instrument articulation. Since its introduction into clinical practice, robotic surgery has been rapidly adopted in high-resource settings and is currently used across several specialties including plastic surgery, cardiac surgery, obstetrics and gynecology, otolaryngology, thoracic surgery, and urology. Benefits of using robotic systems have included reduction in recovery time, shorter hospital course, reduced risk of infections, better surgical precision, and enhanced cosmetic outcomes. ⁷

Remote Robotic Surgery and Its Potential Application to Surgical Care in Resource-Limited Settings

Presently, robotic surgery is performed with the patient and surgeon in close proximity. However, the concept of remote telerobotic surgery, in which the surgeon may operate using a robotic system at varying distances, has existed since the turn of the 21st century. Multiple studies have begun to demonstrate the feasibility of remote robotic surgery. The first remote robotic surgery took place in 2001, in which a surgeon in New York completed a robot-assisted laparoscopic cholecystectomy on a patient who was physically in Strasbourg, France. Multiple studies have subsequently attempted to characterize the critical elements that facilitate successful remote robotic procedures. These elements have included feasible distances for performing operations, lag time between the surgeon's movement and the movement of the robotic arms, mediums for transmission (e.g., 5G network and fiberoptic cables), technical disturbances in communication lines, haptic feedback, and visual displays. ⁸

The Utility of Robotic Surgery in Resource-Limited Settings

Although remote robotic surgery is still in its infancy, the implications are profound for patients and surgical care delivery systems in resource-limited settings. From a patient perspective, the introduction of remote robotic surgery could shorten hospital length of stay, limit intraoperative impact on surrounding tissues, and decrease patient recovery time. Robotic surgery has been associated with increased surgical precision and reduced surgeon-based tremor, which can affect operative complications. Additionally, robotic surgery has been associated with decreased rates of surgical site infections (SSIs). ⁹ It is particularly important to emphasize the benefit of reducing SSI as they can occur in resource-limited settings at rates up to 25 times greater than in high-resource settings. ¹⁰ SSIs remain one of the leading causes of prolonged hospital admission, antibiotic resistance, and loss in productivity ¹⁰ in resource-limited settings. Finally, telesurgery can also reduce the number of patients required to engage in impoverishing and catastrophic spending associated with travel to district hospitals and tertiary care centers.

On a systematic level, access to telesurgery can streamline surgical care delivery systems. Telesurgery may allow for increased access to subspecialized surgical care and multidisciplinary collaboration during complex surgical cases. As surgeons will be less restricted by physical borders, the catchment region of each surgeon can dramatically increase. The remote capacity to operate also allows for the deployment of mobile operating systems in response to natural disasters, civil unrest, interstate conflict, and pandemics.

Finally, telesurgery can also address some of the ethical dilemmas faced by providers in resource-limited settings. Virtual and remote options for surgical care allow for increased patient autonomy in medical decision-making by facilitating a choice in providers and opportunities to obtain a second opinion. Additionally, these platforms create a more just health care infrastructure in resource-limited settings by equalizing access to lifesaving and life-changing surgical procedures ( Table 1 ).

Table 1. Potential clinical benefits of telesurgery for individual patients and health care systems in the perioperative setting.

	Preoperative	Intraoperative	Postoperative
Individual patient	• Decreased travel-associated costs • Increased choice in health care provider • Increased autonomy in medical decision-making	• Increased surgical precision	• Decreased tissue damage • Decreased rate of surgical site infections
Health care system	• Increased surgical access in resource-limited settings • Increased surgical access in areas of natural disaster and conflict • Increased surgical access during pandemic-based travel restrictions • More efficient allocation of financial and human resources	• Increased multidisciplinary collaboration	• Decreased rate of surgical site infections • Decreased hospital length of stay • Increased national level of health

Plastic Surgery, Telesurgery, and the Surgical Patient

Plastic surgery has a well-established history in global surgery. The first surgical nongovernmental organizations that established the framework for many global surgery efforts were founded by plastic surgeons to reduce the burden of cleft lip and palate malformations. ¹¹ The World Bank has worked to identify surgeries that are critical to reducing the disease burden in resource-limited settings. As a result, the World Bank established a list of 44 essential surgeries that include the fields of general surgery, neurosurgery, obstetrics and gynecology, ophthalmology, oral and maxillofacial surgery, orthopaedics, otolaryngology, and plastic surgery. ¹² Remote robotic plastic surgery has the potential to offer reconstructive options to individuals impacted by deforming pathologies in resource-limited settings.

Barriers to Implementation of Advanced Surgical Technologies in Resource-Limited Settings

There are multiple challenges to the employment of advanced surgical technologies in resource-limited settings. Some of these barriers include surrounding infrastructure, cultural acceptance, and development of the local workforce. ¹³ Remote robotic surgery has remained experimental and cannot transition into clinical practice until the current challenges are addressed. The following items outline some of these challenges:

• Financial barriers: Robotic surgical systems continue to be significantly cost-prohibitive. The initial establishment of a robotic system requires a USD1 to 2 million investment. Each subsequent surgery may cost between USD3,000 and 5,000 and yearly maintenance costs approximately USD100,000 per year. ¹⁴ While shorter lengths of stay, decrease in SSI, and decreased recovery time may eventually offset the infrastructural costs, most health care systems in resource-limited settings are unable to afford these initial expenses. To implement such expensive systems and garner the support of key stakeholders, studies on cost-effectiveness are essential.

• Technological constraints: Depending on the medium, there may be a lag time between the surgeon's movement and the movement of the robotic arms. Research has demonstrated that a lag time greater than 200 milliseconds results in a significant deterioration of task performance. ¹⁵ This deterioration of task performance is only minimally improved with simulation training. ¹⁶ To reasonably perform remote robotic surgery, hospital systems in austere settings will also require stable Internet connection and electricity.

• Surgical complications: Surgeons may need to convert from minimally invasive approaches to open procedures when they encounter unclear anatomy, accidental injury to surrounding organs, significant inflammation, uncontrollable hemorrhage, or an inability to progress. Conversion to open procedures can occur at high rates for certain operations. For example, certain colorectal procedures can have a conversion rate of up to 23%. ¹⁷ The use of open techniques as safe maneuvers in complex cases obviates the current need to have a surgeon in close proximity.

• Human resources: Safe surgical care requires anesthesia providers, perioperative nurses, and scrub technicians. Additionally, robotic surgery requires a trained individual to place ports, dock, exchange instruments, and bedside assist. Therefore, while remote robotic surgery can increase access to surgeons, the appropriate human resources must be locally available to increase access to surgical care.

• Technical failures: All robotic platforms have the potential to fail from a hardware, software, and transmission perspective. These failures can range from malfunctioning staplers to loss of the visual field. Consequently, support staff who can troubleshoot each of these elements must be readily available, or a surgeon who may complete the procedure using alternate techniques must be easily accessible. As the infrastructure of remote robotic surgery becomes better established, it will also be necessary to consider the threat of cyberattacks and the role of cybersecurity.

• Accreditation and medicolegal accountability: Telesurgery has the potential to transcend the physical borders of countries and regions. This brings to light the need to address medical licensing in the global arena, international standards of care, and medical liability. Perhaps one of the most important challenges that global surgeons will face in the near term is the establishment of a recognized accreditation system to facilitate international licensing. Additionally, regulations must be established to ensure sites for remote robotic surgery meet minimum standards for safety.

• Acceptance of general population: Remote robotic surgery is a novel concept and, when implemented, may be discordant with the general population's conception and understanding of surgical care. Therefore, normalization of remote robotic surgery in the public eye will be necessary before it can be established as a standard of care in resource-limited settings. This can potentially occur through social media, expert interviews through various media outlets, patient testimonials, and governmental support.

Ultimately, the use of telesurgery is dependent on establishing parameters for performing remote surgery safely, creating guidelines for the development of supportive infrastructure, investing in cost-efficient robotic platforms, training local staff to direct and troubleshoot robotic systems, and determining international procedures for accreditation, billing, liability, and licensing.

Advanced Surgical Technologies and Their Role in Surgical Education

The meaningful incorporation of telesurgery in resource-limited settings may require additional time, financial investment, and consideration. In the interim, multiple virtual platforms to enhance surgical education and foster the development of the surgical workforce in resource-limited settings are available. The Association for Surgical Education (ASE) has developed evidence-based guidelines for the augmentation of virtual surgical education. These guidelines are outlined within the three domains of (1) mentorship and faculty development, (2) cognition and curricula, and (3) psychomotor skills training. ⁵ This section reviews virtual surgical education options for individuals training in resource-limited settings within the ASE framework.

Telementoring as a Tool for Surgical Coaching and Faculty Development

Telementoring involves the use of telecommunication platforms in which an experienced surgeon can provide guidance and coaching to a learner in a remote location. ¹⁸ Experts can guide individuals by observing an operation and providing active feedback. Robotic platforms have enriched telementoring by providing live video feed of an operation, allowing for real-time auditory feedback, and telestration. ¹⁹ Ideally, both the mentor and mentee have prepared for the experience by discussing mutual expectations, meeting the legal requirements for mentorship, ensuring institutional support for this clinical practice, and obtaining appropriate consent from the patient. ¹⁸ Research has shown that telementoring is well received by learners, has low complication rates, and leads to surgical improvement. ²⁰ Telementoring allows surgical trainees and surgeons to obtain more specialized minimally invasive training without the financial burden of travel, regulatory constraints, and absence of clinicians from their home institutions.

Open-Source, Virtual Surgical Libraries as Structured Curricula

In an attempt to create accessible materials on surgical pathology, operative techniques, and perioperative management, multiple global surgery organizations are investing in online educational resources. The purpose of these materials is to provide structured curricula that assist in the cognitive development of local surgical workforces in resource-limited settings. For example, the Global Surgery Foundation has led the development of the United Nations Global Surgery Learning Hub (SURGhub), which consists of e-curricula on topics relevant to operating in resource-limited settings (e.g., recognizing obstructed labor, performing a cesarean section, and appropriate anesthesia for a cesarean section). Similarly, the World Health Organization (WHO) has developed the WHO Academy, which provides educational resources for global health professionals across multiple different virtual platforms. Other resources have also been developed in this process including academic conferences, webinars, and web series with virtual components accessible to individuals in resource-limited settings. Virtual didactics, including the cognitive elements of technical skills, have been shown to improve surgical knowledge. ⁵ These platforms allow for a dynamic exchange of information between clinicians and expeditious inclusion of evolving standards of care.

Virtual Simulations to Enhance Psychomotor Skills

In the field of plastic surgery, virtual simulations and augmented reality have been incorporated into some training paradigms. ¹¹ Virtual training for both minimally invasive and open techniques is a valid alternative to in-person training. ⁵ Additionally, simulation and video-based coaching hold significant promise in improving training in and assessment of surgical skills. Consequently, portable laparoscopic trainers accompanied by telementoring and robotic simulation software are viable avenues for the development of surgical skills.

Virtual training with robotic platforms has become more structured. The Fundamentals of Robotic Surgery (FRS) is one skills training and assessment curriculum. ²¹ The purpose of FRS is to provide a guide for surgeons to develop basic robotic skills and prepare them to perform procedures on a robotic platform across a wide range of specialties. The FRS program was developed over a 2-year period by subject matter experts from multiple surgical societies, surgical educational societies, surgical boards, and other governing organizations through a series of four consensus conferences, which included over 80 international robotic surgery experts, behavioral psychologists, medical educators, statisticians, and psychometrician. ²¹ Structured virtual training programs have the potential to allow surgeons in resource-limited settings to expeditiously obtain necessary training.

Future Directions

The practical incorporation of advanced surgical technologies in the clinical and educational infrastructure of resource-limited settings is contingent on addressing multiple barriers. Perhaps the biggest challenges to overcome include determining the parameters for safe remote robotic surgery, instituting clear credentialing systems, and achieving financial feasibility. Research and randomized controlled trials bound by clear Institutional Review Board (IRB) approvals are necessary to detail the safe parameters of remote surgery and the appropriate supporting infrastructure and human resources necessary to facilitate telesurgery. Health organizations and surgical societies have attempted to construct just pathways for international surgical accreditation. This can be accomplished through the creation of a decentralized global verification system that emphasizes core surgeries and cultural competencies. ²² For example, The WHO Academy has built digital microcertificates into its virtual infrastructure for learners who verify their competencies on the platform. It would be necessary for all participating countries to recognize such a verification system.

Beyond establishing basic parameters for the performance of safe surgical procedures, the most critical barrier to address is the high financial burden of establishing robotic platforms. Appropriate steps can include (1) facilitating universal licensing for robotic surgery platforms, (2) providing free training courses and simulation software for surgeons based in resource-limited settings, (3) subsidizing robotic platforms for low- and lower-middle-income countries, and (4) investing in the development of lower cost transmission services. ¹⁴ Additionally, bidirectional partnerships between institutions in resource-limited settings and institutions in high-resource settings can allow for a more seamless integration of advanced surgical technologies. Shared resources, equipment, and cloud systems can increase educational opportunities through recorded operations, didactics, wet laboratories, dry laboratories, and modular training. ²³ This paradigm can be mutually beneficial as it allows for increased access to surgical care, diverse training opportunities for learners in each institution, and research opportunities.

Conclusion

Advanced surgical technologies have the potential to meaningfully enhance surgical care and surgical education in resource-limited settings. Telesurgery using remote robotic platforms can increase access to surgical care, facilitate multidisciplinary expertise for complex cases, and improve patient outcomes. Moreover, virtual and remote technologies can promote the growth of the surgical workforce through virtual libraries, mentorship, didactics, and simulations. It is essential for global surgeons to begin addressing the technological, sociopolitical, and financial barriers to implementing these technologies in resource-limited settings, as they have the potential to mitigate geographic inequities and alleviate surgeon shortages. The safe incorporation of advanced technologies in surgical infrastructure can conceivably change our approach to the field of global surgery and the paradigms that guide it.

Funding Statement

Funding None.