Clinical application of robotic telesurgery in the Brazilian public health system: a consecutive case series

OBJECTIVE: To report the first clinical application of robotic telesurgery within the Brazilian Unified Health System (SUS) infrastructure, evaluating feasibility, safety, and stakeholder perceptions in a consecutive case series. METHODS: Five consecutive robotic telesurgeries across four surgical specialties were performed using the Toumai/MicroPort platform. The remote surgeon operated from the console at PROMIN-FMUSP, while the robotic unit and patient were located at HU-USP, approximately 5 km away. All procedures used a wired network connection. A structured safety protocol with predefined conversion triggers and a standby bedside surgeon was applied. Outcomes included procedural completion, network latency, intraoperative events, and 30-day postoperative outcomes. Post-procedure structured interviews captured perceptions from the remote surgeon, bedside surgeon, and anesthesia team using Likert scales and the NASA-TLX adapted instrument. RESULTS: Four of five procedures were completed entirely via remote console. One case (radical prostatectomy) required conversion to local surgeon control due to a local cable disconnection at the patient site near the end of the procedure (the network connection itself was preserved); the bedside surgeon completed the remaining approximately 10 min without adverse consequences. Surgical specialties included thoracic surgery (two cases), urology, head and neck surgery, and gynecology. Median operative time was 165 min (range 106‒240). Console-reported latency was approximately 12 ms in each case. No intraoperative adverse events occurred. All remote surgeons rated perceived safety at the maximum score. Bedside surgeons and anesthesiologists uniformly considered the model safe, although saturation of most perception scores at the maximum value limited inter-case discrimination. One patient (Case 2, head and neck) had a Clavien-Dindo grade II complication (edema and pain requiring one additional day of hospitalization). No readmissions, reoperations, or mortality occurred within 30 days. CONCLUSION: The first clinical application of robotic telesurgery within SUS proved technically feasible across four surgical specialties in five consecutive low-to-medium complexity cases, with no major adverse events at 30-days. The single conversion was managed safely by the standby bedside surgeon, consistent with the intended behavior of the structured safety protocol. These initial findings ‒ limited by the small sample and absence of a control group ‒ support the continued, progressive evaluation of telesurgery within Brazil's public health system.