Safety and feasibility of robot-assisted laparoscopic telesurgery in pediatric surgery: a case series

Introduction

Remote surgical practices gained momentum in 2001 when an operation on the gallbladder was carried out via a robotic system from 14,000 kilometers away, connected by an optical fiber link between New York and Strasbourg (1). This pioneering undertaking laid the groundwork for modern telesurgery platforms, integrating communication networks and robotic equipment to facilitate procedures across distances that were formerly considered unworkable. Along with these developments, robotic surgery has attained increasing importance by enhancing procedural dexterity, improving precision, and expanding operative access within anatomically restrictive regions (2). Owing to these benefits, the merger of surgical instruments within a robotic framework and the capacity for remote control—distance-based interventions can be naturally incorporated into robotic-based systems. Notably, the da Vinci telesurgery model has undergone numerous inquiries and tests regarding remote surgical approaches since 2008 (3). Nevertheless, the field confronted periods of minimal advancement attributable to immature technologies and prohibitively high operational expenses (4).

Subsequent improvements in the national infrastructure within China, along with advanced network speeds, reignited interest in distance-based surgical methods. In recent years, advances in robotic surgery have boosted telesurgical techniques. Specific platforms currently feature inherent remote connectivity, potentially lowering procedural expenses and facilitating broader adoption of robotic methods (5-8). Several publications have described remote robot-assisted operations in animal research and selected clinical settings in adult general, urological, and gynecological specialties (9). Despite these achievements, the deployment of robot-assisted laparoscopic telesurgery (RLT), specifically in pediatric contexts, remains rare. Introducing RLT into pediatric care poses additional technical complexities as well as heightened demands for strict safety protocols and ethical vigilance for young patients. Consequently, the absence of thorough investigations dedicated to RLT in the pediatric population highlights the need for preliminary research to demonstrate both safety and efficacy.

To address this gap, a pilot investigation was devised to explore the feasibility of RLT in pediatric patients undergoing procedures, such as appendectomies or choledochal cyst excisions, utilizing the SHURUI Endoscopic Surgical Robotic System (SR-ENS-600) (Beijing, China). This apparatus enables surgeons to perform intricate maneuvers remotely, even when being geographically distant from the operating site (10). With meticulous planning, our clinical team successfully performed robot-assisted appendicitis and choledochal cyst excisions in children using the SHURUI system (11). A systematic pilot study was conducted in Guangzhou and Liuzhou to verify the safety and viability of this approach, focusing on the operative duration, blood loss, and complications. We present this article in accordance with the PROCESS reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-309/rc).

Case presentation

Four individuals, each with a preoperative assessment indicating chronic appendicitis or choledochal cyst, underwent RLT at the Guangzhou Women and Children’s Medical Center and Liuzhou Hospital (Figure 1). The study was prospective and conducted at two centers. The cases included in the study were non-consecutive. Inclusion criteria included age 2–18 years, American Society of Anesthesiologists (ASA) classified I–III, in accordance with the indications of conventional laparoscopic surgery, ability to cooperate with inspections and follow-up, willingness to participate in the trial and providing informed consent by guardian. Exclusion criteria included: emergency, intolerance to pneumoperitoneum anesthesia, unable to cooperate and provide consent, with systemic diseases unsuitable for surgical interventions and other contradictions of conventional laparoscopic surgery. All operations were performed by a surgeon with extensive expertise in minimally invasive pediatric procedures and robot-assisted techniques. This surgeon served as the principal operator in all cases. Technical expertise and properly trained personnel were stationed at the patients’ locations to reduce potential risks. In addition, a trained assistant remained alongside the patient during each operation. The duties of this assistant included making the initial incisions, performing wound closure, and docking the robotic device. Moreover, the assistant was prepared to replace the remote surgeon when performing laparoscopic actions in any urgent scenario.

Figure 1 Network connection schematic diagram of telesurgery. The straight-line distance between the two places was 512 kilometers, and they were connected via wired network.

Patient data were collected from hospital databases and detailed medical records. The information gathered included demographics, preoperative workups, network performance metrics, key surgical parameters, and data from postoperative checkups. Surgical metrics documented for each operation included the total operative time, approximate blood loss, duration of hospital stay after surgery, and any complications. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committees of Guangzhou Women and Children’s Medical Center (approval No. 2024055A01) and Guangzhou Women and Children’s Medical Center Liuzhou Hospital (approval No. 2024206). Written informed consent was obtained from the individual(s) and minor(s) legal guardian/next of kin for the publication of this case series, accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Characteristics of the patients and short-term outcomes

The primary outcome of the study was the proportion of patients who completed RLT without transitioning to alternative techniques. Patient characteristics, including age, sex, body mass index (BMI), laboratory findings, and imaging data, were recorded. Additionally, essential short-term results were documented, including operative duration, total blood loss, complications after surgery, length of hospitalization, and mortality.

The SHURUI Endoscopic Surgical Robotic System

The SHURUI robotic apparatus comprises a control console for the surgeon and a patient-end trolley. Traditionally, both components occupy the same site and rely on direct cable connections for standard surgical operations (10). However, using an internet-based interface, the remote module facilitates real-time data transfer and master-slave communication across geographically separated locations. In practical terms, multiple networking approaches can be adopted to deliver end-to-end connectivity, determined by how the surgeon’s and patient’s sites are configured and the unique needs of each procedure.

During this investigation, the console and patient trolley were generally linked to a wired broadband access port using network cables, whenever feasible. A specialized data tunnel was often set up to help maintain a consistent network speed and reduce jitter during critical telesurgical tasks. In addition, network pathways and intermediate nodes were optimized to bolster reliability, and a real-time monitoring system with early warning features was used to identify potential disruptions. Beyond these measures, a tiered security framework was implemented for remote telesurgery, consisting of encrypted channels, firewalls, intrusion detection, application-level safeguarding, and comprehensive user authentication. These strategies aimed to mitigate cybersecurity risks and ensure stable connectivity (Figure 2).

Figure 2 Display of the actual working scenarios. (A) The assistant was collaborating with the patient-side surgical trolly. (B) The surgeon was operating at the surgeon console. (C) Network monitoring in telesurgery procedures. (D) The appearance of the surgical incision.

Operative procedures

The patients were placed in a supine position with the head tilted upward at an angle of approximately 15 degrees for robot-assisted laparoscopic choledochal cyst excision (RC), and with the foot elevated for robot-assisted laparoscopic appendectomy (RA). A curved incision measuring approximately 3 cm was made on the left side of the umbilicus. For RA, a single cannula of 2.5 cm was inserted through an incision into the abdominal cavity. The assistant managed the docking process, and once docking was finalized, the surgeon executed the operation using the remote-control console. The RA technique largely paralleled that of conventional laparoscopic appendectomy. For RC, the assistant first performed Roux-en-Y anastomosis outside the abdominal space. The Roux segment was then introduced into the abdomen through a retrocolic route via an opening crafted on the right side of the mesocolon. Again, the assistant completed the docking steps, after which the surgeon controlled the robotic system from a distance. More comprehensive descriptions of these techniques have been published elsewhere (11) and surgical video is available (Videos 1,2).

Results

Four pediatric patients were included in this study (see Tables 1,2 for demographic and clinical details). Two participants underwent RA, and two underwent RC. The patient group was comprised of one male and three females, with a median age of approximately seven years (range, 4–11 years). The calculated median BMI was 14.62 kg/m² (range, 11.43–16.28 kg/m²). Three of these four children received operative treatment in Liuzhou, where the primary surgeon was situated in Guangzhou. Conversely, the fourth participant underwent surgery in Guangzhou, whereas the same surgeon remained in Liuzhou (Table 1).

A straight-line distance of approximately 512 km separated the surgeon’s station from the patient’s location. The median round-trip latency of the instruments was measured at 28.50 ms (fluctuating between 25 and 33 ms). Fourteen incidents of network interruption were observed throughout the telesurgical segment (range, 0–37 times). When adjusted on a per-hour basis, this corresponded to a median interruption rate of approximately 3.23 times/hour, varying between 0 and 9.17 per hour. Despite this fluctuation in network stability, every procedure was completed under remote robotic control, without significant interruption.

All four procedures progressed without necessitating conversion to alternative surgical methods, yielding a 100% completion rate. The median overall operative duration recorded was 266 min (range, 90–481 min), encompassing a median time of 171 min (range, 55–308 min) spent in robotic teleoperation. Docking of the robotic platform required a median of three minutes (range, 3–8 min). Estimated intraoperative blood loss had a median value of 3 mL, ranging from as little as 0.5 mL up to 15 mL in the most extensive situation. Following surgery, the length of hospital stay was six days (range, 2–8 days). No perioperative complications, adverse events, or mortalities were documented during or shortly after surgery.

Postoperative follow-up was consistently maintained for all four individuals, with no instances of patient attrition. The median follow-up duration was calculated at 3.5 months, extending from a minimum of two months to a maximum of six months. No significant late complications or readmissions were reported throughout these follow-up intervals. An overview of clinical details and outcomes is provided in Table 2.

Discussion

This study marks the first endeavor to apply the RLT technology in pediatric surgery. Each of the four surgeries was finalized without requiring conversion to a standard open or conventional laparoscopic approach, resulting in a 100% success rate. Previous investigations have predominantly focused on adult populations such as those undergoing general, gynecological, or urological procedures (12). This study adds novel insights by showing that remote pediatric operations can be effectively conducted over a distance of more than 500 km. The abdominal cavity in pediatric patients is smaller, and their tissues are more delicate. Therefore, surgeries in the pediatric abdomen require a higher level of precision and meticulousness to achieve optimal clinical outcomes. Especially in the context of choledochal cyst surgery, which involves intricate procedures, such as resection and reconstruction, this operation is considered challenging in pediatric abdominal surgery (13,14). Completing this surgery via remote operation signifies a substantial advancement in current RLT technology, further enhancing its adaptability and broadening its potential applications.

The RA and RC operations were found to be well-aligned with previously documented benchmarks in the literature, which are reported to range between 80 to 135 minutes for RA and 275 to 443 minutes for RC (15-18). Our findings indicate that even with limited RLT experience, highly skilled surgeons can achieve surgical proficiency comparable to that of local operation. One of the primary concerns among researchers regarding remote surgery is the potential impact of network latency on the precision and safety of the operation. Possible reasons include surgeons adapting to the latency introduced by the network, challenges associated with real-time visual feedback, and the increased demands of managing remote robotic instruments (19). Nankaku et al. (20) suggested that delays of less than 100 ms have no significant impact on the performance of experienced surgeons. The findings of this study further substantiated this hypothesis. The network latencies ranged from 25 to 33 ms for the four surgeries analyzed. This was attributed to the fiber optic network connection between the two locations as well as the preoperative debugging conducted collaboration between the network provider and network engineers. All procedures were completed without any observable adverse effects due to delays. In addition, surgeons place greater emphasis on the role of visual feedback during remote operations to avoid accidents. By implementing frequent and minor amplitude actions, the potential misoperations caused by sudden network interruptions can be effectively prevented. RLT did not increase the hospitalization period or the likelihood of postoperative complications among the four surgeries, and the postoperative results were similar to those of local robotic surgery. These preliminary data demonstrate the potential for future initiatives focused on validating RLT as a safe option for pediatric interventions, with reduced concerns regarding network latency.

The implementation of RLT surgery in pediatric patients remains a subject of significant ethical controversy. Given the long-term cooperative partnership between Liuzhou Hospital and our hospital, the surgeon communicated comprehensively with the patient’s guardians before the operation and secured informed consent. Postoperatively, the team from Liuzhou and Guangzhou collaborated to provide remote nursing guidance and conduct follow-up visits. Technically, the surgical team made a thorough preparation. Before the operation, remote meetings were conducted for preoperative discussion, during which both teams collaboratively developed detailed treatment plans and comprehensive emergency protocols. Both the network infrastructure and medical team were on standby to ensure continuity. In the event of an interruption in the remote connection, a backup medical team was prepared to assume operational control promptly. For choledochal cyst surgery, individual differences in surgical difficulty are significant. Therefore, even in ordinary laparoscopic surgery, there is a risk of conversion to laparotomy. In this exploratory study, patients were rigorously assessed to mitigate the risks associated with excessive procedural complexity. Consequently, individuals with recurrent cholangitis and severe adhesions around the cyst, as well as those in the acute inflammatory stage, were excluded from this study. In the future, ethical concerns are expected to diminish as communication technology advances. Convenient and real-time communication methods effectively mitigate the ethical and technical challenges associated with geographical distance. Moreover, the standardization of RLT surgery facilitates the further regulation of this emerging technology by legal and administrative bodies, thereby enhancing public confidence in telemedicine.

However, certain constraints remain (21,22). Firstly, adequate bandwidth and network speed are essential prerequisites for remote surgeries, as they directly impact the safety and precision of the operations. Second, the high cost of equipment and cross-manufacturer platform incompatibility partly hinder the large-scale deployment and widespread adoption of the technology. Third, as a contingency against unexpected difficulties, on-site personnel must always be ready to intervene, which may limit their potential for cost reduction. Additionally, this was a pilot study; however, certain limitations exist in its design. The small sample size and short follow-up duration (a median of approximately 3.5 months) may preclude adequate monitoring of potential long-term issues, such as late complications. The reliance on a single surgeon’s skill restricts the diversity of the experience captured. Therefore, future investigations should incorporate larger and more diverse patient cohorts to facilitate robust comparisons and to yield more conclusive data regarding teleoperated interventions.

Conclusions

This report documents the earliest known application of RLT in pediatric cases using the SHURUI SR-ENS-600 robotic system. Based on preliminary data from four patients, the safety and feasibility of such remote operations in pediatric surgery appear promising. Future research should establish standardized protocols, collect extended follow-up data to evaluate postoperative and long-term outcomes, and conduct rigorous multi-center trials involving diverse surgical teams. Through these efforts, RLT could transition from a novel technique to a routine component of pediatric minimally invasive surgery, thereby transforming the delivery of advanced surgical treatment in children.

Acknowledgments

The authors extend their gratitude to the surgical team and the engineering team for their involvement in the surgery.

Footnote

Reporting Checklist: The authors have completed the PROCESS reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-309/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-309/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-309/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committees of Guangzhou Women and Children’s Medical Center (approval No. 2024055A01) and Guangzhou Women and Children’s Medical Center Liuzhou Hospital (approval No. 2024206). Written informed consent was obtained from the individual(s) and minor(s) legal guardian/next of kin for the publication of this case series, accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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