High-speed communication for surgery care (5G technology): basis for ubiquity in surgical practice
José María Balibrea · British journal of surgery · 2024
Remote surgical assistance and direction, previously limited to academic ‘live surgical demonstrations’, is increasingly used for everyday surgical proctoring. At the same time, remote real-time surgical education and assessment, spanning both theoretical and technical domains, is now being adopted in surgical training programmes. This development has been facilitated by the rapid acceleration and adoption of everyday technology, allowing large amounts of digital data to be exchanged in real time. The concurrent widespread uptake of robotic surgery has created a surgical environment where remote surgery may be considered routinely feasible and safe. Surgery is a complex communication process, with well-known elements, considered to be sender, receiver, content, and code, but, to date, the ‘channel’ has been the limiting factor. The digitization of surgery involves the generation and application of an immense amount of digital data that, if it is to be shared in real time, requires technology capable of transporting it efficiently, quickly, and securely. Surgery requires constant decision-making (based on multiple sources of data), which is honed by exposure and experience. The transmission of incorrect, incomplete, or poorly timed information can be dangerous for patients. Despite the numerous laws regarding the use of healthcare devices and data, the technical quality of transmitted surgical data remains unregulated. Agencies such as the US Food and Drud Administration (FDA) have established regulations in the field of robotics regarding the level of autonomy of devices1, yet not when considering ‘telesurgery’ as an isolated item. European Union (EU) regulations include 2017/745 and 2017/746, which classify the devices involved and define ‘telesurgery’, but do not elaborate on telementoring or the prerequisite technical requirements2,3. Meanwhile, there are uncertainties regarding liability and responsibility for patient outcomes. To date, there are few guidelines on the subject, the most relevant being those of the Japanese Society of Surgery4. They state that, except in the case of remote telesurgery, a patient undergoing a procedure involving telementoring and telecare remains the responsibility of the local team. Data governance and the use of experimental techniques within a remote surgical set-up continue to generate controversy. In 2019, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) made a series of recommendations within the framework of the so-called ‘Project 6’ that mainly focused on remote assistance5 (Table 1). The recommendations highlight the need to guarantee data security, image quality, transmission stability and reliability, the existence of graphic tools for teaching purposes, and accessibility. The emergence of fifth-generation (5G) technology has provided adequate support to ensure high-quality transmission, with bandwidths allowing download speeds of up to 10 Gbit/s. This will enable its use beyond telephony, supporting desktop and laptop hardware, or areas such as the Internet of Things (IoT) and ‘machine-to-machine’ information exchange. Summary of the technical recommendations of the Society of American Gastrointestinal and Endoscopic Surgeons to ensure the quality and safety of surgical telementoring processes Telementoring systems must comply with US FDA Class II device regulations, as well as HIPAA regulations. Any wireless network must ensure the security of transmission using WPA2 encryption and, in addition, a VPN or end-to-end secure tunnel. A minimum of 128-bit encryption is required, along with authentication protocols, to prevent unauthorized viewer/user connections. Minimum bandwidth must be 40 Mbit/s. Maximum latency must be <450 ms and there can be no choppiness or pixelation. Minimum resolution should be 480 progressive scan lines (480 p) at 15 frames per second (standard definition); ideally, a resolution of 1080 progressive scan lines (1080 p) at 30 frames per second is preferable. Annotation is essential for proper telementoring. Portability and accessibility of telementoring systems must be ensured. Telementoring systems must comply with US FDA Class II device regulations, as well as HIPAA regulations. Any wireless network must ensure the security of transmission using WPA2 encryption and, in addition, a VPN or end-to-end secure tunnel. A minimum of 128-bit encryption is required, along with authentication protocols, to prevent unauthorized viewer/user connections. Minimum bandwidth must be 40 Mbit/s. Maximum latency must be <450 ms and there can be no choppiness or pixelation. Minimum resolution should be 480 progressive scan lines (480 p) at 15 frames per second (standard definition); ideally, a resolution of 1080 progressive scan lines (1080 p) at 30 frames per second is preferable. Annotation is essential for proper telementoring. Portability and accessibility of telementoring systems must be ensured. Adapted from Bogen et al.5. FDA, Food and Drug Administration; HIPAA, Health Insurance Portability and Accountability Act; WPA2, Wi-Fi Protected Access 2 protocols; VPN, virtual provider network. Summary of the technical recommendations of the Society of American Gastrointestinal and Endoscopic Surgeons to ensure the quality and safety of surgical telementoring processes Telementoring systems must comply with US FDA Class II device regulations, as well as HIPAA regulations. Any wireless network must ensure the security of transmission using WPA2 encryption and, in addition, a VPN or end-to-end secure tunnel. A minimum of 128-bit encryption is required, along with authentication protocols, to prevent unauthorized viewer/user connections. Minimum bandwidth must be 40 Mbit/s. Maximum latency must be <450 ms and there can be no choppiness or pixelation. Minimum resolution should be 480 progressive scan lines (480 p) at 15 frames per second (standard definition); ideally, a resolution of 1080 progressive scan lines (1080 p) at 30 frames per second is preferable. Annotation is essential for proper telementoring. Portability and accessibility of telementoring systems must be ensured. Telementoring systems must comply with US FDA Class II device regulations, as well as HIPAA regulations. Any wireless network must ensure the security of transmission using WPA2 encryption and, in addition, a VPN or end-to-end secure tunnel. A minimum of 128-bit encryption is required, along with authentication protocols, to prevent unauthorized viewer/user connections. Minimum bandwidth must be 40 Mbit/s. Maximum latency must be <450 ms and there can be no choppiness or pixelation. Minimum resolution should be 480 progressive scan lines (480 p) at 15 frames per second (standard definition); ideally, a resolution of 1080 progressive scan lines (1080 p) at 30 frames per second is preferable. Annotation is essential for proper telementoring. Portability and accessibility of telementoring systems must be ensured. Adapted from Bogen et al.5. FDA, Food and Drug Administration; HIPAA, Health Insurance Portability and Accountability Act; WPA2, Wi-Fi Protected Access 2 protocols; VPN, virtual provider network. Telesurgery requires sustainable high-speed networks, with appropriate software. 5G networks can facilitate this through the rapid transfer of large amounts of data and simultaneous connections (up to 1 million per km2, with a capacity of up to 1 Tb/s in the same extension). Crucially, they eliminate the main problem detected by the clinical end user, ‘latency’. Latency is a measure of the delay in a system and, for perception and execution according to an instruction, is usually considered to be between 250 and 300 ms. 5G networks can reduce it to below 1 ms. Fibre connection can have similar speeds, but may not support the same amount of data. 5G technology is also more flexible, by requiring a simpler infrastructure, without wiring, thus supporting such approaches in remote environments. The first experiences employing 5G technology in surgical telementoring were carried out in Barcelona and Shanghai in 2019 during colorectal surgery interventions in which surgeon and mentor were in the same metropolitan area, but several kilometres apart6 (Fig. 1 and Images S1, S2). In all cases, the latency was less than 250 ms and the transmission quality was excellent. Subsequently, other experiences with telementoring across numerous other fields of surgery have been reported7. More recently, its use has been incorporated for monitoring diagnostic procedures and assisted surgeries with commonly available robotic platforms8. These reports are worlds apart from the first robot-assisted remote cholecystectomy almost 20 years ago9, which was conducted using an already disused robotic platform and a fibre optic-based telecommunications network. Schematic of the design of the first fifth-generation network used for telementoring in surgery in 2019 during the Mobile World Capital Congress in Barcelona OR, operating room; CPE, customer premises equipment; 5G, fifth generation. 5G technology has limits that must be considered. First, is a human’s own cognitive capacity adequate to process all of the information that 5G technology can provide? Next, the application of 5G technology in surgery will suffer from the exponential growth of data traffic due to ever higher image quality and data-hungry applications. These will soon include artificial intelligence tools for surgical navigation, as well as for guidance regarding decision-making and execution. Thus, surgery in the future will require the emergence of the sixth generation (6G) of telecommunications10. 6G networks are developing rapidly and are expected to begin rolling out in the early 2030s. The transmission speed (between 100 GHz and 3 THz) and capacity will be much higher than those of current networks. Before then, telesurgery may yet forge its place in routine surgical practice, based on existing networks. Meanwhile, unlike the networks that fuel them, ethical and governance arguments trundle on and must surely now be urgently discussed and debated within the surgical and wider healthcare community. The author has no funding to declare. José M. Balibrea (Conceptualization, Supervision, Validation, Writing—original draft, Writing—review & editing) J.M.B. has participated as a scientific advisor regarding initial experiences of 5G tele-assisted surgery in collaboration with AIS Channel, GSMA, and Vodafone Spain. Supplementary material is available at BJS online.