Leveraging 5G technology for robotic surgery and cancer care

Abstract Background The field of robotic surgery has seen significant advancements in the past few years and it has been adopted in many large hospitals in the United States and worldwide as a standard for various procedures in recent years. However, the location of many hospitals in urban areas and a lack of surgical expertise in the rural areas could lead to increased travel time and treatment delays for patients in need of robotic surgical management, including cancer patients. The fifth generation (5G) networks have been deployed by various telecom companies in multiple countries worldwide. Our aim is to update the readers about the novel technology and the current scenario of surgical procedures performed using 5G technology. In this article, we also discuss how the technology could aid cancer patients requiring surgical management, the future perspectives, the potential challenges, and the limitations, which would need to overcome prior to widespread real‐life use of the technology for cancer care. Recent findings The expansion of 5G technology has enabled some countries to conduct remote surgical procedures, tele‐mentored and real‐time interactive procedures on animal models, cadavers, and humans, demonstrating that 5G networks could offer a potential solution to previously experienced latency and reliability hurdles during the remote surgeries performed in the 2000s. Conclusion New technological advancements could serve as a ground for emerging novel therapeutic applications. While limitations and challenges related to the 5G infrastructure, cost, compatibility, and security exist; researching to overcome the limitations and comprehend the potential benefits of integrating the technology into practice would be imminent before widespread clinical use. Remote and tele‐mentored 5G‐powered procedures could offer a new tool in improving the care of patients requiring robotic surgical management such as prostate cancer patients.


| INTRODUCTION
Significant advancements have been made in the field of robotic surgery in the past few years. 1,2 Robotic surgery is preferred for urologic, gynecologic, thoracic, cardiothoracic, and gastrointestinal procedures. 3 Moreover, many large hospitals across the United States 4 and the countries around the world 4,5 have adopted robotic surgery as a standard. The emergence of robotic surgery has created a significant impact on the surgical management of prostate cancer (PCa) 6 making robotic assisted radical prostatectomy (RARP) a standard procedure for localized PCa. 2 The use of robotic surgery the hospitals in Michigan increased 8.4-fold in 6 years (from 1.8% in 2012 to 15.1% in 2018), demonstrating how robotic surgery continues to diffuse among common surgical procedures. 7 Remote robot-assisted surgery was first successfully conducted 8 in 2001 but has not been integrated into clinical practice due to technological barriers, including high latency. The lack of surgical expertise in rural areas is a problem faced by various countries. [9][10][11] In addition, the location of robotic surgeons in urban areas may increase the travel burden and cause treatment delay in cancer patients requiring robotassisted surgical management. 12 These shortages could be addressed by tele-surgery, 13 which utilizes the real-time communication and exchange of medical information, including image, audio, and video, to be digitized and transmitted via telecommunication networks, allowing surgeons in an urban location to conduct a real-time procedure. 14 Currently, the deployment of fifth-generation (5G) networks is in progress in multiple countries worldwide. The expansion of the novel technology has enabled clinicians to conduct remote procedures, telementored surgeries, and real-time interactive surgeries on animal models, cadavers, and humans. In the following article, the authors discuss detail the history of robotic surgical systems, a summary of the internet and the 5G networks, and the current scenario of remote procedures using the 5G network with an aim to update the readers about the novel technology, illustrate the efficacy and feasibility of the use the novel technology and potential benefits for the cancer patients requiring surgical interventions.

| HISTORY OF SURGICAL ROBOTIC SYSTEMS
Robotic surgical systems have been in development for over 40 years.
Arthrobot, developed and used in Vancouver in 1983, was the world's first surgical robot. 15,16 The PUMA 200 was a robotic system used initially for industrial purposes. In 1985, researchers released a better and improved version of PUMA 200 called the PUMA 560, both made by Unimation Limited. 17 It was a programmable robot whose computer was compatible with varied imaging computers used in past biomedical fields. Numerous tests were conducted on the robotic system to calibrate and test the accuracy, including tests on a chessboard and watermelons.
A neurosurgical procedure that involved holding the fixture close to the patient's head was conducted using PUMA 560. The surgeon used the fixture to guide drills and biopsy probes, making it the first robotassisted surgical procedure to conduct a brain tissue sample biopsy under CT guidance. However, PUMA 560 had drawbacks, including high setup times, accuracy, and safety issues. [17][18][19] In 1988, transurethral resection of the prostate (TURP) was performed using the PUMA 560 and was considered to be the first urologic use of a medical robot. 20 PROBOT was developed in England and utilized in prostate reconstruction and transurethral prostate resection surgeries. 21,22 In 1992, the ROBODOC, developed by the Integrated Surgical Supplies, Inc., became the first US Food and Drug Administration (FDA) approved surgical robot. The ROBODOC was developed to perform hip replacements, specifically. 21,[23][24][25] Through the late 1980s and early 1990s, Computer Motion developed their robotic system named AESOP, Automatic Endoscopic System for Optimal Positioning. AESOP assisted surgeons by providing a steady operating field without the risk of a fatigued or inexperienced scope holder. AESOP controlled the orientation of the laparoscope initially using a foot pedal. Later the orientation was controlled using voice commands. AESOP received FDA approval for intra-abdominal surgeries in 1994 and became the first FDA-approved robotic device for intra-abdominal procedures. 21,26 ZEUS was the second-generation robotic system introduced by Computer Motion. It provided instrument and camera control, had three robotic arms and a 2D video screen. Out of the three arms, one arm was for a 2D laparoscope and two other arms were to control the surgical instruments.
The surgeon used a remote console to control the instrument arms and similar to the AESOP, the camera could be operated with voice commands The surgeon's movements were translated into the laparoscopic instruments with the help of a computer. 8,21,27 In September 2001, the first transatlantic robot-assisted telesurgery was conducted successfully using ZEUS, which laid the foundation of remote surgery, demonstrating the feasibility and medical potential to provide surgical support to rural and international areas. It was a robot-assisted laparoscopic cholecystectomy on a porcine model, transmitting the signals between Strasbourg, France, where the animal models were located, to New York, where the surgeon was located. 8 While ZEUS gained significant popularity, the da Vinci robotic system, developed by American company Intuitive Surgical, Inc., was shown to have a shorter learning curve than ZEUS and more intuitive technical movements. The da Vinci robotic system was approved by the FDA in 2000 for general laparoscopic procedures. 28 The system includes a surgeon master console, a four-armed surgical robot on a patient trolley, an imaging system and is approved for a wide variety of surgical procedures. 29 Using the da Vinci robotic system, surgeons in the United States conducted four right laparoscopic transcontinental telesurgical nephrectomies in porcine models in 2008. 30 Animal subjects were located in Sunnyvale, California, and the surgeon was

| BACKGROUND OF THE INTERNET AND 5G
A simplified visual representation of how devices transfer data via wired or broadband ( Figure 1) and wireless ( Figure 2) connections is shown in the figures. Advancements in 2G, 3G, and 4G mobile networks have drastically improved wireless internet services. 32 5G networks provide a high data transfer rate at 10 GB/s. 33 4G networks utilize a system that incorporates every aspect into one network and functions as one body. 33,34 On the other hand, 5G networks have developed a "network splicing/slicing" scheme that divides the network architecture into multiple networks specialized in one specific function. 33,34 Splicing allows the 5G network to optimize resources toward the relevant functions being used. These advancements allow 5G networks to achieve higher data transfer speed, communication, reliability, and ultra-low-latency than 4G networks. [32][33][34] It is essential to understand latency. Latency is the response delay between a device and the hosting server or target device, which is affected by the data transfer rate of a network and the amount of data needed to be transferred. In remote surgery, these characteristics are essential for the surgeon to respond adequately to changing circumstances and the quality of the video stream to provide appropriate information. Inadequate time or poor video quality could lead to surgical trauma and complications for the patient. The maximum resolution possible for Dr. Marescaux and colleagues, in their surgery conducted in early 2000s, was 1024 pixels by 768 pixels and a data transfer rate of 10 Mbps. 8 A maximum latency for successful surgery at 330 ms was established but conducted most of the surgery at an average latency of 155 ms. 8 Better video quality and faster data transfer speed would be needed to improve the success of remote surgery. The increasing resolution will increase the amount of data required to be transferred but improve the video quality for the surgeon to conduct the surgery accurately.
Similarly, data transfer speed increases can help the surgeon reduce the latency and allow the surgeon to respond more quickly.
The DaVinci robot is capable of at least 1920-pixel by 1080-pixel resolution (about 2.6 times larger than Dr. Marescaux), and 5G networks can reduce both the latency and improve video stream quality through their maximum transfer rate of 10Gb/s. Concerning surgeons, Zheng and colleagues found the average endoscopic surgeon's response time to their most complex scenario was 397 ms ± 19 s. 35 Most successful remote surgeons utilized average latencies between 76 and 150 ms for a potential approximate response time of 475-660 ms. [36][37][38] As such, we can speculate the maximum safe latency period to be around 150 ms, which is approximately a 37.5% increase in normal surgeon response time. Thus, to data transfer speeds from improved mobile networks can lead to lower latencies or improvements in resolution.

| CURRENT SCENARIO OF THE USE OF 5G IN ROBOTIC SURGERY
Many countries are slowly adopting 5G networks. 39 In addition, the expansion of surgical robot technologies and 5G network systems has enabled some countries to conduct remote robotic procedures using 5G. In the following paragraphs, we present different robotic procedures, which involve the use of 5G technology.
In December 2018, a remote hepatectomy in a porcine model was performed at the Fujian, People's Republic of China (PRC) using F I G U R E 1 Simplified visual of representation of how devices transfer data via wired/fixed-broadband connections using Wi-Fi routers. The sender sends the message in a binary language signal to the router. The router will transfer the signal to the internet service provider's (ISP) station and internet hub via cables. The signal travels to the receiver's ISP and internet hub. From there, the signal travels to the receiver's device via cables to the router the Kangduo robotic surgery system and 5G network by Huawei Technologies Company and China Unicom. The equipment control was located in the Fujian Branch of China Unicom, and the operating theater was located in Mengchao Hepatobiliary Hospital in Fujian, Fuzhou, PRC, approximately 48 km (30 miles) away. Two robotic arms (bipolar coagulation and electrocoagulation hooks) and lens were controlled remotely by the surgeon to resect a 2 cm Â 2 cm Â 3 cm portion of the liver. The surgery lasted for around 60 min, with a total blood loss of approximately 5 ml. In addition, average latency was reported at less than 150 ms 40 (Figure 3).
In 2019, a study to evaluate the performance of 5G in two different medical applications was conducted in Munich, Germany, and involved camera positioning. The video streaming rate was 900 KB-1 Mbps (7.2-8 Mbps), and the robotic control command rate was 2.4-7.2 KB/s (19.2-57.6 KB/s). The latency was 2-60 ms, and it depended on the transmitted data packet length. A Delphi study was also conducted, which showed that the participants agreed that 5G has a great potential in the healthcare domain and needs to be further explored 41 (Figure 4).
In March 2019, clinicians remotely controlled implants for deep brain stimulation (DBS) through 5G to treat Parkinson's disease and brain ailments. Three patients (two Parkinson's disease, one essential tremor) were recruited and operated on-site to install the headframe, craniotomy, and microelectrode puncture in Beijing.
The remote-control group controlled the microelectrode recording and imaging to confirm the implantation of the electrode. The remote-control group was located approximately 2400 km away (Hainan Hospital of Chinese PLA General Hospital, Sanya City, PRC) from F I G U R E 2 Simplified visual of representation of how devices transfer data via wireless 5G mobile connections. The sender sends the message via smartphone in a binary language to an internet service provider (ISP) tower wirelessly through radio frequency (RF) electromagnetic waves. The ISP tower is connected to a base station that transfers the signal through cables to the receiver's base station. The signal reaches the receiver's device via RF waves were conducted. The first procedure, the "one-to-two" simultaneous remote orthopedic pedicle screw placement, was conducted in June 2020 between Beijing Jishuitan Hospital, Shandong Yantaishan Hospital, and Zhejiang Jiaxing Second Hospital. 37 The second procedure, the "one-to-three" simultaneous remote orthopedic pedicle screw placement, was conducted in August 2020 between Beijing Jishuitan Hospital, Tianjin First Central Hospital, Second Hospital of Zhangjiakou City, and Karamay Central Hospital. 37 In both surgeries, the master control room and surgeon responsible for the operations were   (Figure 6).
Furthermore, four laparoscopic procedures: left nephrectomy, partial hepatectomy, cholecystectomy, and cystectomy, were performed on 25 kg porcine models in 2020. Surgeons were located in Qingdao, PRC, and porcine models were in Anshun, PRC, approximately 3000 km away. 50 The "MicroHand" surgical robot was used, assisted by the Hisense computer-assisted system (CAS) for remote access. They compared a wired 100 Mbps wired China Unicom connection to a 5G 1Gbps China Unicom connection during the procedure. 50 Average latency of 264 ms with a round trip delay of 114 ms and a 1.2% packet loss ratio was noted by the 5G network. The "control" wired connection had an average latency of 206 ms with a round trip delay of 56 ms. The total duration was 120 min, and the total blood loss was 25 ml 50 ( Figure 3). The details of the procedures discussed above are summarized in Table 1. and reconfirmed the maximum latency threshold at 300 ms. 38,44 These studies demonstrate against Ullah and colleagues that a highly reliable connection with ultra-low latency of less than 10 ms is required for robotic surgery. 52 56 The speeds and coverage are likely to improve in the coming years all across the country due to the expansion of the network by multiple telecom companies. For instance, in a report published by T-Mobile in the Forbes, they discuss about covering 90% of rural Americans in the next 6 years. 56 In addition to a widespread 5G connectivity, 5G-compatible laptops, cell phones, and robotic surgical systems would be needed. 57 For 5G robotic surgeries, we must also be aware that a backup surgery team may be required to be onsite if a connection is hindered or lost. In the following surgical cases, we will review their usage of 5G networks and how they managed the limitations of 5G-powered robotic surgeries.

| POSSIBLE CHALLENGES AND LIMITATIONS
It is also essential to conduct a cost-benefit analysis before any potential implementation of 5G-powered robotic surgery for rural

| FUTURE PERSPECTIVES
The procedures discussed demonstrate that the latency and reliability difficulties experienced by Marescaux et al. 8

DATA AVAILABILITY STATEMENT
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.