Remote robot-assisted pancreatoduodenectomy for one patient with pancreatic ductal adenocarcinoma

Robot-assisted telesurgery represents the forefront of surgical technology. Its core value lies in providing patients in resource-limited areas access to top-tier surgical expertise by overcoming geographical barriers. Since the landmark transatlantic “Lindbergh” robotic cholecystectomy in 2001 (1), breakthrough advances in 5G communication technology, with its high speed, low latency, and massive connectivity, have revolutionized the precision and stability of telesurgery, and significantly accelerated its clinical applications (2). The telesurgery has gradually expanded from simple cholecystectomy to more complex procedures. In 2022, Yang et al. (3) reported a successful radical cystectomy performed with the “MicroHand” surgical robot across a remarkable distance of 3,000 kilometers, representing a pioneering demonstration of remote urological surgery. In 2024, Tian et al. (4) documented the feasibility of 5G-based telesurgery in thoracic procedures through a case of remote robotic-assisted right upper lobectomy. In the same year, Zhou et al. (5) further validated the clinical viability of this approach by completing a series of 14 separate urological operations using 5G-enabled telerobotic laparoscopic systems, constituting a substantial case series that reinforced the reliability of the technology. Recently, Fan et al. (6) reported 5 cases of remote hepatobiliary-pancreatic procedures, including three cholecystectomies, one hepatic angioma resection and one spleen-preserving distal pancreatectomy, using a domestically developed robotic platform and 5G network. Pancreatoduodenectomy is the treatment of choice for pancreatic ductal adenocarcinoma (PDAC) at the pancreatic head, ampullary carcinoma, papillary carcinoma and distal common bile duct carcinoma. It remains the major challenging procedure and the technical apex of abdominal surgery due to its complexity of resection and multiple anastomoses, and is highly technique-demanding. Up to date, there has been no report of remote robot-assisted pancreatoduodenectomy (RPD) for PDAC in the literature, provided there was one case report of remote RPD for ampullary carcinoma (7). This letter aimed to present one case of the remote RPD for the patient with PDAC and the perioperative outcome utilizing a domestically developed robotic system and a 5G network. It thereby filled up the technological gap and preliminarily validated the safety and feasibility of remote RPD for PDAC.

The patient was a 65-year-old female who suffered from poor appetite and fatigue for 4 months, followed by jaundice for over half a month. At her local hospital, the computed tomography (CT) imaging revealed a slightly hypodense nodule in the pancreatic head, with dilatation of the main pancreatic duct and biliary tract. The patient was therefore referred to Department of General Surgery, Guangxi Hospital of The First Affiliated Hospital of Sun Yat-sen University, in Nanning city, Guangxi Province, China (abbreviated as “Guangxi Hospital” in the following), for further evaluation and management. Laboratory tests in Guangxi Hospital showed markedly elevated levels of total bilirubin (179.3 µmol/L; normal: 0–21.0 µmol/L), direct bilirubin (100.9 µmol/L; normal: 0–4.0 µmol/L), indirect bilirubin (78.4 µmol/L; normal: 5.1–18.3 µmol/L), alanine aminotransferase (60 U/L; normal: 7–40 U/L), aspartate aminotransferase (62 U/L; normal: 13–35 U/L), gamma-glutamyl transferase (1,072 U/L; normal: 7–45 U/L), PIVKA-II (958.2 ng/mL; normal: 0–40.0 ng/mL) and carbohydrate antigen 19-9 (62.97 U/mL; normal: 0–35.0 U/mL). The hemoglobin (104.0 g/L; normal: 115–150.0 g/L) was decreased. Contrast-enhanced magnetic resonance imaging scanning demonstrated one lesion at the pancreatic head (22 mm × 20 mm in size, Figure 1A) with dilatation of the main pancreatic duct and biliary tract, highly suggestive of pancreatic carcinoma. Contrast-enhanced CT scanning was consistent with the magnetic resonance imaging (MRI), revealing a mass in the pancreatic head (21 mm × 20 mm in size, Figure 1B) and dilatation of both the pancreatic and biliary ducts. The patient was diagnosed as pancreatic carcinoma preoperatively. Percutaneous transhepatic cholangial drainage (PTCD) for biliary decompression was performed.

Figure 1 MRI, CT and operation of the case. (A) MRI showed one lesion at the pancreatic head (yellow arrow). (B) CT showed a mass in the pancreatic head (yellow arrow). (C) General view of surgeon console. (D) The picture of division of uncinate process. (E) The picture of completion of pancreatoduodenectomy. (F) The picture of pancreaticojejunostomy. (G) The picture of hepaticojejunostomy. (H) The picture of gastrojejunostomy. (I) CT showed no recurrence or metastasis after 1 month postoperatively. CT, computed tomography; MRI, magnetic resonance imaging.

Multidisciplinary team consultation considered that the patient had resectable pancreatic carcinoma at the pancreatic head and recommended curative resection for her. After adequate informed consent, the remote RPD was planned for the patient. All procedures performed in this study were in accordance with the ethical standards of the Ethics Committee of The First Affiliated Hospital of Sun Yat-sen University ([2024] No. 643), and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

The remote RPD was performed on September 30, 2025 using the Toumai four-arm robot (Thoracic and Abdominal Endoscopic Surgery System, Model: MT-1000). The remote surgeon used the surgeon console in Guangzhou city, to manipulate the robotic arms at patient side in Nanning city via 5G broadband network to carry out the operation. There was one assistant surgeon at patient side in Nanning to manage the robotic arms (Figure 1C). The physical distance between the Guangzhou and Nanning was 600 km, and the network transmission distance was 2,840.9 km. The RPD lasted 470 minutes and was completed uneventfully (Figure 1D-1H), with intraoperative blood loss of 50 mL and no blood transfusion. The network maintained a stable image frame rate with a median delay of 25 ms. System monitoring confirmed only 0.1% of packet loss and absence of network disruptions during the operation, providing the critical technical foundation for precise remote manipulation. The RPD procedures were performed as described in our previous publications (8,9). Briefly, (I) adequate dissection of the duodenum and the pancreatic head was achieved by Kocher maneuver until inferior vena cava, abdominal aorta, left renal vein, and the root of superior mesenteric artery (SMA) were exposed; (II) superior mesenteric vein (SMV) and portal vein were dissected along posterior to the pancreatic neck, and right gastroepiploic vessels and Henle’s trunk were ligated and divided; (III) the stomach was transected at the body with a stapler, then common hepatic artery, proper hepatic artery, right gastric artery (RGA) and gastroduodenal artery (GDA) were dissected, and then RGA and GDA were divided; (IV) the pancreas was transected at neck by the electrocauterization; (V) the proximal jejunum was divided by widely opening and resecting part of mesocolon, and uncinate process was divided along the right margin of SMA; (VI) common bile duct was transected along with gallbladder resection; (VII) pancreatojejunostomy was completed by end-to-side “mucosa-to-mucosa” anastomosis; (VIII) cholangiojejunostomy was completed by continuous suturing; (IX) finally, end-to-side gastrojejunostomy was completed by robotic-assisted double-layered suturing.

Postoperative pathology confirmed PDAC in the pancreatic head. Thirteen lymph nodes were harvested, with metastases in 3 of them (3/13). Surgical margins were negative. The pathological stage was pT2N1M0 (stage IIB) based on the American Joint Committee on Cancer (AJCC) 8th edition criteria. The patient recovered well and was discharged on postoperative day 12 with no complications. No recurrence or metastasis was found during the follow-up after 1 month postoperatively (Figure 1I). The patient has completed three cycles of the nab-paclitaxel plus gemcitabine (AG) regimen, with each 21-day cycle administered on days 1 and 8. Recent imaging revealed no recurrence or metastasis. We acknowledge the limited oncological follow-up inherent to this early report and plan for longitudinal surveillance.

This successful case of remote RPD for PDAC preliminarily demonstrated that, with current 5G network technology support, utilizing a domestically developed robotic system to perform a remote, highly complicated abdominal surgery is technically feasible and safe. It is extremely valuable in promoting the development and extending clinical applications of tele-surgery in the future.

The successful execution of telesurgery is critically reliant on high-quality network performance. Academic studies consistently identified a network latency of less than 200 ms as optimal for remote surgical procedures, provided 320 ms was generally represented as the maximum permissible latency for maintaining operational safety and efficacy (10). Exceeding this critical latency threshold could substantially impair the surgeon’s real-time control and procedural accuracy, potentially introducing risks to patient outcomes. In the present case, the network connection demonstrated high stability, recording a median latency of 25 ms with 0.1% of packet loss and absence of network disruptions, which served as a fundamental technical prerequisite for the successful completion of the operation. In authors’ opinion, widespread application of remote RPD still faces some challenges. Firstly, RPD involves meticulous dissection around critical vasculature. Any unexpected network latency could pose risks. Future efforts should focus on building heterogeneous reliable network architectures integrating 5G, satellite communications, and edge computing to cope with complex transmission environments. Secondly, the remote surgeon should have profound experiences and skillful surgical techniques in performing RPD and remote robotic operations, strong stamina and good coordination with the patient-side surgical team. The remote surgeon of the present case has personal experiences in successfully completing nearly 400 RPD and 10 cases of remote robotic operations before performing the remote RPD. Thirdly, for such highly complicated cross-regional surgeries, there is an urgent need to establish unified standards for surgical licensing, medical liability attribution, and emergency response protocols. The high initial investment costs also need to be balanced through optimized service models and improved surgical efficiency.

In summary, a remote robotic-assisted pancreatoduodenectomy was successfully conducted in a patient with PDAC. The entire procedure was completed without any network-related adverse events, confirming the safety and feasibility of utilizing the Toumai thoracic and abdominal endoscopic surgery system supported by the 5G network from China Telecom.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-1-913/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-2025-1-913/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. All procedures performed in this study were in accordance with the ethical standards of the Ethics Committee of The First Affiliated Hospital of Sun Yat-sen University ([2024] No. 643), and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. 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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