Abstract
Telerobotic surgery has undergone remarkable advances over the past two decades, driven by the integration of sophisticated robotic platforms and modern communication technologies, thereby alleviating many constraints of conventional surgical procedures. Building upon previous studies that focused on individual specialties or specific innovations, this review provides a comprehensive and integrated perspective by tracing the evolution of the field and highlighting applications in gastroenterology, urology, neurology, and cardiology. Landmark achievements include the 2001 transatlantic remote cholecystectomy and the introduction of next-generation platforms such as the Hinotori surgical robot, enabling low-latency remote interventions. Moreover, the integration of advanced technologies such as 5G networks, extended reality (XR), and multi-console surgical systems has enhanced surgical precision, minimized latency, and improved procedural coordination, thereby collectively expanding global access to high-quality care. Despite these achievements, telerobotic surgery continues to face challenges, including high costs, communication delays, cybersecurity vulnerabilities, and unresolved ethical and legal concerns. Nonetheless, emerging solutions such as 6G-enabled communication, advanced haptic feedback systems, and AI-assisted surgical platforms hold promise for addressing these obstacles by refining precision, reducing costs, and broadening the scope of remote interventions. By offering a comprehensive review of these developments, this article underscores the inherently interdisciplinary nature of telerobotic surgery, connecting engineering, communications, and clinical medicine. It also provides strategic insights to overcome current barriers and foster both technological and clinical innovation in surgical care.
Keywords: telerobotic surgery, 5G technology, extended reality, multi-console telesurgery, artificial intelligence, Tactile Internet
Introduction
Surgery, as a cornerstone of modern medicine, has successfully tackled critical challenges such as pain management, infection control, and hemostasis, steadily evolving into a sophisticated field. Over time, surgical techniques have transitioned from traditional open procedures to minimally invasive methods, including endoscopic, laparoscopic, and robot-assisted approaches. However, the inherent limitations of laparoscopic surgery – such as reduced tactile feedback, loss of three-dimensional visualization, and restricted instrument dexterity – have spurred the development of robotic surgery[1,2]. In the 21st century, surgical practice has increasingly integrated intelligent technologies, and telerobotic surgery has emerged as a major milestone, marking a significant advancement in the evolution of surgical techniques.
HIGHLIGHTS
Systematically summarizes the evolution and multidisciplinary adoption of telerobotic surgery, emphasizing its convergence with emerging technologies.
Demonstrates that telerobotic surgery continues to gain global traction, reflecting a sustained upward trajectory in clinical adoption.
Telerobotic surgery enhances surgeon safety, expands equitable access to high-quality medical resources, and strengthens multidisciplinary collaboration efficiency.
Widespread implementation of telerobotic surgery remains challenged by persistent barriers, including latency, bandwidth limitations, cybersecurity vulnerabilities, legal liability concerns, and substantial implementation costs.
Outlines emerging technologies and innovative strategies to overcome existing limitations, broaden global applicability, and optimize the clinical implementation of telerobotic surgery.
The concept of telepresence surgery was first articulated in 1972 by the U.S. National Aeronautics and Space Administration (NASA), with the objective of delivering remote surgical care to astronauts aboard orbital missions[1,3,4]. At the time, however, the technological limitations of early computing and robotics rendered this vision impractical. This early concept was later revitalized by the successful development of a prototype system at the Stanford Research Institute (SRI), which drew renewed interest from the Defense Advanced Research Projects Agency (DARPA). DARPA envisioned the deployment of such systems in combat settings, where surgeons could remotely operate robotic platforms mounted on military vehicles to provide immediate surgical intervention for battlefield injuries[1,3,4]. With sustained advances in enabling technologies, the telepresence surgery paradigm has since expanded into the civilian sector, not only accelerating the progress of robotic-assisted surgery but also establishing key technological and conceptual foundations for the broader field of telemedicine[1,2].
In 2001, Marescaux et al successfully conducted the first officially documented transatlantic telerobotic-assisted laparoscopic cholecystectomy[2,5,6], marking a significant milestone in telemedicine by proving the feasibility of remote surgery across great distances. Since the early 21st century, the global demand for surgical care has grown substantially, accentuating the strategic value of telerobotic surgery in mitigating inequities in healthcare access and resource distribution. The third edition of Disease Control Priorities, published by the World Bank in 2015, was the first to underscore the disparities in surgical resource allocation, estimating that the availability of basic surgical services in low- and middle-income countries could prevent between one and five million deaths annually[7]. Today, equitable access to surgical care is widely recognized as a critical issue in global public health, with numerous studies documenting significant disparities in this area[8]. Current estimates suggest that approximately 68% of the global population lacks adequate access to surgical services, a disparity that shows a strong inverse correlation with national economic status[9]. In response to this pressing challenge, telerobotic surgery emerges as a promising solution, integrating cutting-edge technologies to ensure surgical precision and quality while significantly improving healthcare access in remote and underserved regions. The convergence of enabling innovations – such as 5G communications, artificial intelligence (AI), and the Tactile Internet (TI) – alongside rising surgical demand and the impact of the COVID-19 pandemic, has markedly accelerated the development and deployment of these systems. This momentum not only drives surgical innovation but also fosters unprecedented interdisciplinary collaboration across engineering, medicine, and telecommunications. In this context, a comprehensive and integrated perspective is urgently needed to systematically trace the evolution of telerobotic surgery, evaluate its current technological landscape, distill key insights, and identify future directions for cross-disciplinary advancement.
Following the recently published general-purpose guideline for transparent reporting of artificial intelligence use in academic manuscripts[10], this review conducted a systematic search using the PubMed and Web of Science databases with keywords including “telesurgery,” “remote surgery,” “robotic surgery,” “teleoperation,” “telerobotic surgery,” “5G,” “6G,” “Tactile Internet,” “multi-console,” “artificial intelligence,” “haptics,” “augmented reality,” “virtual reality,” and “mixed reality.” Drawing on these published studies and reports, this paper provides a comprehensive review of the evolution of telerobotic surgery over the past two decades, with a particular focus on recent advances in the research and application of emerging technologies. By virtue of its interdisciplinary nature, this review facilitates enhanced collaboration across clinical, engineering, and telecommunications domains, thereby promoting more integrated and sustainable advancements in telesurgical practice. Additionally, it systematically evaluates the strengths and limitations of current telerobotic surgical systems, providing a deeper understanding of their present stage of development while offering forward-looking insights that may catalyze future innovation and guide the refinement of clinical applications. Overall, by comprehensively integrating current knowledge and technological trends, this review aims to offer a more systematic and forward-looking perspective, deepen understanding of this evolving field, promote the sustained and holistic optimization of clinical practice, and enhance global accessibility.
Applications of telerobotic surgery across medical disciplines
Over the past two decades, telerobotic surgery has made significant strides across multiple disciplines, encompassing a range of procedures from flexible assisted laparoscopic techniques to precise neurovascular minimally invasive surgeries. Despite the varying surgical characteristics and differing levels of adoption across fields, the active exploration and notable achievements in these disciplines highlight the practical value and potential of telerobotic surgery.
Gastrointestinal surgery
The application of telerobotic surgery in digestive surgery began with remote surgical guidance and was first successfully demonstrated in 2001 by Marescaux et al[2,5,6,11,12]. In this landmark procedure, known as the transatlantic cholecystectomy, surgeons based in New York remotely operated on a patient in Strasbourg, covering a round-trip distance of over 14 000 km. The surgery was completed in just 54 minutes using a dedicated asynchronous transfer mode (ATM) communication service, with an average transmission latency of only 155 ms[2,5,6,12]. This groundbreaking operation not only marked the first successful application of telerobotic surgery in the digestive field but also represented a major milestone in the broader advancement of remote surgical technology. In 2003, a stable telerobotic surgical service was established between a teaching hospital and a rural hospital in Canada, enabling 23 successful remote laparoscopic procedures without major intraoperative complications or conversions to open surgery. This case holds significant value in promoting the routine clinical adoption of telerobotic surgery[13]. Nonetheless, constrained by the technological limitations of commercial networks at the time, these procedures primarily relied on costly dedicated lines, making network communication a major technical barrier to the advancement of telerobotic surgery. With the ongoing evolution of communication technologies, the implementation of telerobotic surgery has gradually expanded to a wider range of countries. In 2015, Su et al utilized a remote surgical system based on the “Micro Hand S” robot and a TCP/IP protocol to successfully conduct China’s first remote cholecystectomy on a pig, covering the distance between Beijing and Tianjin, with an intraoperative delay of 253 ms[14]. In 2023, Takahashi et al reported that 11 surgeons utilized the Medicaroid surgical robot to perform remote procedures on gallbladder models over a distance of 150 km. The accuracy of tasks such as cholecystectomy and intestinal suturing was comparable to that of local surgeries, demonstrating overall favorable performance[15]. During the same year, Ebihara et al utilized the newly developed Japanese surgical robot, hinotori, to perform a remote distal gastrectomy and lymphadenectomy over a distance of 250 km on a cadaver with gastric cancer, achieving an average latency as low as 40 ms[16], indicating significant advancements in latency management. These advances collectively demonstrate that the technical prerequisites for the large-scale implementation of telerobotic surgery in the digestive system are already in place. Subsequently, in 2024, two cases of telerobotic gastrectomy for gastric cancer were successfully performed in China over a 5G network[17]. One case involved a surgical distance of 1700 km with an average intraoperative latency of 99 ms and no postoperative complications, confirming the clinical feasibility of conducting telerobotic digestive surgeries via commercial networks in real-world settings.
Urological surgery
Urinary organs are anatomically deeper and more complex than those of the digestive system, which makes robotic surgery particularly advantageous for its precision, flexibility, and enhanced three-dimensional visualization. These benefits have driven the adoption and deeper exploration of telerobotic surgery in this field. Similarly, the development of telerobotic surgery in urology began with remote guidance[18,19]. In 2000, Lee et al reported a case in which an inexperienced surgeon in Singapore, guided remotely by an experienced laparoscopic surgeon in the United States, successfully performed a radical nephrectomy and varicocelectomy[19]. During this period of clinical experimentation, robotic surgical equipment also continued to advance. Reports from that year indicated that using the conventional da Vinci® system for radical prostatectomy required up to 420 minutes[20]. By 2002, even for more complex procedures like right kidney transplantation, surgical times had been reduced to 178 minutes, demonstrating remarkable advancements in both the utilization and technological sophistication of telerobotic systems[21]. The adoption rate of robotic surgery also steadily increased. By 2006, 42% of radical prostatectomies in the United States were performed using robotic systems[22], catalyzing further advancements in telerobotic surgery for urology. The first telerobotic animal experiment in this discipline was conducted in 2005, during which a remote procedure was successfully performed on a pig using the da Vinci® system. Although the surgical outcome was favorable, the procedure experienced latency of up to 900 ms[23]. After nearly two decades of advancement, by 2020, remote laparoscopic radical nephrectomy was successfully performed over 5G networks in a cohort of 29 patients, with operative distances reaching up to 1775 km and a median total latency of 176 ms[24]. All procedures were completed with a 100% success rate, with only two patients experiencing minor postoperative complications. Long-term follow-up indicated favorable outcomes for all patients. By 2024, a transcontinental remote radical prostatectomy was successfully carried out over a distance of 7000 km via fiber-optic broadband networks, with an average intraoperative latency of 181.4 ms and without any reported postoperative complications[25]. Despite the remaining challenges in latency optimization, the successful implementation of these remote procedures has provided compelling evidence of their clinical acceptability and practical value, suggesting the growing maturity and reliability of telerobotic surgery in urology.
Neurological surgery
While telerobotic surgery in neurosurgery also originated from remote surgical guidance, its clinical implementation was not documented until 2005. At that time, a mentor in Halifax remotely guided a surgeon located 400 km away via a robot-controlled camera over an Integrated Services Digital Network (ISDN) line, successfully performing three craniotomies for brain tumors, one for an arteriovenous malformation, a carotid endarterectomy, and a lumbar laminectomy[26]. All surgeries were successfully completed without any intraoperative complications. In 2008, Tian et al reported a successful frameless stereotactic surgery performed by a Beijing-based neurosurgeon on a patient 1300 km away using the Computer-Assisted Surgical Robot BH5 (CAS-BH5) robotic system via a dedicated network. Favorable postoperative functional recovery demonstrated the clinical feasibility and effectiveness of remote neurosurgery[27]. Building upon advancements in miniaturized surgical instrumentation and precision motion control, Burgner et al, in 2014, pioneered the application of a mechanically actuated concentric tube continuum robot model to endonasal skull base surgery, demonstrating significant improvements in anatomical accessibility and operative dexterity compared to conventional rigid endoscopic systems[28]. Parallel to these developments, in 2015, Wirz et al reported that a surgeon in Nashville, Tennessee, successfully performed a pituitary phantom tumor resection on a patient simulator located in Chapel Hill, North Carolina – approximately 800 km away – using a remote robotic system over a public Internet connection, with both control and video latency kept below 100 ms. This experiment not only marked the first successful remote surgical trial involving a tentacle-like concentric tube manipulator but also demonstrated the feasibility of ultra-low-latency telerobotic surgery over standard Internet infrastructure[29]. Collectively, these cases underscore the considerable potential of remote neurosurgery to expand access to care while preserving surgical precision. Continuous advancements in robotic control, latency optimization, and instrument accuracy are propelling its adoption in complex neurosurgical procedures and laying the groundwork for broader clinical integration.
Cardiovascular surgery
Despite their transformative potential in cardiovascular interventions, including enhanced catheter stability, high-precision manipulation, and reduced radiation exposure, robotic systems remain underutilized in this field, which continues to lag behind other surgical specialties, primarily due to the lack of prospective randomized controlled trials (RCTs) and a steeper learning curve[30]. Consequently, translational research and clinical adoption of cardiovascular telerobotics have progressed at a markedly slower pace compared to the well-established applications in urology or general surgery. It was not until 2016 that Guo et al reported a significant breakthrough in vascular interventional telerobotic surgery. They reconstructed a virtual reality model of the catheter based on the patient’s position and the real-time shape and position of the catheter, achieving a maximum error of just 0.93 mm and significantly reducing procedural latency[31]. This advancement not only provided valuable opportunities for training novice surgeons in catheter and guidewire techniques but also facilitated effective collaboration among surgeons during complex procedures. Moreover, in 2022, Legeza et al conducted a detailed study on network latency in cardiovascular telerobotic surgery, recommending that remote robot-assisted interventions for femoral, carotid, or coronary arteries maintain network latency below 400 ms to ensure seamless control of remote devices[32]. To enhance stability during intervention and mitigate risks posed by mechanical vibrations, blood flow, lipids, or intravascular thrombus affecting the guidewire tip, Ma et al proposed a control algorithm combining an active disturbance rejection controller (ADRC) with intelligent algorithms. This approach enhances the controller’s ability to compensate for system disturbances, thereby improving its performance[33]. As demonstrated above, leveraging the successful experiences of other disciplines, telerobotic surgery in cardiovascular surgery is currently at a pivotal stage of technological innovation. The effective integration of multiple cutting-edge technologies is urgently needed. Advancing the initiation of first-in-field animal studies and subsequent clinical trials would constitute a milestone breakthrough, offering expanded treatment opportunities for patients in need.
Multidisciplinary insights and translational challenges
Despite discipline-specific differences, the development of telerobotic surgery has largely followed a shared trajectory. It began with early-stage applications in real-time surgical guidance and intraoperative assistance, progressed through experimental remote procedures, and eventually advanced to fully remote primary surgeries (Fig. 1). Although certain specialties were slower to adopt the technology, they have nonetheless shown encouraging progress in recent years. Latency management remains a central and shared challenge across disciplines. Over the past few decades, significant improvements have been made, with latency reduced from approximately 900 ms in early urological experiments to around 40 ms in recent gastrointestinal procedures, primarily due to advances in high-speed communication networks and improvements in robotic system performance[16,23]. These developments suggest that technological convergence across specialties may accelerate the broader adoption of telerobotic surgery. However, in minimally invasive disciplines that demand extremely high levels of real-time precision, such as neurosurgery and cardiovascular surgery, technical advancement has been relatively constrained by persistent latency bottlenecks.
Figure 1.
Global deployment of telerobotic surgery. The evolution of telerobotic surgery has progressed sequentially from remote surgical assistance, through telerobotic surgery experiments, to clinical applications. Coordinates indicate specific locations where these procedures were performed, and dashed lines illustrate surgical distances, with annotations specifying precise distances and procedure types.
From a global perspective, telerobotic surgery is steadily advancing toward international clinical adoption. Since the successful completion of the first transatlantic cholecystectomy in 2001[2,5,6,12], countries such as France, Canada, and China have undertaken various forms of clinical exploration[13,24], demonstrating the technology’s feasibility and adaptability across geographic regions.
From a disciplinary perspective, urologic surgery has emerged as the leading field in telerobotic applications, owing to its strong compatibility with robotic technologies, particularly in meeting the demands for precision and enhanced visualization[24]. Its early success has provided valuable technical pathways and clinical experience for later-developing specialties such as cardiovascular surgery. In particular, its effectiveness in addressing anatomical complexity offers instructive insights for broader implementation. Nevertheless, it is important to recognize that different specialties present distinct technical adaptation requirements. For example, cardiovascular procedures necessitate specialized vibration compensation algorithms[33]. Therefore, discipline-specific optimization remains a key challenge for advancing the clinical integration of telerobotic surgery.
Despite the promising outlook of telerobotic surgery, its widespread adoption still faces several real-world challenges. First, the number of relevant clinical studies remains limited, and existing reports may be affected by success bias, with a tendency to highlight positive outcomes while underreporting failed or inconclusive attempts[34]. Second, most current studies evaluate outcomes solely based on procedure completion rates or the presence of complications, with little attention to systematic mid- and long-term prognostic data. Just as robotic surgery gained clinical traction through its demonstrated improvements in patient prognosis[35], telerobotic surgery must also be supported by robust, high-quality clinical evidence to achieve broad clinical acceptance. Consequently, large-scale, multicenter RCTs are essential to systematically compare its efficacy and safety with that of conventional laparoscopy and robotic approaches.
Moreover, the development of telerobotic surgery in certain specialties has experienced notable stagnation, which may be partly attributed to the mismatch between high resource requirements and limited clinical return, thereby discouraging researchers from undertaking the associated risks. Of even greater concern is that the rapid expansion of telerobotic surgery in urology partly reflects a preferential allocation of resources to disciplines with higher market value[24]. This concentration of investment may lead to insufficient support for technically demanding fields such as neurosurgery, ultimately constraining their developmental potential and impeding clinical translation.
It is also important to emphasize that advancements in latency management and other technical parameters remain geographically uneven. In regions lacking robust communication infrastructure or high-performance robotic systems, the testing and deployment of telerobotic surgery remain largely inaccessible, raising critical concerns regarding digital health equity. Additionally, the field’s current dependence on proprietary systems (e.g., da Vinci®, Hinotori) poses the risk of technological monopolization[16], thereby elevating entry barriers and stifling innovation. Promoting the development and adoption of open-source platforms could significantly improve accessibility, while simultaneously encouraging industry diversification and enabling more equitable progress across medical disciplines.
In summary, the development of telerobotic surgery is marked by a coexistence of technological convergence and disciplinary divergence. While the rapid progress in urologic surgery provides a valuable paradigm for other fields, specialties such as neurosurgery and cardiovascular surgery continue to encounter substantial challenges due to technical barriers and limited resources. Moving forward, it is essential to promote cross-disciplinary collaboration and optimize resource allocation. Equally important is the accumulation of robust clinical evidence through systematic research, which will be critical for advancing the widespread and equitable adoption of telerobotic surgery across various specialties and regions.
Technological advancements in telerobotic surgery
The rapid advancements in information technology and AI in recent years have been instrumental in driving significant progress in telerobotic surgery. These technologies have not only overcome many previously challenging hardware limitations but have also fostered a wave of innovative solutions and optimization strategies, greatly enhancing the precision, safety, and operability of surgical procedures. These developments have substantially expanded the potential applications of telerobotic surgery and established a solid foundation for the future evolution of medical technologies.
5G technology
Early successful cases of telerobotic surgery predominantly relied on costly dedicated communication lines, whose high deployment costs and infrastructural complexity severely limited their scalability. In contrast, the use of commercial networks presents a more practical and scalable alternative, offering greater feasibility for the widespread implementation of telerobotic surgery. The Fifth Generation Mobile Communication Technology (5G) represents the most recent breakthrough in global mobile networks[36,37]. Compared to 4G, 5G enhances the theoretical data transmission speed by up to 20 times and reduces latency by a factor of 10, achieving minimum latency levels as low as 1–10 ms[38,39]. Although its performance in real-world settings often falls short of that observed under theoretical conditions, the high speed, large capacity, and low latency of 5G render it particularly well-suited to meet the demands of real-time tracking and telemedicine applications, such as remote consultations that require stability, efficiency, and immediacy[40,41]. As a result, 5G has attracted significant attention from researchers and clinicians, driving further exploration and application in the field of telemedicine.
5G can be categorized into three parallel technological architectures, namely Enhanced Mobile Broadband (eMBB, supporting high-speed and high-bandwidth data transmission), Ultra-Reliable Low-Latency Communication (URLLC, enabling millisecond-level latency), and Massive Machine-Type Communication (mMTC, allowing large-scale device connectivity)[42,43]. These advancements facilitate the transmission of large data volumes at very high speeds while enabling the simultaneous connection of numerous devices to the same network without interference[43]. This enhanced connectivity enables more stable and efficient real-time control and multi-device coordination in telerobotic surgery, thereby substantially broadening its clinical applicability[44]. URLLC, which features millisecond-level latency and extremely high reliability[45], is extensively utilized in fields such as remote operations, immersive virtual reality, and cooperative autonomous driving[46]. In the context of telerobotic surgery, URLLC enables the instantaneous transmission of surgical commands and maneuvers, while its high reliability ensures uninterrupted data flow during procedures, thereby reducing the likelihood of medical errors. Building on these features, the human-in-the-loop robotic teleoperation platform, which was developed based on a URLLC prototype system, has been experimentally validated to achieve millisecond-level latency and high control transparency. This platform is expected to be applicable in clinical settings of telerobotic surgery, further advancing the clinical adoption of the technology[47].
In recent years, the application of 5G technology in telerobotic surgery has demonstrated significant practical success. In 2020, Tian et al reported 12 successful cases of telerobotic spinal surgeries conducted using 5G technology, with only one postoperative complication reported, which was unrelated to the intraoperative procedures[48]. Furthermore, as previously mentioned, a tertiary hospital in Qingdao, China, leveraged a 5G network to remotely perform robot-assisted laparoscopic radical nephrectomies on 29 patients across eight primary hospitals, further validating the reliability and clinical feasibility of 5G-enabled telerobotic surgery[24]. Similarly, Morohashi et al demonstrated the feasibility of using existing commercial networks for remote surgery in Japan, paving the way for broader social implementation[49]. However, due to limitations in network coverage and base station infrastructure, relying solely on 5G may not be sufficient for all scenarios. In 2023, Rocha et al concluded that utilizing redundant links, such as 4G combined with WiFi, can better ensure the reliability and stability of communication during telerobotic surgeries, providing valuable insights for enhancing communication in 5G-based remote surgery[50]. In this regard, a promising direction is to incorporate satellite communications and algorithmic optimization into a multi-tiered hybrid communication architecture, aiming to enhance system reliability and security while ensuring high performance[51]. Additionally, Kumar et al proposed a low-complexity hybrid algorithm that significantly improves bit error rate and power spectral density (PSD), enhancing 5G communication for smart healthcare, and showing potential value for applications in telerobotic surgery[44].
Objectively, although 5G technology promises high data rates and low latency, its real-world performance is often constrained by factors such as base station density and frequency band selection[52]. In particular, high-frequency millimeter-wave signals are highly susceptible to physical obstructions, resulting in actual performance frequently falling short of theoretical expectations[53]. These limitations present significant challenges in maintaining stable and continuous communication in telerobotic surgery. In remote robotic operations relying on 5G or other commercial networks, prioritizing the transmission of critical surgical data is essential to ensure procedural continuity and safety. At the same time, compared to private dedicated networks, commercial infrastructures are more susceptible to cybersecurity threats, an issue that warrants substantial attention[54]. More importantly, the high deployment costs associated with 5G infrastructure may limit its reach in resource-constrained settings, potentially worsening existing disparities in healthcare access. Furthermore, while the integration of redundant communication strategies may enhance system-level fault tolerance, it also introduces considerable architectural complexity and financial burden[50]. Finally, it is noteworthy that most current studies on 5G-enabled clinical applications have been conducted in well-connected urban environments, leading to potential selection bias and overlooking performance in edge cases such as network fluctuations or equipment failures. These limitations hinder a comprehensive evaluation of 5G’s reliability in real-world surgical contexts. Therefore, before 5G-supported telerobotic surgery can be integrated into routine clinical practice, large-scale, multicenter RCTs are essential to establish robust clinical evidence. In parallel, well-defined technical and safety standards must be developed and rigorously enforced to ensure secure and reliable implementation.
Extended reality (XR) technology
The absence of stereoscopic visualization has been an inherent limitation of laparoscopic surgery since its inception[1,2], fundamentally constraining depth perception and spatial orientation. Despite the introduction of three-dimensional (3D) systems aiming to address this long-standing deficit, suboptimal adoption rates and technical limitations in real-world clinical settings continue to hinder their efficacy, perpetuating a challenge that has persisted across decades of laparoscopic innovation[55,56]. Given the critical role of visual perception in surgical procedures, this challenge becomes even more pronounced in telerobotic surgery, where precise spatial understanding is crucial. Studies have shown that stereoscopic three-dimensional (S3D) visualization significantly enhances the operator’s spatial awareness compared to two-dimensional (2D) visualization, particularly in remote surgical environments, leading to marked improvements in operative performance[57]. XR refers to a broad set of technologies that enhance the user’s perception of their environment by integrating interactive computer graphics into their field of view, comprising augmented reality (AR), virtual reality (VR), and mixed reality (MR), each with distinct characteristics[58]. Since its inception, there have been numerous efforts to integrate XR into surgical practice, with reports indicating that by as early as 2018, various AR and VR applications had already become part of routine surgical procedures. These integrations are anticipated to reduce complications and improve surgical outcomes, underscoring their growing potential to enhance surgical performance. Although promising, these anticipated benefits still await full validation through high-quality clinical trials[59].
VR can simulate most human senses, providing users with an immersive virtual experience that allows them to visualize operations and interact with computers in a realistic virtual environment[60]. Unlike AR and MR, VR does not incorporate any elements of the real world[61]. As early as 2005, researchers began exploring the use of VR in remote surgery to mitigate the effects of latency and other factors in remote operations, demonstrating its potential to enhance system stability[62]. In recent years, the rapid advancement of VR technology, along with the emergence of novel display and input devices, has significantly expanded its range of applications, most notably in the field of telerobotic surgery[63]. This trend has been reflected in several notable developments. The virtual reality-based digital twin robotic minimally invasive surgery (VRDT-RMIS) simulator developed by Cai et al, which has shown promising progress in surgical testing[64], together with recent efforts to develop diverse VR-based platforms for remote surgical simulation[65], underscores the growing potential of VR integration in telerobotic surgery.
AR enhances the perception of the real-world environment by superimposing digital information onto physical surroundings[66,67]. The application of AR in surgery primarily focuses on integrating imaging technology, allowing for the real-time display of patient CT or magnetic resonance imaging (MRI) images during procedures[68]. More specifically, unlike VR, which immerses the user in a fully virtual environment, AR seamlessly overlays virtual model images and guidance information onto the real-world environment, dynamically illustrating the anatomical relationships between surgical instruments and the target site[69]. This capability aids surgeons in executing procedures with enhanced precision and simultaneously supports the advancement of their technical proficiency and surgical skills[70]. Additionally, reports from 2020 on lumbar fusion surgeries using customized AR glasses have demonstrated that AR can expedite surgery and reduce postoperative complications by providing expert remote teaching and surgical guidance[71]. The novel AR-based telerobotic surgical guidance system offers surgeons a more intuitive and information-rich interface than conventional methods, significantly improving operative performance and achieving superior outcomes in experimental evaluations[72].
MR is a technology that blends the real and virtual worlds to create an enhanced visualization environment in which physical and digital elements coexist, enabling users to interact with both in real time[67,73]. Compared with AR and VR, MR enables simultaneous interaction with both physical and virtual objects, supporting deeper engagement and enhanced perception of depth and perspective[74]. This significantly improves the three-dimensional visualization of surgical anatomy and offers substantial benefits for visual perception during surgery. During the COVID-19 pandemic, the IRCCS hospital in southern Italy successfully employed MR technology to achieve favorable outcomes in the remote guidance of cancer surgeries, enhancing surgeons’ operative skills and receiving widespread acclaim[75]. Moreover, MR has the potential to overcome the spatial and ergonomic constraints associated with bulky surgical consoles by enabling a more flexible operative workspace and enhancing surgeons’ situational awareness of the patient. Its feasibility has been demonstrated in remote endoscope manipulation, as reported by Ai et al[76], and the approach warrants further investigation.
In brief, VR immerses users in a fully virtual environment, AR overlays virtual content onto the real world, while MR combines both to enable more advanced interactions between virtual elements and the physical environment. In practice, however, many studies on telerobotic surgery do not clearly distinguish among VR, AR, and MR, instead referring to them collectively as XR. Over the past two decades, the exploration of XR in surgery has gained increasing momentum. Numerous practical applications have demonstrated that XR can assist in identifying key anatomical landmarks during surgery, shorten operative times, reduce unintended trauma[77,78], and even enhance surgeons’ confidence[78]. Additionally, the success of XR in digital anatomical teaching has offered valuable insights into its potential for remote surgery applications[79]. For instance, XR devices facilitate the sharing of surgical images among doctors, which not only aids novice surgeons in learning surgical techniques but is also instrumental for enabling multi-port remote surgical guidance and collaboration in the future[80]. These technological advances have enabled several successful implementations of XR-based real-time remote guidance, enhancing surgeons’ spatial and depth perception and extending its application across multiple surgical disciplines. This, in turn, has sparked growing interest and deeper investigation in the field[81,82]. In 2023, Li and Lou integrated XR, cloud computing, electromagnetic positioning, and force feedback technologies to develop a 5G-based intelligent clinical surgery real-time interactive platform, providing a promising solution for XR applications in remote surgery[83]. Although this platform has not yet undergone practical testing, it presents new possibilities for incorporating XR into telerobotic surgery. Moreover, using XR for real-time monitoring of patient health during surgery also represents a potential application for supporting telerobotic surgery[84].
Despite the promising potential of XR technologies in telerobotic surgery, their clinical integration remains challenged by several critical factors. First, the absence of mature integration frameworks and standardized interfaces with existing robotic platforms significantly increases technical complexity in both development and clinical deployment. Second, current XR devices remain bulky and heavy, which can lead to operator fatigue during prolonged procedures and compromise surgical stability and continuity[85]. In addition, several latent risks persist in clinical applications. Limitations in resolution and restricted fields of view may compromise the identification of critical anatomical structures and diminish surgical accuracy[86]. Ineffectively designed digital overlays can increase cognitive load, distract the surgeon, or obscure vital intraoperative information, thereby posing risks to surgical safety. While XR-induced immersion may enhance spatial perception and procedural engagement[87], excessive immersion, if not properly managed, can blunt the surgeon’s sensitivity to real-world tactile and visual feedback, a concern that merits careful consideration. To improve clinical applicability, a real-time collaborative model inspired by anatomical education may be adopted[72]. By assigning dedicated personnel to manage and dynamically optimize digital overlays throughout the procedure, this strategy may enhance information accuracy and contextual relevance, thereby facilitating the practical adoption and refinement of XR technologies in surgical settings.
Multi-console surgical system
As an integral component of telerobotic surgical systems, the surgeon console functions as the primary interface for executing complex surgical tasks with high precision via robotic arm manipulation[30,88]. In response to the increasing complexity and diversification of surgical demands, the development of multi-console systems has emerged as a natural progression. These systems not only offer redundancy in the event of single-console failure but also enable interdisciplinary and multi-institutional collaborative surgery. The dual-console configuration was first introduced in the da Vinci® system in 2009[89], allowing two surgeons to operate independently at separate consoles and enabling real-time transfer of control[90]. Initially adopted for surgical training and education, the dual-console approach has since been applied to routine robotic procedures, demonstrating favorable outcomes in colorectal and pancreatic surgeries, thereby supporting its broader clinical integration and facilitating its incorporation into telerobotic surgery[89–93]. In 2022, following successful preclinical validation in animal models, Li’s team performed the world’s first dual-console telerobotic surgery, a pyeloplasty, marking a pivotal milestone – albeit over a short distance of 6 km and with an intraoperative latency approaching 300 ms[94]. With subsequent technological refinements, the team accomplished a more complex remote operation in July 2023, conducting a radical prostatectomy and pelvic lymphadenectomy over a 1500 km cross-sea distance, with latency reduced to below 200 ms[95]. Shortly thereafter, in November 2023, the first triple-console robotic surgery was successfully performed in a prostate cancer patient undergoing prostatectomy, with a maximum latency of only 45 ms[96]. This achievement represents a major advancement in the field. Concurrently, the application of dual-console telerobotic systems has begun to expand globally; for example, a recent clinical trial in India successfully demonstrated the feasibility and adaptability of this approach across diverse healthcare environments[97].
Although multi-console systems have made notable progress, inherent technical limitations persist. In a latency simulation study, Takahashi et al demonstrated that dual-console systems require a stricter latency threshold, with acceptable levels falling below 150 ms, compared to conventional telerobotic setups[98–100], highlighting the ongoing need for latency optimization. Furthermore, existing multi-console architectures are limited by their ability to accept control inputs from only one console at a time, thereby maintaining a fundamental single-master/single-slave (SM/SS) structure[93]. Breaking through this limitation to enable concurrent, collaborative control from multiple consoles would markedly broaden clinical applicability and unlock new procedural capabilities. The surgical co-training framework proposed by Shahbazi et al thus offers a valuable conceptual basis for such system-level innovation[93].
Alignment of technological development with surgical disciplines
It is evident that emerging technologies in telerobotic surgery are not evolving in isolation but are increasingly converging into integrated solutions. The effective operation of both XR and multi-console systems relies heavily on robust 5G connectivity, and the recent widespread deployment of 5G has significantly expanded their application potential. Meanwhile, XR has played an increasingly prominent role in improving multi-console surgical training, owing to its strengths in visualization and interactivity[90,93,94].
The prioritization of these technologies varies across medical specialties. Laparoscopic procedures emphasize high-resolution visualization and interdisciplinary collaboration, making them well-suited for early integration of XR and multi-console platforms. Neurovascular minimally invasive interventions require highly precise manipulation and are extremely latency-sensitive, thereby imposing stringent demands on the ultra-low-latency performance of 5G networks. In orthopedic surgery, where intraoperative imaging such as X-rays and MRI is routinely employed[101], the need to incorporate XR technology is particularly pronounced. A retrospective assessment of the developmental trajectories of these technologies helps to elucidate discipline-specific integration pathways.
However, each of these technologies continues to face distinct limitations. Key challenges include the limited coverage and insufficient security and stability of 5G networks, the clinical integration and miniaturization of XR-enabled telerobotic systems, and architectural constraints along with latency optimization in multi-console configurations. Moreover, the lack of large-scale RCTs across all three technologies remains a critical gap. Effectively addressing these issues will be essential to advancing the next stage of technological development.
Critical evaluation of telerobotic surgery
Telerobotic surgery has been under development for over two decades, with applications extending across multiple surgical disciplines (Table 1). Although its early adoption was constrained by high costs and limitations in network and hardware infrastructure, the emergence of advanced technologies such as 5G, XR, and multi-console surgical systems has significantly renewed interest in this surgical modality. In particular, the COVID-19 pandemic served as a catalyst for accelerating the integration of these technologies, thereby driving the evolution of telerobotic surgery. Despite offering distinct advantages over conventional surgical approaches, the widespread clinical adoption of this technology continues to face several unresolved challenges. To facilitate the seamless integration of telerobotic surgery into routine medical practice, it is essential to systematically evaluate its current limitations, recognize its technical potential, and actively explore viable strategies to overcome existing barriers.
Table 1.
Summary of experimental and clinical studies in telerobotic surgery
| Year | Surgeon location | Patient location | Procedure performed | Operative time (mean) | Mean latency (mean) | Distance | Operative performance/clinical outcomes | Network medium | Robotic system | Study type |
|---|---|---|---|---|---|---|---|---|---|---|
| 2000 | United States | Singapore | Radical nephrectomy and varicocelectomy | / | / | >15 000 km | Uneventful recovery | / | / | Remote surgical assistance |
| 2001 | New York, USA | Strasbourg, France | Laparoscopic cholecystectomy | 54 min | 155 ms | >7000 km | No postoperative complications | ATM communication service | ZEUS robotic surgical system | Clinical telerobotic surgery |
| 2003 | Hamilton, Canada | North Bay, Canada | Fundoplication, sigmoid colectomy, right hemicolectomy, anterior resection, and inguinal hernia repair | 74.1 ± 31.3 min | 135–140 ms | >400 km | No intraoperative complications; dysphagia in 2 cases at 2 weeks; atypical chest pain in one-third. | Commercial dedicated IP-VPN | ZEUS-TS | Clinical telerobotic surgery |
| 2004 | Halifax, Canada | New Brunswick, Canada | Craniotomy, carotid endarterectomy, and lumbar laminectomy | / | / | >400 km | No intraoperative or postoperative complications | ISDN lines | Socrates robotic telecollaboration system | Remote surgical assistance |
| 2005 | Cincinnati, USA | Sunnyvale, USA | Right Nephrectomy in Pigs | / | 450–900 ms | 2400 miles | No intraoperative complications | Nondedicated telecommunication lines | da Vinci® Surgical System | Telerobotic surgery experiment |
| Denver, USA | ||||||||||
| 1300 miles | ||||||||||
| 2005 | Beijing, China | Yan’an, China | Frameless Stereotactic Surgery | 30.2 min | / | >1300 km | No postoperative complications with neurological improvement in 90% of patients | Dedicated digital data network | CAS‑BH5 frameless robotic system | Clinical telerobotic surgery |
| 2014 | Beijing, China | Tianjin, China | Remote laparoscopic cholecystectomy in sows | 50 min | 253 ms | >150 km | No intraoperative complications | TCP/IP | Micro Hand S surgical robot system | Telerobotic surgery experiment |
| 2015 | Nashville, USA | Chapel Hill, USA | Simulated phantom pituitary tumor removal | 20 min | <100 ms | >800 km | Uneventful procedure | Public Internet connection | Concentric tube robotic platform | Telerobotic surgery experiment |
| 2019 | Beijing, China | Karamay, China, etc. | Spine surgery | 142.5 ± 46.7 min | 28 ms | >2800 km | No intraoperative complications; one postoperative CSF leak unrelated to robotics | 5G | TiRobot Surgical System | Clinical telerobotic surgery |
| 2020 | Bari, Italy | Bari, Italy | Laparoscopic gastrectomy | / | / | / | Effective remote guidance | / | / | Remote surgical assistance |
| 2021 | Hirosaki, Japan | Mutsu, Japan | Cholecystectomy and intestinal suturing in a surgical model | 1247.3 s | 29 ms | >150 km | No significant difference (local vs remote) | IP-VPN over fiber optic network | hinotori™ Surgical Robot System | Telerobotic surgery experiment |
| 610.3 s | ||||||||||
| 2021 | Qingdao, China | Gansu, China, etc. | Robot-assisted laparoscopic radical nephrectomy | 67 min (Median) | 176 ms (Median) | >1700 km | Delayed incision healing and mild ileus in two elderly female patients | 5G | Micro Hand S surgical robot system | Clinical telerobotic surgery |
| 2021 | Beijing, China | Beijing, China | Partial nephrectomy in pigs | 94 min | 130 (60–200) ms | 80 km | No intraoperative complications | Wired dedicated network | KD-SR-01 System | Telerobotic surgery experiment |
| 2022 | Beijing, China | Beijing, China | Pyeloplasty | 106 min | 271 (206–307) ms | 6 km | No intraoperative complications | 5G wireless network combined with wired network | KD-SR-01 System | Clinical telerobotic surgery |
| 2023 | Kushiro, Japan | Hokkaido, Japan | Distal gastrectomy with LND in adult cadavers | 199 min | 40 ms | >250 km | No intraoperative complications | Guaranteed dedicated network with IPSec encryption | hinotori™ Surgical Robot System | Telerobotic surgery experiment |
| 2023 | Beijing, China | Beijing, China | Radical prostatectomy in dogs | 80.2 ± 32.1 min | / | / | No intraoperative or postoperative complications | Wired dedicated network | KD-SR-1500 System | Telerobotic surgery experiment |
| 2023 | Haikou, China | Beijing, China | Radical prostatectomy with pelvic LND | 136 min | ≤200 ms | >1500 km | Uneventful procedure | 5G wireless network combined with wired network | KD-SR-1500 System | Clinical telerobotic surgery |
| 2023 | Beijing, China | Hainan, China | Radical prostatectomy | 120 min | 45 ms (maximum) | ≈2600 km | No intraoperative or postoperative complications | Combination of 5G and fixed networks | KD-SR-01 System | Clinical telerobotic surgery |
| Hunan, China | ||||||||||
| Hainan, China | ||||||||||
| 2024 | Lanzhou, China | Lanzhou, China | Radical gastrectomy with LND and GIR | 308 min | 48 ms | 70 km | No postoperative complications | 5G | TRSS | Clinical telerobotic surgery |
| 2024 | Yangzhou, China | Lanzhou, China | Radical gastrectomy with LND and GIR | 285 min | 99 ms | >1700 km | No postoperative complications | 5G | TRSS | Clinical telerobotic surgery |
| 2024 | Shanghai, China | Kuwait City, Kuwait | Radical prostatectomy | 300 min | 181.4 ms | ≈7000 km | No postoperative complications | Fiber-optic broadband network with 5G backup | TRSS | Clinical telerobotic surgery |
| 2024 | Gurugram, India | Gurugram, India | Cholecystectomy, radical nephrectomy, cystectomy, and prostatectomy in pigs | 58 min | 40–50 ms | 5 km | No intraoperative complications | Secure fiber-optic P2P data network | Dual-Console SSI Mantra Surgical Robotic System | Telerobotic surgery experiment |
| 2024 | Gurugram, India | Gurugram, India | Cholecystectomy | 60 min | 40–50 ms | 5 km | No intraoperative complications | Secure fiber-optic P2P data network | Dual-Console SSI Mantra Surgical Robotic System | Clinical telerobotic surgery |
| 2024 | Gurugram, India | Delhi, India | Cystectomy with LND, right nephrectomy and hysterectomy | 144.25 ± 43.15 min | 40–50 ms | 40 km | No intraoperative complications | Secure fiber-optic P2P data network | Dual-Console SSI Mantra Surgical Robotic System | Clinical telerobotic surgery |
ATM, asynchronous transfer mode; IP-VPN, IP-based Virtual Private Network; ZEUS-TS, ZEUS Telesurgical System; ISDN, Integrated Services Digital Network; CAS-BH5, Computer-Assisted Surgical Robot BH5; TCP/IP, Transmission Control Protocol/Internet Protocol; CSF, cerebrospinal fluid; KD-SR-01, KangDuo Surgical Robot-01; LND, lymph node dissection; IPSec, Internet Protocol Security; KD-SR-1500, KangDuo Surgical Robot-1500; GIR, gastrointestinal reconstruction; TRSS, Toumai Robotic Surgery System; P2P, peer-to-peer.
Note. Data and content not reported in the references are indicated by “/.”
Advantages of telerobotic surgery
As an emerging surgical technology, telerobotic surgery offers several distinct advantages that surpass the capabilities of traditional surgery. One key advantage is its ability to provide a safe operating environment for surgeons, particularly when managing high-risk infectious disease patients. The expertise gained in managing COVID-19-positive cases offers valuable solutions for the future surgical treatment of similar high-risk patients[71,102–105]. Moreover, telerobotic surgery helps protect surgeons from radiation exposure in procedures that require X-ray assistance, such as orthopedic and vascular interventions[33,106]. On the other hand, telerobotic surgery has extended and evolved its original mission of providing timely surgical aid to battlefield casualties[1,3]. It enables patients, regardless of their location, including those in remote, aerial, or other extreme environments, to access high-quality surgical expertise from specialists in developed regions[107]. This approach helps alleviate the regional shortage of highly skilled surgeons and promotes a more equitable distribution of quality medical resources[108,109]. Furthermore, telerobotic surgery also presents several advantages, including simplifying preoperative preparation and enhancing the efficiency of multidisciplinary surgical collaboration, building on these strengths to help create a more seamless and effective surgical process.
Current limitations of telerobotic surgery
Telerobotic surgery, which is highly dependent on both equipment and communication infrastructure, inevitably encounters hardware-related constraints that present significant challenges. Foremost among these is latency, encompassing both communication and information processing delays, which remain difficult to eliminate entirely[49,110]. Although advanced network technologies such as 5G can significantly reduce communication latency, data transmission still entails a sequence of encoding, transfer, and decoding, during which processing delays remain inevitable, particularly for data-intensive tasks such as surgical video compression and reconstruction, which demand more efficient hardware solutions[99,110]. These residual latencies can disrupt video fidelity and compromise the precision of surgical manipulation. Research suggests that a delay below 300 ms is manageable[98,99], but surgeons must undergo adaptive training to handle such latency[99,111], which in turn raises the bar for operational skills. In addition to latency, bandwidth is another critical, yet often overlooked, factor impacting communication. Akasaka et al discovered that low bandwidth degrades video transmission quality, thereby compromising surgical performance and increasing surgeon fatigue[112]. Therefore, ensuring both acceptable latency and sufficient bandwidth simultaneously poses a considerable challenge.
Additionally, unforeseen equipment failures, device incompatibilities across different manufacturers, and the risk of cyber intrusions via network connections remain key safety concerns that must be addressed to enable the widespread implementation of telerobotic surgery, challenges that have already been observed in the broader Internet of Things (IoT) environment[113,114]. To mitigate these risks, it is essential to adopt dedicated communication lines and reserved frequency bands to minimize interference from external users and enhance transmission security. The strong dependence of remote robotic surgery on secure data transmission further demands more stringent encryption protocols. For example, Wu et al proposed an improved authentication and key agreement scheme specifically designed for telesurgical applications, which was verified using the Real-or-Random (ROR) model and the ProVerif formal analysis tool, providing a technically robust reference for future developments in this field[115]. Furthermore, the use of multi-channel communication redundancy has been repeatedly validated as a critical strategy to ensure operational continuity and enhance the stability and reliability of remote surgical procedures in the event of unexpected network disruptions[116,117].
The safety risks associated with telerobotic surgery are inextricably linked to ethical considerations. Non-maleficence, a longstanding principle in bioethics that emphasizes “do no harm,” is particularly relevant in this context[118]. The inherent risks of telerobotic procedures raise concerns about patient vulnerability[9], especially when surgeons are unable to adequately anticipate or respond to potential complications, thus violating the principle of non-maleficence and creating serious ethical challenges[119]. To mitigate such risks, it is essential that an experienced on-site backup surgeon be present during telerobotic procedures to intervene directly or switch to remote guidance if unexpected events occur. In addition, patients must receive comprehensive preoperative information about potential risks and contingency measures to ensure informed consent and autonomous decision-making. Given that informed consent is a cornerstone of medical ethics, it should be prioritized in telerobotic surgical practice[120]. Furthermore, the doctor–patient relationship in telerobotic surgery differs significantly from that in conventional surgical settings. With typically only a single intraoperative interaction, there is a risk of objectifying the patient as a mere operator target, which may undermine patient dignity[121]. Perioperative continuity of care and postoperative follow-up should therefore be carefully maintained. Although ethical issues surrounding telerobotic surgery have garnered growing attention, internationally standardized ethical review and regulatory frameworks remain limited, particularly in the context of cross-border surgical practice. This gap constitutes a key barrier to the large-scale clinical adoption of telerobotic surgery.
Moreover, the lack of a global consensus on legal accountability in cases of malpractice during remote procedures remains a significant challenge[105,122]. These challenges span multiple complex domains, including data security, attribution of legal responsibility, compensation mechanisms, and licensure requirements. As previously discussed, cybersecurity threats not only jeopardize procedural integrity but also compromise patient privacy, as data transmitted across networks are vulnerable to interception or misuse by malicious actors[114]. Ensuring information security thus requires both the adoption of advanced encryption protocols and compliance with legal frameworks such as the Health Insurance Portability and Accountability Act (HIPPA) in the United States[9]. However, significant disparities in existing legal frameworks across different regions pose substantial barriers to the establishment of unified international standards for cross-border surgical procedures. For example, the European Union’s General Data Protection Regulation (GDPR) primarily addresses general data protection rather than providing specific regulatory guidance for medical applications such as telerobotic surgery[123]. Equally important in the development of relevant legal frameworks is the urgent need to clearly define the legal consequences of cyberattacks within remote surgical environments, in order to safeguard the reliability and security of telerobotic procedures[108]. In addition to cybersecurity-related legal concerns, the nature of the doctor–patient relationship in telerobotic surgery raises its own set of accountability challenges. In telerobotic surgery, the interaction between patients and remote surgeons is entirely mediated by technical systems and network infrastructure, resulting in a unique spatial and relational dynamic. In the event of an adverse outcome or surgical accident, current legal systems offer no unified framework for determining liability. Multiple stakeholders, including the operating surgeon, the network service provider, the device manufacturer, and even the patient, may be implicated in legal disputes. Cross-border procedures further complicate this issue, as no international agreement currently exists regarding which jurisdiction’s laws should apply in case of litigation[105,122]. This ambiguity directly affects how compensation responsibilities are assigned and enforced. Additionally, inconsistent licensure and credentialing requirements across countries pose another significant barrier to the implementation of transnational telerobotic surgery[9]. At its core, the establishment of a unified international legal framework for cross-border telerobotic surgery is hindered by two principal barriers. First, profound disparities in national legal systems, regulatory rigor, cultural norms, and healthcare policies render legal harmonization exceptionally challenging. Second, the rapid pace of innovation in telerobotic surgery has far exceeded the capacity of traditional legal frameworks to adapt, as its real-time, transnational operational model lacks established legal precedents. In light of the growing clinical potential and global demand, the development of a proactive, adaptable, and internationally coherent legal infrastructure is both necessary and increasingly urgent. Taken together, these issues highlight the urgent need for international collaboration to establish a coherent and unified legal framework that supports the safe, ethical, and scalable integration of telerobotic surgery into routine clinical care.
Finally, cost remains a critical barrier to the widespread adoption of telerobotic surgery. Many hospitals with limited medical resources and financial capacity may find it challenging to afford the substantial expenses associated with acquiring and maintaining robotic systems, consumables[124], and dedicated communication infrastructure[49]. To address this challenge, strategies can be explored at multiple levels. At the technical supply level, the development of interoperable surgical platforms and the acceleration of technological iteration may help reduce costs, enhance scalability, and prevent monopolization that could otherwise inflate equipment prices. Notably, as early as 2007, a drone-enabled remote robotic surgery experiment successfully demonstrated the feasibility of such cost-saving models[125]. From an operational perspective, regional platform sharing and inter-hospital collaboration frameworks represent potentially viable strategies for distributing infrastructure costs and optimizing resource utilization. Alternative financing mechanisms also warrant consideration. For instance, vendor-based leasing models, in which suppliers cover the upfront deployment costs and charge hospitals or patients based on usage metrics such as procedural volume or operating time, could offer a more sustainable pathway to implementation while promoting broader accessibility. Another viable strategy is to emulate the multilateral cooperation model exemplified by the COVID-19 Vaccines Global Access (COVAX) initiative in global vaccine distribution[126]. In this context, collaboration with the World Health Organization (WHO) or other international bodies to subsidize the procurement of robotic surgical systems in under-resourced regions and to provide comprehensive technical training programs could help ensure more equitable access to telerobotic surgery on a global scale. As the market continues to expand, economies of scale may further reduce unit costs, drive ongoing technological refinement, and ultimately establish a virtuous cycle of innovation and clinical integration. Collectively, these approaches may represent promising avenues for addressing cost-related barriers and facilitating the broader integration of telerobotic surgery into clinical practice.
Future directions and emerging opportunities in telerobotic surgery
Although telerobotic surgery continues to face numerous unresolved challenges, these obstacles have, in part, fueled ongoing technological innovation. As a result, a growing number of emerging research directions (Table 2) have not only demonstrated encouraging progress but also further highlighted the field’s substantial potential. Over the past few years, design optimization efforts have mainly concentrated on several key aspects (Fig. 2). From a connectivity standpoint, the focus has been on minimizing latency while enhancing the stability and security of remote connections in specific ways. Regarding intraoperative operations, optimizing visual and tactile feedback has been key to improving operational efficiency. Building on these previous strategies, emerging technologies that have surfaced in recent years offer additional inspiration for further optimizing telerobotic systems.
Table 2.
Key technologies in telerobotic surgery: a comparative summary
| Technology | Advantages | Primary applications | Limitations | Future directions |
|---|---|---|---|---|
| 5G |
|
Real-time control, data transmission, and communication support in telerobotic surgery |
|
|
| XR |
|
Intraoperative navigation and surgical training |
|
|
| Multi-console Surgical System |
|
Collaboration among multiple surgeons and surgical teaching platforms |
|
|
| 6G |
|
Multi-terminal collaboration, immersive sensing, and data synchronization |
|
|
| TI, etc., Intraoperative Haptic Feedback |
|
Intraoperative tactile feedback and surgical training support |
|
|
| AI-Assisted Surgical Techniques |
|
Preoperative planning and intraoperative collaboration and navigation |
|
|
XR, extended reality; SM/SS, single-master/single-slave; TI, Tactile Internet; VR, virtual reality; AI, artificial intelligence.
Figure 2.
Simplified models of telerobotic surgery and their corresponding optimization factors. Telerobotic surgery primarily consists of the master console system, the communication and data transmission system, and the patient-side robotic arms (the visualization system and control modules are not shown). Corresponding optimization efforts include connectivity enhancement, haptic feedback improvement, visual experience refinement, AI-assisted operation integration, and cybersecurity strengthening. AI, artificial intelligence.
6G technology
Communication technology has entered a mature 5G phase, with 5.5G gradually being rolled out. The introduction of 5G has accelerated the growth of URLLC, and societal demand for it continues to grow, with ever-increasing expectations[127]. However, the inherent limitations of 5G, including relatively low capacity and lack of uniform performance, are becoming more apparent[128], making it difficult to meet the stringent requirements for reliable, low-cost, high-speed, low-latency, and scalable communication demanded by advanced distributed systems such as heterogeneous IoT networks and telerobotic surgical platforms[129].
According to recent projections, 6G is projected to become commercially available around 2030[128], offering a peak data rate of up to 1 Tbps, nearly 50 times faster than 5G, along with 10-fold improvements in both energy efficiency and regional traffic capacity (1 Gb/s)[130]. Although these estimates are primarily derived from theoretical analyses and still require validation through large-scale empirical studies, such advancements hold strong potential for meeting the extremely high demands of telerobotic surgery in terms of speed, bandwidth, and reliability. Moreover, it will further expand upon the three key capabilities of 5G networks. The ubiquitous mobile ultra-broadband (uMUB) in 6G systems will support performance transmission across space, air, land, and sea. Meanwhile, ultra-reliable low-latency communication (uRLLC) will provide extremely high transmission rates and ultra-low latency[131], enabling higher bandwidth and reduced latency[128], thereby creating greater opportunities for the advancement of telerobotic surgery.
Recent advances in 6G network research also offer valuable insights for optimizing telerobotic surgery. Targeting 6G network allocation and optimization, researchers have proposed leveraging AI for intelligent resource management, automated network adjustments, and smart service provisioning[132], providing a new perspective for enhancing connectivity in telerobotic surgery. Additionally, integrating 6G with low Earth orbit (LEO) satellite networks for long-distance wireless relays[133], and combining 6G with unmanned aerial vehicles (UAVs) to deliver ultra-low latency services in remote areas[134], are both promising avenues for further exploration regarding their potential integration with telerobotic surgery.
Taken together, communication technology forms the essential foundation of telerobotic surgery. The introduction and widespread adoption of 5G networks have greatly improved the real-time responsiveness and stability of telerobotic surgery, thereby driving its rapid advancement. With the ongoing development and implementation of 6G and other cutting-edge technologies, it is expected that the technical bottlenecks currently limiting telerobotic surgery will be overcome, accelerating its adoption and integration into clinical practice.
Although 6G holds considerable promise, its widespread integration into clinical practice remains a long-term goal. A key barrier is infrastructure readiness: large-scale deployment of 6G requires extensive rollout of supporting technologies. Currently, 6G base stations are scarce worldwide, and the technology itself is still in its early developmental stages. Key technical standards, including spectrum allocation, signal power, and hardware compatibility, have not yet been unified, and their interoperability with existing communication infrastructure remains unresolved[135]. In addition, current FDA regulatory frameworks apply only to 5G-enabled gateways, and approval pathways for 6G-based systems have not yet been defined[136]. While the distributed architecture of 6G may improve data transmission efficiency, it also introduces significant cybersecurity vulnerabilities, placing increased demands on encryption schemes and authentication protocols[137]. Finally, as with the broader scaling of telerobotic surgery, the advancement of 6G in the medical domain will require substantial capital investment, and the high initial infrastructure costs may significantly delay its clinical adoption. Therefore, amid rapid technological advancement, an exclusive emphasis on performance metrics, if not adequately balanced with economic feasibility and clinical relevance, may result in a misguided technology-centric approach that misaligns with real-world healthcare priorities and undermines the long-term sustainability of these innovations[138,139].
Intraoperative haptic feedback
Haptics plays a vital role in telerobotic surgery by enabling operators to perceive direct interaction with the remote environment[140], thereby enhancing surgical manipulability and improving procedural safety[141]. The exploration of haptics in robotic surgery has a long history, with several notable successes. For example, Gertler et al developed lightweight, electromagnetically driven wearable silicone fingertip gloves that deliver rich haptic feedback[142], and Giri et al designed the soft, flexible haptic joystick named Hapstick[143], both of which have successfully provided effective haptic feedback in conventional robotic surgery. Haptic systems have also been applied in surgical training, where they provide expert-level tactile feedback to guide novice surgeons[140]. Nevertheless, traditional communication networks, with their inherent latency and bandwidth limitations, have caused the issue of missing haptic feedback to resurface in remote operations[144]. In fact, as early as 2014, Talasaz et al introduced a dual-arm teleoperation system that offered haptic feedback to the remote operator[145], but hardware limitations at the time kept this system at a conceptual level. This underscored the need for advanced haptic transmission technologies, a demand that the recent development of the TI aims to address.
The TI concept was first introduced by Professor Fettweis in 2014[146]. TI refers to a communication paradigm designed to transmit real-time control, tactile, and sensory/actuating data via highly reliable, low-latency, and intelligent connections[147]. By leveraging advanced haptic codecs for the compression and reconstruction of tactile data, it can efficiently compress and accurately reconstruct high-dimensional haptic signals, including composite parameters such as force and vibration, thereby ensuring the precise and timely transmission of tactile information[148]. TI has emerged from recent advances in robotics and haptic technologies and represents a novel paradigm that enables real-time haptic interaction, offering a transformative approach to human-to-machine (H2M) communication[149]. The advent of ultra-low latency TI networks has enabled the integration of human–machine interfaces with actuator sensors, allowing operators to experience real-time tactile feedback while controlling robots that mimic human actions[150], making TI particularly suitable for application in telerobotic surgery.
To realize its full potential, TI requires advanced communication support. In this regard, 5G has played a pivotal role in its advancement by fulfilling TI’s stringent demands for high reliability and low latency[151–154]. This contribution has been repeatedly emphasized in the work of Sharma et al, who also proposed a general architecture for TI[155]. Similarly, following their analysis of a 5G-based TI healthcare 4.0 remote surgery system, Gupta et al proposed a remote surgical architecture with two distinct communication channels: a traditional network and a 5G-supported TI, which is expected to be expanded in the future[144]. Furthermore, VR and TI can work in concert to enhance user experiences. By leveraging the communication capabilities of TI[134], users can interact with shared haptic virtual environments in VR, perceiving both the sound and tactile sensations of objects[63]. Collectively, these studies highlight the TI as a pivotal integration direction for the future of telerobotic surgery. As TI continues to evolve and integrate with enabling technologies such as 5G and XR, it is anticipated to contribute significantly to the development of future real-time and immersive surgical platforms.
However, integrating the TI into telerobotic surgery also presents considerable security challenges that should not be overlooked. Given the importance of addressing these challenges, researchers have proposed several strategies to secure TI in remote surgery. Specifically, Wazid et al proposed a general authentication model[156], Kamil et al developed an efficient mutual authentication and key agreement protocol[157], and Lee et al introduced an enhanced one-time key scheme[158] – together offering valuable contributions toward the foundational development of secure TI deployment in remote surgical procedures. However, it is important to note that most of these security mechanisms are essentially general-purpose communication security frameworks and may lack optimization for the high-frequency and real-time characteristics of haptic data. Consequently, they may face performance constraints during real-time deployment in surgical settings.
In addition to cybersecurity concerns, the clinical translation of TI is hindered by a range of technical and operational constraints. These challenges are not unique to TI but are shared across the broader spectrum of haptic feedback technologies. Consequently, although haptic systems are widely regarded as essential for enhancing the quality of remote surgical procedures[159,160], their development and deployment remain limited. From a technical perspective, the ultra-low latency required for precise haptic signal transmission renders TI heavily dependent on ongoing advances in communication infrastructure. While 5G networks provide a promising foundation, several key performance parameters remain unmet[161]. To address this, edge computing can enable predictive haptic rendering by locally inferring and caching feedback signals in advance, thereby reducing dependence on real-time communication latency[162]. However, this strategy must be carefully designed to avoid erroneous haptic feedback resulting from prediction inaccuracies. In addition, the absence of standardized system architectures and open interoperability protocols in both TI and existing haptic platforms poses a significant barrier to widespread adoption. Such deficiencies not only hinder scalable deployment but also introduce a risk of vendor lock-in[163], thereby elevating implementation costs for healthcare institutions. Equally important is the need to replicate tactile sensations as realistically as possible to reduce the additional cognitive and operational burden on surgeons. This highlights another critical issue: the current lack of a universal and objective framework for evaluating the quality of haptic technologies. For instance, standardized quantitative metrics for key parameters, including haptic fidelity and force feedback accuracy, are not yet well established[164], which makes it difficult to conduct consistent comparisons and evaluations across studies and commercial applications. From a practical perspective, the frequent need for sensor calibration and replacement imposes considerable maintenance burdens[165]. The development of automated calibration technologies, including adaptive mechanisms based on machine learning, could improve system accuracy and reliability[166]. Moreover, large-scale RCTs are essential for generating robust clinical evidence to support the effectiveness of haptic technologies in telerobotic surgery. However, before this can be achieved, the technology must undergo animal studies and staged validations. As large-scale RCTs are implemented, standardizing equipment across multiple centers is expected to pose a major challenge. Collectively, these limitations constitute major barriers to clinical implementation and highlight the need for continued technical refinement and clinical validation.
AI-assisted surgical techniques
In current telerobotic surgeries, the primary surgeon’s work requires the support of several assisting doctors at the operating table, often leading to a greater workload than traditional surgeries. Given the nature of telerobotic surgery, integrating AI to assist in the procedure represents a feasible and impactful solution that will significantly enhance efficiency.
Currently, in minimally invasive neurosurgery, platforms for transnasal procedures that integrate navigation and control systems have been validated through in vitro experiments. The validated platform consist of a surgeon-operated remote robotic system alongside an autonomous robot dedicated to secondary tasks, allowing the surgeon to focus on the primary procedure[167]. Similarly, in 2021, Dede et al developed the NeuRoboScope robotic assistant for endonasal endoscopic surgery, which provides the necessary means to control the endoscope’s position and orientation, thereby taking over its manipulation during the procedure and consequently reducing the workload of the primary surgeon[168]. These studies lay the preliminary foundation for future advancements, demonstrating the initial feasibility and potential value of such systems. A research team at Johns Hopkins University recently demonstrated fully autonomous execution of critical surgical steps by a robotic system in eight ex vivo porcine cholecystectomies, achieving a 100% success rate[169]. This breakthrough not only marks a major advancement in current robotic surgery but also provides a forward-looking technological reference for future telerobotic applications. Building on this foundation, deeper integration of AI with advanced learning capabilities into autonomous robotic systems holds promise to significantly enhance operative efficiency, adaptive autonomy, and system-level fault tolerance in telerobotic surgery.
AI assistance can be utilized not only for surgical tasks but also for calibrating surgical operations. During high-intensity surgical operations, maintaining sufficient surgical performance can be challenging for surgeons, making fatigue-induced tremor (FIT) often unavoidable during prolonged laparoscopic surgeries[170]. Research has demonstrated that FIT in healthy surgeons may introduce deviations in the control of robotic surgical arms and laparoscopic scissors, potentially leading to a 2.5% increase in tracking inaccuracies during extended non-invasive procedures. This issue becomes even more intricate in telerobotic surgery, making it more challenging to ensure surgical stability. To address this challenge, Lin et al proposed a method that utilizes a wavelet broad learning adaptive filter (WBLAF), an algorithm designed for real-time identification and compensation of tremor signals in complex dynamic environments, to predict and mitigate physiological tremors[171]. If AI assistance could be integrated into this framework, it might significantly enhance prediction accuracy and enable real-time correction of tremors, thereby potentially minimizing the interference caused by FIT during surgical procedures.
Beyond intraoperative modulation, AI can be harnessed to optimize preoperative planning and enhance surgical navigation. In fact, as summarized by Chen, AI is currently being utilized in the planning and navigation phases of orthopedic surgical robots[69]. It leverages existing imaging data to construct two-dimensional or three-dimensional models of the surgical space. Based on these models, it facilitates the planning of surgical pathways and simulation of the surgical process, while also enabling real-time analysis and processing of intraoperative images. This includes autonomous segmentation and labeling of anatomical structures, along with the development of more scientifically sound surgical pathways derived from identified key points[69]. Furthermore, the combination of AI and AR opens novel avenues for enhancing surgical precision and enabling real-time decision support. This very integration yields a synergistic effect, empowering capabilities that surpass the sum of their individual functions. It facilitates intelligent matching and precise localization, dynamic three-dimensional observation, visualization of the depth and angles of surgical pathways, avoidance of hazardous areas, comprehensive surgical imaging, and continuous monitoring of the surgical environment and procedures, among other advanced functionalities. Such capabilities have already been successfully applied in orthopedic, trauma, and spinal surgeries, thereby validating the clinical value of this synergistic approach[69]. In telerobotic surgery, where comprehensive preoperative planning, real-time precision, visual clarity, and accurate remote decision-making are essential, these AI-enabled functionalities serve as key enablers of safe and effective surgical execution across distances. These capabilities are anticipated to play an increasingly important role in ongoing research and future clinical applications.
Although AI-assisted technologies hold potential for enhancing telerobotic surgery, they continue to face several critical challenges, as is the case with many other emerging innovations. Most current platforms remain at the prototype stage and lack clinical-grade validation within real-world, multidisciplinary telerobotic environments, indicating that clinical translation is still in its infancy. To facilitate more effective clinical translation, technology integration should be guided by clinical needs. Employing a user-centered design (UCD) approach, in which surgeons, patients, and engineers collaboratively define the functional priorities of AI systems, may be critical to improving their real-world applicability and stakeholder adoption[139]. In practical applications, a major barrier lies in the complexity and variability of medical data across specialties and patient populations, which necessitates the development of robust models trained on large-scale, high-quality datasets[172]. Achieving reliable generalization across diverse clinical scenarios is essential for delivering accurate and context-specific decision support. In parallel, as with other emerging technologies, integrating AI into remote robotic surgery imposes stringent requirements on the stability and reliability of real-time network infrastructure. The additional data processing introduced by AI may further exacerbate system latency, thereby necessitating even stricter control compared to conventional surgical systems. While upgrading communication systems remains important, it is equally critical to establish a hybrid edge–cloud AI architecture, in which latency-sensitive processing is performed locally and computationally intensive analytics are delegated to the cloud[173]. Importantly, the development and deployment of AI models must strictly comply with data privacy regulations and informed consent standards, while also navigating complex ethical, regulatory, and certification challenges[174]. These multiple regulatory demands further underscore the urgency of establishing a unified legal framework specifically tailored to AI applications, particularly in the context of telerobotic surgery.
In summary, the integration of AI-assisted technologies into telerobotic surgery represents a complex undertaking that involves both significant challenges and substantial opportunities. Its successful implementation is essential for advancing the intelligence and precision of remote surgical procedures. Although further clinical validation is still required, this approach has shown promise to meaningfully influence future operative workflows and clinical decision-making paradigms.
Emerging technologies shaping the future of telerobotic surgery
In addition to the technologies mentioned above, researchers have increasingly explored the integration of emerging innovations into telerobotic surgery, including robotic magnetic navigation (RMN, which uses magnetic fields to guide internal magnetic devices)[175], Digital Twin technology (which enables real-time digital reconstruction and feedback of surgical scenarios), the IoT (which interconnects surgical devices), and, more recently, holographic technologies (which provide intraoperative three-dimensional visualization)[64,176–179]. While these technologies are still in their formative stages, their convergence presents transformative potential. As these technologies continue to mature and become integrated within a unified clinical framework, telerobotic surgery is anticipated to evolve from a high-cost intervention into a scalable, intelligent, and widely deployable surgical paradigm, thereby ushering in a new era of connected healthcare.
Within this evolving landscape, telerobotic surgery stands out as a key application of telemedicine, which refers to the transmission of information between locations via electronic digital signals[19]. It is poised to become a core component of future digital healthcare[154]. Beyond contributing to the digitalization of surgical workflows, its development (Fig. 3) also creates new opportunities for the global sharing of surgical expertise and collaboration. By promoting the globalization of medical resources and communication, telerobotic surgery ultimately extends access to high-quality medical services across diverse healthcare settings.
Figure 3.
Key milestones in the evolution of telerobotic surgery. Arrows denote significant events and their corresponding years.
Conclusion and future perspectives
Over the past two decades, telerobotic surgery has undergone extensive investigation and clinical validation across various surgical disciplines, demonstrating its distinct clinical advantages and disruptive potential. Despite numerous advancements, its development remains uneven, primarily due to discipline-specific variations in surgical protocols and regional disparities in healthcare infrastructure. Current implementations continue to face persistent barriers, including latency constraints, cybersecurity vulnerabilities, hardware reliability issues, ethical and legal challenges, and considerable operational costs, thereby hindering their widespread clinical adoption. Nevertheless, recent progress and the convergence of emerging technologies, including 5G, 6G, XR, multi-console surgical systems, the TI, and AI-powered surgical assistance, are gradually mitigating critical limitations in connectivity, haptic feedback, visual perception, and intraoperative manipulation. These innovations not only optimize existing surgical workflows but also foster interdisciplinary collaboration and the exchange of surgical knowledge through next-generation technologies. By overcoming traditional technical and geographical barriers, telerobotic surgery has the potential to transform global standards of surgical care, significantly enhancing remote healthcare accessibility, strengthening emergency response capabilities, and advancing international surgical training.
Footnotes
Yichen Ding and Shihao Wang contributed equally to this article.
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Published online 10 September 2025
Contributor Information
Yichen Ding, Email: 3170103822@zju.edu.cn.
Shihao Wang, Email: doctorwsh6@163.com.
Ruichao Lan, Email: 24520231154666@stu.xmu.edu.cn.
Wanling Lin, Email: wagf1017@126.com.
Xianzhi Liu, Email: liuxzh37@mail2.sysu.edu.cn.
Ethical approval
Not applicable.
Consent
Patient consent was not required due to the article being a review.
Sources of funding
This work was supported by the National Key Research and Development Plan (2022YFC3401000), the National Natural Science Foundation of China (92359302, 82472087), the Guangdong Provincial Key Areas R&D Programs of “Precision medicine and stem cells” (2023B1111020005), the Natural Science Foundation for Outstanding Youth Team Project of Guangdong Province (2024B1515040030), the Natural Science Foundation of Fujian Province (2024J011004), the Fujian Provincial Health and Medical High-Level Talent Team (XM050005), the Postdoctoral Fellowship Program of CPSF (GZB20240394).
Author contributions
Y.D., S.W., and W.H. contributed to the study’s conception and design. Y.D. and S.W. drafted the manuscript. R.L. and W.L. were responsible for figure preparation, with final revisions and optimizations performed by Y.D. to ensure compliance with journal formatting standards and visual clarity. Y.D., S.W., X.L., and W.H. critically revised the manuscript, conducted the final review, and approved the final version for submission.
Conflicts of interest disclosure
The authors declare no conflicts of interest.
Guarantor
Weiling He.
Research registration unique identifying number (UIN)
Not applicable.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Data availability statement
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. All information is derived from publicly available articles and datasets.
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Associated Data
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Data Availability Statement
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. All information is derived from publicly available articles and datasets.