Abstract
The field of robotic surgery has grown exponentially over the past few decades. Surgical robots offer numerous benefits that enhance surgical precision, improve patient outcomes, and expand the capabilities of surgeons. Telesurgery, also known as a remote surgery, is a branch of telemedicine, which offers to perform surgical procedures requiring expertise of a surgeon located at a distance from a patient by using robotic systems and telecommunications technology. In a previous reported case, an animal experiment and clinical trial telesurgery using a dual console were performed. However, the mean latency time and data packet loss were considerably high. As a result, the performance of the telesurgery got severely impacted. This paper evaluates the feasibility, safety, and efficacy of remote telesurgery to precisely carryout predetermined surgical procedures using dual console SSI Mantra Surgical Robotic System. The trials were registered prospectively with trial registration number CTRI-2024-06-068361.
Keywords: Telesurgery, Dual surgeon console, Leased line, Radio frequency transmission, Dual console SSI Mantra Robotic Surgical System
Introduction
Telesurgery is based on a concept of a master and a slave system. It utilises transmission of digitised images, audio, and video via cable or wireless telecommunication networks. The surgeons can manipulate the surgical robot to perform operations from a distance via the networks. The first remote telesurgery data were reported [1], wherein a renal access procedure was performed between USA and Italy using plain old telephone system (POTS) line. However, low data rates and high latency of POTS line make it impractical for telesurgery. High-speed, reliable, and secure broadband connections are essential to meet the demanding requirements of telesurgery, ensuring precise control, high-quality video transmission, and robust data security. Nonetheless, time delays and instability in existing network transmission raised concerns for patient safety and thus, the progress in this field was slowed further. A preclinical trial was reported in [6, 7]. Previously, a single console was used to perform telesurgery in [2–6, 9, 10]. However, in case of network failure, there existed a high risk to patient safety and the solution was to convert the telesurgery to open/laparoscopic one. Recently, an animal experiment [11] and human trial were reported using a dual console [8, 12]. However, the mean latency time and data packet loss need to be reduced.
Recently, the SSI Mantra® Surgical Robotic System (a patent protected technology) is developed by a medical technology company named Sudhir Srivastava Innovations Pvt Ltd. This is the first Surgical Robotic System made in India. The dual console SSI Mantra Surgical Robotic System is a multi-arm surgical robotic system designed to assist surgeons in performing minimally invasive surgery. It has a surgeon console located in the operating room near a patient and another surgeon console at a remote location near an expert surgeon. Clinical trials have been done for remote telesurgery by performing surgical procedures using dual console Mantra Surgical Robotic System. First, an experiment on an animal model and then clinical trials on five human patients were performed.
Methodology
The dual console SSI Mantra Surgical Robotic System was used for the planned surgical procedures. The clinical study was performed at two places: World Laparoscopy Hospital, Gurugram and Rajiv Gandhi Cancer Institute, Delhi. The written approvals for clinical study were taken from institutional Ethics committee/Institutional review boards by the sponsor/investigator at both World Laparoscopy Hospital, Gurugram and Rajiv Gandhi Cancer Institute, Delhi. All the telesurgery procedures adhered to the laid standards. For animal experiment a healthy male pig was chosen. The welfare of the chosen animal was taken care of. For clinical trials, human patients in the age group of 40–60 were selected. A signed consent was taken from each patient. The telesurgeries were performed by expert surgeons with a track record of successful robotic surgical procedures using the dual console SSI Mantra Surgical Robotic System. Further, all the assisting surgeons/side-staff were extensively trained in performing/assisting standard robotic surgical procedures using the dual console SSI Mantra Surgical Robotic System. Round-trip time and data packet loss is measured during the animal experiment and clinical trials on human patients. Round-trip time is measured as the time elapsed in transmitting the control signal from the master surgeon console to the slave surgeon console and transmission of video data from the surgical site to the master surgeon console. Data packet loss is measured as the number of data packets travelling though the transmission network but could not reach destination.
Network for telesurgery
As a part of this study, the fibre-optic telecommunication network was provided by Bharti Airtel Limited, commonly known as Airtel, which is an Indian multinational telecommunications services company based in New Delhi. The telecommunication network is used to establish a secure private P2P connectivity over fibre between the locations listed below in the Table 1 for data network.
Table 1.
Locations and connectivity
| S. No. | Location | Connectivity (in Mbps) |
|---|---|---|
| A |
Sudhir Srivastava Innovations Pvt. Ltd Plot No. 404–405, 3rd Floor, iLabs Info Technology Centre, Phase-III, Udyog Vihar, Gurugram, Haryana, India, 122,016 |
100 |
| B | World Laparoscopy Hospital, Cyber City, DLF Cyber City, DLF Phase 2, Sector 24, Gurugram, Haryana 122,002 | 100 |
| C | RGCI, Sir Chotu Ram Marg, Sector-5, Rohini Industrial Area, Rohini, New Delhi, 110,085 | 100 |
Prior to telesurgery, the network values like, the mean transmission latency, packet loss ratio, and jitter service levels were measured between location A and B, and location A and C. The measured network values are shown in the Table 2 below.
Table 2.
Network values
| Mean transmission latency time | Between 3 and 10 ms |
|---|---|
| Data packet loss | ≤ 0.1% |
| Jitter service level | ≤ 10 ms |
The network was end-to-end encrypted and observed to be secured.
Working
Figure 1 illustrates the block diagram for telesurgery showing master surgeon console, slave surgeon console, patient side arm carts, patient on an operating table, and transmission network for telesurgery. The dual console SSI Mantra Surgical Robotic System has two consoles: a master surgeon console situated at a remote location and a slave surgeon console located in an operation theatre. Both the surgeon consoles have a system controller, a pair of hand controllers, and various other control pedals/toggle switches etc. In an operation theatre multiple patient side arm carts are arranged around an operating table. Multiple robotic arms (each having a robotic surgical instrument) are mounted on the patient side arm carts. One of the patient side arm carts is equipped with an endoscopic camera. The dual consoles are connected via a transmission network. During the telesurgery, the system control is with the master surgeon console. The remote expert surgeon manoeuvres the hand controllers to perform specific surgical actions, and these action/control signals are transmitted to a network router via a network switch locally present near the master surgeon console. Then the control signals are sent over the chosen transmission network (the schematic representation of network architecture is illustrated in Fig. 2), to the system controller of the slave surgeon console via a local network router. These action/control signals are then transmitted to the patient side arm carts, present at the location of surgical site of the patient. The chosen fibre-optic telecommunication network uses a Soliton ZAO-X telecaster having an encoder and decoder H.265. The 3D video stream of the surgical site is encoded using a H.265 compression Ultra-low latency (ULL) mode and sent to the network switch connected to the master surgeon console. Then the encoded 3D video stream is decoded back using a H.265. This decoded video is displayed for the expert surgeon operating remotely using the master surgeon console. The resolution of the video frame at the encoder and decoder is 1920 × 1080 (1080i50).
Fig. 1.
Block diagram for telesurgery
Fig. 2.
Schematic representation of network architecture for telesurgery
The master surgeon console is provided with a toggle switch and by pressing the switch, the slave surgeon console in the operation theatre can be made active. After the slave surgeon console is active, the surgeon present in the operation theatre can control the robotic arms of the robotic surgical system. Anytime during the surgical procedure, the control can be switched between the slave surgeon console to the master surgeon console or vice versa, just by pressing the toggle switch again. Further, in case of any unforeseen problem in the telecommunication network, the system control can be transferred to the slave surgeon console by pressing the toggle switch. Thus, two expert surgeons at two different locations can use their respective expertise and can perform parts of a complicated surgery or any surgeon can perform complete surgery remotely. For this study, the master surgeon console was located at remote location A (SSI headquarter), from where the expert surgeon performed the surgery. The slave surgeon console was located either at the location B or C where the patient was present. Further, support during the surgical procedures was provided by the clinical and Engineering team of Sudhir Srivastava Innovations Pvt. Ltd.
To check the efficacy of the telesurgery using a dual console SSI Mantra Surgical Robotic System, a Round-trip time (RTT) in milliseconds is measured. RTT is the summation of the time required for the control signals generated at the master surgeon console (by the surgical actions of the expert surgeon) to travel to the surgical robotic instruments connected to the patient side arm carts in the operation theatre, the time required for the encoded video stream of the surgical site to the network switch near the master surgeon console, and the time taken to decode the received video stream and send the video stream to a 3D display/stereoscopic display connected to the master surgeon console.
Animal experiment
In March 2024, an experiment of telesurgery was performed on a healthy male pig weighing 12 kg. Four surgical procedures namely cholecystectomy, radical nephrectomy, cystectomy, and prostatectomy were performed. During this telesurgery, the master surgeon console was at location A, and the slave surgeon console was at location B, as shown in Table 1.
Figure 3 illustrates the protocol for telesurgery using dual console SSI Mantra Surgical Robotic System. Figure 3a shows the patient side arm carts with male pig on the operating table at location B, Fig. 3b shows the geographical distance between the location A and B (which is approximately 5 km), Fig. 3c shows the surgeons performing the surgeries from remote location A, and Fig. 3d shows configuration of the transmission network.
Fig. 3.
a The patient side arm carts with the animal on the operating table b geographical distance between the location A and B c surgeons performing the surgery from remote location A d configuration of transmission network
The network configuration chosen was based on fibre and RF. The mean transmission latency time using dual console SSI Mantra Surgical Robotic System was observed to be within a range of 40–50 ms. Further, a data packet loss of < 0.1% was observed, which is a significant improvement. Further, by using the dual console SSI Mantra Surgical Robotic System, a nominal blood loss of 100 ml occurred during the above-mentioned four surgeries. All the four surgeries, cholecystectomy, radical nephrectomy, and cystectomy and prostatectomy were performed by the expert surgeons. Time taken for Cholecystectomy, Radical Nephrectomy, Cystectomy, and Prostatectomy is indicated in Table 3. The total duration of surgery was 58 min. Further, there were no complications in the telesurgery procedures.
Table 3.
Time taken for each procedure
| Procedure | Time (min) |
|---|---|
| Cholecystectomy | 20 |
| Radical nephrectomy | 15 |
| Prostatectomy | 11 |
| Cystectomy | 12 |
Clinical trials
For telesurgery clinical trials, five patients were registered between June 2024 and July 2024. All the telesurgeries were performed by expert surgeons. For all the patients, preoperative data including age, gender, weight, height, BMI was collected. Further, data during the surgeries, like docking time, console time, blood loss, and mean latency time were observed. Also, post-operative data like need of blood transfusion, mortality, conversion to laparoscope/open, and complications (if any) were monitored. The time interval between arrangement of all the robotic arm carts near the operating table and docking of cannulas to the corresponding robotic arms was noted as docking time. The time interval between docking of first cannula till all the robotic arms are undocked was noted as console time. First telesurgery was performed at location B and other four telesurgeries were performed at location C.
First telesurgery trial at location B
First clinical trial of telesurgery on a human patient was performed in June 2024. A human male patient aged 42 years was selected for cholecystectomy surgical procedure. The master surgeon console was at location A and the slave surgeon console was located at an approximate distance of 5 km, at a location B, as indicated in the Table 1. An expert surgeon present at location A, performed Cholecystectomy through telesurgery on the patient present at location B.
Figure 4 illustrates the protocol for telesurgery using dual console SSI Mantra Surgical Robotic System. In Fig. 4a the patient side arm carts with the human male patient on the operating table at location B, is shown. In Fig. 4b geographical distance of approx. 5 km between the location A and B is shown. Figure 4c shows the expert surgeon performing the surgery at location A, and Fig. 4d shows configuration of transmission network based on fibre and RF.
Fig. 4.
a Patient side arm carts with the human male patient on the operating table b geographical distance between the location A and B c surgeon performing the surgery d configuration of transmission network
Figure 5 illustrates traffic plot for transmission network at SSI headquarter of Sudhir Srivastava Innovations Pvt. Ltd., Plot No. 404–405, 3rd Floor, iLabs Info Technology Centre, Phase-III, Udyog Vihar, Gurugram, Haryana, India, 122,016. The system was tested prior to telesurgery for any data packet loss and mean latency time as shown in part (a). After successful testing of the system, the telesurgery was performed during part (b). It was observed that data utilisation was lesser than 55 mbps out of commercially available 100 mbps in the entire telesurgery.
Fig. 5.
Traffic plot for transmission network at SSI headquarter, a system testing b performance of telesurgery
Figure 6 illustrates traffic plot for transmission network at World Laparoscopy Hospital, Cyber City, DLF Cyber City, DLF Phase 2, Sector 24, Gurugram, Haryana 122,002. The part (a) of Fig. 5 corresponds to part (a) of Fig. 4. In the part (b) of Fig. 4, the telesurgery was performed.
Fig. 6.
Traffic plot for transmission network at World Laparoscopy Hospital, a system testing b performance of telesurgery
During this telesurgery, the mean transmission latency time was within a range of 40–50 ms. Data packet loss was observed to be < 0.1%. No significant blood loss of the patient occurred during the surgery. There were no complications during the surgery, and thus there was no need to convert the surgery to laparoscopic or open.
Telesurgery trials at location C
Four telesurgery trials on human patients were performed by expert surgeons sitting at SSI headquarter with patient being present at location C. In June 2024, a second clinical trial of telesurgery for a surgical procedure of cystectomy with lymph node dissection was performed on a human male patient aged 54 years. In the third clinical trial, a surgical procedure for Right Nephrectomy was being performed in June 2024, on a male patient aged 55 years. In the fourth clinical trial, a surgical procedure for Hysterectomy was being performed in July 2024, on a female patient aged 45 years. In the fifth clinical trial, a surgical procedure for Cystectomy with Lymph node dissection was being performed in July 2024, on a male patient aged 53 years. During these telesurgeries, the master surgeon console was at location A and the slave surgeon console was at location C, as indicated in the Table 1. The locations A and C were approximately 40 km apart.
Figure 7 illustrates the protocol for telesurgery using dual console SSI Mantra Surgical Robotic System. Figure 7a shows the patient side arm carts with human patient on the operating table, Fig. 7b shows a geographical distance between the location A and C, Fig. 7c shows surgeons performing the surgery remotely, and Fig. 7d shows the configuration of transmission network based on dedicated fibre line.
Fig. 7.
a The patient side arm carts with a human patient on the operating table for four clinical trials at location C b geographical distance between the location A and C c surgeons performing the surgery being present at location A d configuration of transmission network
Figure 8 illustrates traffic plot for inbound and outbound transmission network at SSI headquarter located at Sudhir Srivastava Innovations Pvt. Ltd., Plot No. 404–405, 3rd Floor, iLabs Info Technology Centre, Phase-III, Udyog Vihar, Gurugram, Haryana, India, 122,016. The part (a) of the Fig. 8 shows data consumed for reception of inbound video data of the surgical site from the location C and the part (b) shows data consumed for outbound transmission of control signal generated by the remote surgeon console.
Fig. 8.
Traffic plot for inbound and outbound transmission network at SSI headquarter: a data consumed for reception of inbound video data of surgical site, b data consumed for outbound transmission of control signal
Figure 9 illustrates traffic plot for inbound and outbound transmission network at RGCI, Sir Chotu Ram Marg, Sector, 5, Rohini Industrial Area, Rohini, New Delhi, 110,085. The part (a) of the Fig. 9 shows data consumed for reception of control signal to be communicated to the surgical instruments connected to the patient side arm carts. The part (b) shows data consumed for transmission of video data of the surgical site.
Fig. 9.
Traffic plot for inbound and outbound transmission network at RGCI: a data consumed for reception of control signal, b data consumed for transmission of video data of the surgical site
Figure 10 illustrates traffic plot for transmission network at RGCI, Sir Chotu Ram Marg, Sector-5, Rohini Industrial Area, Rohini, New Delhi, 110,085. It was observed that data utilisation was lesser than 25mbps out of commercially available 100 mbps in the entire telesurgery.
Fig. 10.
Traffic plot for transmission network at RGCI
The mean transmission latency time was observed to be 40–50 ms. Data packet loss was observed to be < 0.1% loss in the process of transmission. There were no complications during the telesurgery. Further, there was no need to convert the surgery to laparoscopic or open.
Efficacy
The telesurgery data for clinical trials on five human patients is shown in Table 4.
Table 4.
Telesurgery data
| Clinical trial | 1st | 2nd | 3rd | 4th | 5th |
|---|---|---|---|---|---|
| Surgical procedure | Cholecystectomy | Cystectomy with Lymph node dissection | Right Nephrectomy | Hysterectomy | Cystectomy with Lymph node dissection |
| Center | WLH, Gurugram | RGCI, New Delhi | RGCI, New Delhi | RGCI, New Delhi | RGCI, New Delhi |
| Approx. distance (Km) | 5 | 40 | 40 | 40 | 40 |
|
Patient age (years) |
42 | 54 | 55 | 45 | 53 |
| Gender | Male | Male | Male | Female | Male |
|
Weight (Kg) |
77 | 74 | 54 | 50 | 55 |
|
Height (cm) |
167 | 164 | 180 | 146 | 155 |
|
BMI (Kg/m2) |
27.6 | 27.5 | 16.7 | 23.5 | 22.9 |
|
Docking time (min) |
10 min | 3 min | 10 min | 2 min | 5 min |
| Console time | 1 h | 1 h 45 min | 2 h 36 min | 1 h 56 min | 3 h 20 min |
|
Blood loss (ml) |
10 | 50 | 80 | 90 | 80 |
|
Mean transmission latency time (ms) |
40–50 | 40–50 | 40–50 | 40–50 | 40–50 |
| Round-trip time (ms) | 260 | 260 | 260 | 260 | 260 |
| Data packet loss | ≤ 0.10% | ≤ 0.10% | ≤ 0.10% | ≤ 0.10% | ≤ 0.10% |
|
Bandwidth (Mbps) |
102.4 | 102.4 | 102.4 | 102.4 | 102.4 |
|
Data transfer rate (Mb/sec) |
≥ 25 | ≥ 25 | ≥ 25 | ≥ 25 | ≥ 25 |
| Conversion to laparoscopy | No | No | No | No | No |
| Blood transfusion | No | No | No | No | No |
| Mortality | No | No | No | No | No |
|
Complications (if any) |
None | None | None | None | None |
The time taken for the video to transmit from the operation theatre to the remote surgeon is 100 ms. The time taken for the control signal to transmit from the remote surgeon to the operation theatre is 40 ms. The hardware latency is 120 ms. Thus, RTT is 260 ms. It can be seen in the Table 4, that the mean transmission latency time has been observed to be 40–50 ms. Further, the data packet loss as seen in the Table 4 using dual console SSI Mantra system is < 0.1%. The network transmission was established using a secure private P2P connectivity over fibre between the two locations. Thus, the telesurgery using dual console SSI Mantra system is feasible and safe. All telesurgery clinical trials were performed successfully. No complications were reported during or after the surgery. There was no need to convert the robotic telesurgery to either laparoscopic or open. A follow up with the patients after the telesurgeries showed that the patients had faster recovery. The blood loss was nominal and hence there was no need of blood transfusion.
Results
One animal experiment was performed in March 2024. Further, clinical trials on five human patients were performed between June 2024 and July 2024. The results of the clinical trials are illustrated in the Table 4. The clinical trials for Cholecystectomy on the first human patient, Cystectomy with lymph node dissection on the second patient, right nephrectomy on the third patient, Hysterectomy on the fourth patient, and cystectomy with lymph node dissection on the fifth patient were performed respectively. Our analysis indicates improved surgical outcomes while ensuring patient safety and precision with telesurgery. The appropriate cybersecurity measures were taken, and data encryption was done to ensure data integrity. The mean transmission latency time of 40–45 ms and a round-trip time of 260 ms were observed. Further, data packet was < 0.1% and thus, no interruptions in the telesurgery occurred due to the Network Bandwidth. Moreover, an expert surgeon could operate a patient remotely. Thus, expertise of an expert surgeon could be utilised remotely. Moreover, it is observed that by using dual console SSI Mantra Surgical Robotic System, the round-trip time is very much in the tolerable range and the telesurgery is seamless.
Discussion
In a tele-surgical procedure, there is no need for an expert surgeon to travel to distant places to make his/her expertise available to the patients. Thus, the popularity of the telesurgery has increased tremendously, since it was first being performed in 2001. However, due to unavailability of an efficient network and data security, the further improvement and usage of telesurgery was jeopardised. Nowadays, the worldwide situation has improved by the possibility of using dedicated fibre optic cables. These clinical trials established the efficacy of telesurgery with dual console SSI Mantra Surgical Robotic System, particularly in complex procedures which needed expertise of a remotely located surgeon. Additionally, the dual console SSI Mantra Surgical Robotic System offers technical advancements that could shape the future of surgery.
Acknowledgements
All the authors thank Sudhir Srivastava Innovations Pvt. Ltd. for full support.
Author contributions
All authors have contributed equally to the study. Sudhir Prem Srivastava and Vishwajyoti Pascual Srivastava have contributed to study conception and design. Avinesh Singh has contributed to network and security, Suraj Dwivedi, Munish Batra, Shivam Gupta have contributed to software development, Sonu Singh has developed firmware, Shubhankar Sanjiv Kulkarni, Anson Paul have contributed to system integration, and Amit Kumar gave clinical support. Material preparation, data collection and analysis were performed by Avinesh Singh, Suraj Dwivedi, Shubhankar Sanjiv Kulkarni, and Manjusha Agwan. The first draft of the manuscript was written by Manjusha Agwan, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
The authors declare that Sudhir Srivastava Innovations Pvt. Ltd. provided all the required monetary or material support.
Data availability
Data supporting the reported results are available from the corresponding author upon request. All the data and materials comply with field standards. The participants consented to use of their personal data and samples as allowed by the research ethics committees.
Declarations
Conflict of interest
All the authors are either directors or employees of Sudhir Srivastava Innovations Pvt. Ltd. As per their employment agreement the research and the clinical trials were performed by these authors in discharge of their duties towards their employment. Hence, there is no conflict of interest. The authors have no financial or proprietary interests in any material discussed in this article.
Ethics approval
The written approvals for clinical study were obtained from institutional Ethics committee/ Institutional review boards by the sponsor/investigator. The trials were registered prospectively with trial registration number CTRI/2024/06/068361. All procedures performed in studies involving human participants were in accordance with the ethical standards as per the approval. The welfare of animal used in animal experiment was taken care of. Written consent was taken from the human patients participated in the clinical trials.
Informed consent
The individual rights of the individuals participating in the clinical trials are not infringed.
Consent to participate
Informed signed consent was obtained from all individual participants included in the study.
Consent to publish
The manuscript does not contain any individual person’s data in any form (including any individual details, images or videos).
Disclosures
The authors declare that Sudhir Srivastava Innovations Pvt. Ltd. provided all the required monetary or material support. All the authors are either directors or employees of Sudhir Srivastava Innovations Pvt. Ltd. As per their employment agreement the research and the clinical trials were performed by these authors in discharge of their duties towards their employment. The written approvals for clinical study were taken from institutional Ethics committee/ Institutional review boards by the sponsor/investigator. The trials were registered prospectively with trial registration number CTRI/2024/06/068361.
Footnotes
Publisher's Note
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data supporting the reported results are available from the corresponding author upon request. All the data and materials comply with field standards. The participants consented to use of their personal data and samples as allowed by the research ethics committees.