Mobile phone-based surgical telemedicine in Sudan: a conflict-driven innovation with global relevance

Summary box.

• Mobile phones are used to support surgical care in conflict-affected areas of Sudan.

• Voice calls, photo sharing and messaging apps facilitate triage, intraoperative guidance, postoperative care and remote mentoring.

• Mobile phone-based surgical telemedicine is a low-cost and adaptable approach in resource-limited settings.

• This model emerged from field practice in areas with restricted access to hospitals.

• Integration of such methods into policy and training may strengthen crisis-response health systems.

The collapse of surgical access in Sudan

Sudan’s ongoing civil war has devastated its healthcare infrastructure, displacing professionals, destroying facilities and cutting off entire populations from surgical services. Operating theatres have been rendered inaccessible or destroyed, and access to essential surgical care is now beyond reach for many. In this extreme context, telemedicine has rapidly evolved from a support tool into a vital strategy for surgical continuity, but this is not telemedicine in the traditional sense. It is not powered by sophisticated platforms or high-speed internet. Instead, it relies on mobile voice calls, image sharing and messaging apps—basic tools being used with extraordinary ingenuity to sustain surgical services in a war zone. In this setting, surgical telemedicine refers to the use of these mobile-based tools to provide remote triage, intraoperative guidance, postoperative care and mentorship when in-person surgical access is impossible.

A new mode of surgical practice

A recent national survey conducted during the early phase of the conflict in Sudan was led by a team of Sudanese researchers and supported by 26 collaborators. Carried out over a 1-week period from 18 to 25 July 2023, the study included 2463 licensed Sudanese physicians—medical officers, residents, specialists and consultants—actively providing teleconsultations during the crisis. Among them, 371 (15.1%) were surgeons, representing one of 17 medical specialties. Although the survey employed convenience sampling and was distributed online, the large and diverse sample, spanning both local and diaspora clinicians, offers a reasonably representative snapshot of teleconsultation practices in conflict-affected Sudan.¹ The findings revealed that over 50% of physicians relied on teleconsultations— primarily via mobile phones—to deliver care. Despite the unstable infrastructure, 73.3% reported improved patient trust, and over 60% considered teleconsultation comparable to in-person visits for many conditions, while still emphasising the importance of physical examination in some cases.^{1 2} In surgery, this shift enabled remote triage, postoperative wound care, mentoring of junior providers and even real-time intraoperative guidance across conflict-divided cities—marking a profound transformation in surgical practice under extreme constraints. In practice, mobile phones are being used by surgeons to conduct remote triage, guide intraoperative decisions, assess postoperative wounds and mentor junior providers across distant or besieged areas. These interactions often occur via voice calls, photo sharing or instant messaging, allowing for real-time or asynchronous surgical consultation. However, the war has severely impacted mobile infrastructure—towers have been damaged, coverage is uneven, and network outages are common.^{2 3} A nationwide shutdown in early 2024 cut mobile and internet services for over a month for nearly 30 million people. In some central regions, connectivity was entirely offline for more than a year, forcing doctors to risk travel through military zones or pay steep fees (up to ~$1/hour) to access satellite ‘Starlink cafés’ just to transmit clinical data. Despite these barriers, clinicians continue to improvise with basic connectivity to maintain surgical oversight and coordination.2,4

Real-life vignettes of mobile-based surgical support

In July 2023, a junior surgical resident at a rural Sudanese clinic encountered a young patient with penetrating abdominal trauma. With no senior surgeon nearby, the resident initiated a voice call with a consultant located over 400 km away. Using real-time guidance via mobile phone and WhatsApp image sharing, the remote surgeon directed the operation. The patient’s bowel injury was successfully repaired, and they recovered without major complications. In another case, a health professional in a displacement camp observed signs of infection in a postoperative wound. With no internet access, they transferred images via Bluetooth to a villager, who then travelled by donkey to an area with Starlink coverage. The images were sent to a surgeon, who responded the following day with a voice note outlining wound care steps. He also annotated a photo to indicate the area requiring suture removal due to localised infection. The health professional followed his instructions and sent daily photo updates, which documented steady wound healing. These cases illustrate not only the clinical adaptability of Sudanese healthcare providers but also the extraordinary lengths they go to in order to preserve surgical safety amid infrastructure collapse. These cases are based on the author’s first-hand communications with surgical teams in Sudan during July 2023 (personal communication).

Operational, legal and quality considerations in mobile-based surgical telemedicine

Despite its clear lifesaving potential, mobile-based surgical support introduces significant limitations and risks. The inability to perform a physical examination—such as palpation or vital sign assessment—remains a fundamental clinical drawback in remote surgical triage. In conflict-affected and low-resource settings, intermittent connectivity and poor internet or power infrastructure can delay consultation and disrupt real-time intraoperative guidance.^{3 5} Medicolegal uncertainty compounds these challenges: practitioners often operate across regions without formal licensure or clear accountability frameworks, heightening liability risks.⁶ Ethical and legal concerns also emerge around informed consent, confidentiality breaches and data security when using informal, unsecured communication platforms.⁷ To ensure quality and accountability, it is essential to implement standardised processes—comprehensive informed consent procedures, secure data transmission, meticulous case documentation, peer-review systems and regionally harmonised ethical and licensure regulations—even in resource-limited or crisis environments.⁸

From emergency response to scalable innovation

These frontline innovations are not merely reactive. They represent a pragmatic, cost-effective and reproducible model of surgical telemedicine that could benefit millions of people living in other fragile or conflict-affected health systems. Sudan’s experience also highlights how fragile the foundation for surgical telemedicine remains in conflict zones. While many providers viewed remote consultation as essential for bridging gaps in surgical expertise, a recent national assessment revealed that only 19% of facilities had the infrastructure to support telemedicine services. In Khartoum and other urban hubs, fixed telemedicine installations were dismantled or rendered non-functional due to power outages, physical attacks and lack of connectivity. Even where platforms existed, the widespread failure of operating room equipment and ICU systems limited the effectiveness of remote surgical decision-making. Yet, despite these setbacks, clinicians emphasised the value of telemedicine for managing complex surgical cases when referrals were no longer possible. These findings underscore the urgent need to invest in conflict-resilient, mobile-based telemedicine systems as a core component of surgical care in fragile settings.⁹ The World Bank estimates that over two billion people live in settings where conflict or disaster routinely disrupt healthcare. For these populations, Sudan’s model offers something rare: proof that effective surgical communication and oversight can be maintained, even when infrastructure collapses.^{10 11}

The integration of telemedicine into surgical care in rural Sudan has proven to be a critical enabler of clinical decision-making in resource-limited environments. In a recent intervention across three district hospitals, telemedicine facilitated remote consultations with urban-based specialists in 80% of complex surgical cases, enhancing the confidence and capabilities of local surgical teams. Despite challenges such as unreliable internet connectivity, this approach improved the management of emergencies and reduced unnecessary referrals to distant tertiary centres. The study reinforces the potential of telemedicine—not as a luxury, but as a practical, life-saving tool in under-resourced and conflict-affected settings.¹² Parallel to wartime adaptations, proactive infrastructure planning is also reshaping telemedicine’s role in rural surgical care. A recent hospital design initiative in Al-Jazira State, Sudan, demonstrated strong community support (85%) for telemedicine-integrated care and proposed a rural facility model with dedicated virtual consultation rooms, integrated outpatient and diagnostic services, and scalable energy-efficient infrastructure. Though conceptual, such models emphasise that even in fragile settings, telemedicine can be embedded into future-ready surgical systems—with benefits extending beyond access to include environmental sustainability and community empowerment.¹³ In contrast, Sudanese providers are demonstrating that low-bandwidth, secure and accessible tools can be sufficient to maintain life-saving surgical care—with appropriate adaptation and trust.¹⁴

What the global health community must do

Despite the urgency and relevance of these developments, there has been little attention from global surgical and health policy circles. If these innovations are viewed as temporary stopgaps or humanitarian improvisations, their long-term value will be lost. To support sustainable integration of these practices, the global health community must develop context-sensitive guidelines for surgical telemedicine in conflict and low-resource settings, balancing feasibility, safety and ethical concerns.

• Invest in digital infrastructure for healthcare systems in fragile states, ensuring equitable access to secure, scalable platforms that function under minimal connectivity.

• Redesign surgical training programmes to include modules on remote triage, virtual supervision, asynchronous communication and digital documentation—skills now essential for working in unstable environments.

These changes should not wait for postcrisis periods. The innovations happening now in Sudan must be documented, studied and embedded into broader global health policy and practice.¹⁵

Telemedicine as a surgical lifeline

Sudan’s experience reframes telemedicine not as a luxury of modern health systems, but as a surgical survival tool born out of necessity. While some health systems explore artificial intelligence, remote robotics and digital twins, millions of people simply need a doctor who can guide surgical procedures through a mobile phone. This is not a step backward—it is a leap forward in adaptability and innovation. The resilience of Sudanese surgeons, working under fire, offers a new blueprint for global surgical practice in the era of climate shocks, displacement and armed conflict. Sudan’s story must be studied. More importantly, it must be scaled.

Data availability statement

All data relevant to the study are included in the article.