Langenbeck's Archives of Surgery (2022) 407:3783–3791
https://doi.org/10.1007/s00423-022-02710-6

RESEARCH

Establishment of a new practical telesurgical platform using
the hinotori™ Surgical Robot System: a preclinical study
Masaya Nakauchi1 · Koichi Suda2,3 · Kenichi Nakamura2 · Tsuyoshi Tanaka4 · Susumu Shibasaki2 · Kazuki Inaba1 ·Tatsuhiko Harada5 · Masanao Ohashi6 · Masayuki Ohigashi7,8 · Hiroaki Kitatsuji8 · Shingo Akimoto2 · Kenji Kikuchi8,9 ·Ichiro Uyama1
Received: 22 July 2022 / Accepted: 9 October 2022 / Published online: 14 October 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
Aim The recent development of new surgical robots and network telecommunication technology has opened new avenues
for robotic telesurgery. Although a few gastroenterological surgeries have been performed in the telesurgery setting, more
technically demanding procedures including gastrectomy with D2 lymphadenectomy and intracorporeal anastomosis havenever been reported. We examined the feasibility of telesurgical robotic gastrectomy using the hinotori™ Surgical Robot
System in a preclinical setting.
Methods First, the suturing time in the dry model was measured in the virtual telesurgery setting to determine the latency
time threshold. Second, a surgeon cockpit and a patient unit were installed at Okazaki Medical Center and Fujita Health University, respectively (approximately 30 km apart), and connected using a 10-Gbps leased optic-fiber network. After evaluating
the feasibility in the dry gastrectomy model, robotic distal gastrectomies with D2 lymphadenectomy and intracorporeal B-I
anastomosis were performed in two porcine models.
Results The virtual telesurgery study identified a latency time threshold of 125 ms. In the actual telesurgery setting, thelatency time was 27 ms, including a 2-ms telecommunication network delay and a 25-ms local information process delay.
After verifying the feasibility of the operative procedures using a gastrectomy model, two telesurgical gastrectomies weresuccessfully completed without any unexpected events. No fluctuation was observed across the actual telesurgeries.
Conclusion Short-distance telesurgical robotic surgery for technically more demanding procedure may be safely conductedusing the hinotori Surgical Robot System connected by high-speed optic-fiber communication.
Keywords Gastrectomy · Lymphadenectomy · Remote operations · Robotic surgical procedure* Koichi Suda
ko-suda@nifty.com
1

Department of Advanced Robotic and Endoscopic Surgery,Fujita Health University, Toyoake, Japan2

Department of Surgery, Fujita Health University, 1‑98
Dengakugakubo, Kutsukake, Toyoake, Aichi 470‑1192,
Japan

3

Collaborative Laboratory for Research and Developmentin Advanced Surgical Intelligence, Fujita Health University,
Toyoake, Japan

4

Collaborative Laboratory for Research and Developmentin Advanced Surgical Technology, Fujita Health University,
Toyoake, Japan

5

Department of Anesthesiology and Critical Care Medicine,
Fujita Health University, Toyoake, Japan

6

Global Management Division, Sysmex Corporation, Kobe,
Japan

7

MR Business Division, Sysmex Corporation, Kobe, Japan

8

Medicaroid Corporation, Kobe, Japan

9

Department of Surgery, Okazaki Medical Center, Fujita
Health University, Okazaki, Japan

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Introduction
In 2001, Marescaux and colleagues reported the first successful completion of transatlantic robot-assisted cholecystectomy using the Zeus surgical robot (former Computer
Motion, CA) in clinical practice [1]. They performed cholecystectomy from New York in six porcine models and one
human located in Strasbourg, France, which are approximately 7000 km apart. Subsequently, Anvari and colleagues
reported 21 successful procedures routinely performed using
the Zeus surgical robot and Canadian telesurgical network[2, 3]. Thus far, a limited number of telesurgical procedures, including cholecystectomy, gastric banding, Nissen
fundoplication, hemicolectomy, and anterior resection, havebeen performed in the gastroenterological field [2, 4, 5].
Despite its introduction in the early 2000s, telesurgery has
not widely spread because of the limited telecommunication
network technology, its high cost, and the fact that telesurgery has not been implemented in the da Vinci™ Surgical
System (Intuitive Surgical Inc., CA), which is the most common surgical robot installed worldwide [6]. Recently, thedevelopment of new surgical robots and network telecommunication technology using optical fiber, and 5G has expanded
the potential use of telesurgery [6–8].
As several studies demonstrated the advantage of robotic
surgery over open or conventional laparoscopic approach,
the Japanese government approved robotic surgery for three
gastrointestinal cancers including gastric cancer under thenational medical insurance coverage in 2018 [9]. Subsequently, robotic surgery has rapidly spread nationwide. It
is mandated by the Japanese Society of Endoscopic Surgery to invite expert surgeons for new application of robotic
approach, which causes excessive burden for the experts.
The telesurgical platform, which enables training, mentoring, and proctoring of surgery, is expected to solve this issue.
In 2019, a new surgical robot named the hinotori™ Surgical Robot System was launched by Medicaroid Inc. (Kobe,
Japan), Japan. This surgical robot has a surgeon cockpit witha manipulator and operation unit with four arms for instruments, including a camera scope. In addition, a telesurgery
system was implemented in this surgical robot.
For patients with gastric cancer, R0 resection with lymphadenectomy is a mainstream curative treatment [10].
Minimally invasive surgery for gastric cancer has been utilized for a few decades, and recently, a robotic approach
using the da Vinci Surgical System has rapidly gained
popularity globally. However, this technique is technicallydemanding, and there is no report of telesurgical gastrectomy for gastric cancer.
Following these previous examples, this study aimed toestablish a telesurgical system that enabled us to perform
complex procedures including gastrectomy combined with

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D2 lymphadenectomy and intracorporeal anastomosis using
the hinotori Surgical Robot System.

Methods
hinotori Surgical Robot System
We used a new Japanese surgical robot named the hinotori
Surgical Robot System in this study. This surgical robot wasdeveloped by Medicaroid Inc., which was established in 2013as a joint investment between Kawasaki Heavy Industries,
Ltd. (Tokyo, Japan) and Sysmex Corporation. (Kobe, Japan),by focusing on “compactness,” “safety,” and “maneuverability,” and it consists of an operation unit with four arms
and a surgeon cockpit (Fig. 1a, b). This system became thefirst robotic-assisted surgery system created in Japan to gain
Japanese regulatory approval in August 2020. In the urology
field, the first human surgery with the system was successfully conducted in December 2020. As points differing fromthe da Vinci Surgical System, (1) each robotic arm has eightaxes that enable more flexible arm movement and reduce theinterference between the arms as well as between the arm andthe patient body (Fig. 1c), (2) the software calibrates the trocar
position (pivot position) without attaching the trocar (Fig. 1d),which can provide a large space around trocars and prevent thetissue damage of the abdominal wall by excessive traction, and(3) the surgeon cockpit has a flexibly positioned 3D viewerthat can reduce the fatigue of the surgeon’s neck and shoulder.

Virtual telesurgery settingFirst, we conducted an experiment to identify the latency
time threshold using the virtual telesurgery setting, which
consisted of the hinotori Surgical Robot System and thelatency generator (Fig. 2). Seven gastric surgeons certified by the Endoscopic Surgical Skill Qualification Systemcreated by the Japanese Society for Endoscopic Surgery[11] who had performed at least 20 robotic gastrectomies
for gastric cancer (M. N., K. S., K. N., T. T., S. S., K. I,
and I. U.) participated in this experiment. Under the virtual latency setting ranging from 25 to 625 ms, the time
for suturing in the dry model was measured. In addition,
to examine the latency time threshold in more detail, thesuturing time was measured further, dividing the latency
time into smaller segments around the threshold obtainedin the above setting. The suturing technique was standardized as one surgical knot and two normal knots using a
12-cm 3–0 Vicryl™ suture (Ethicon, Inc., Johnson & Johnson Company, Somerville, NJ, USA). The suturing procedure was performed from the initial position consisting of
the bilateral arms and needle in place to complete the knots(Fig. 3a). After suturing under each delay setting, surgeonsLangenbeck's Archives of Surgery (2022) 407:3783–3791

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Fig. 1  The hinotori Surgical
Robot System. A surgical cockpit (a), an operation unit (b),four manipulating arms witheight axes without attaching the
trocar (c, d)Fig. 2  The network map in thevirtual telesurgical setting andactual telesurgical gastrectomy
setting in porcine models. In thevirtual setting, the delay generator was inserted between the
network switches

answered the questionnaires to evaluate the procedure’s
feasibility with a score of 0–10 (Fig. 3b). Technical failures including incomplete suturing and deviation from thesuturing point were subsequently evaluated. Each surgeon
was blinded to the other surgeons’ procedures.

Network connections
We leased a commercial fiber-optic network connected
between Fujita Health University (Toyoake, Japan) andOkazaki Medical Center (Okazaki, Japan), which were

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Fig. 3  Suturing under the virtual telesurgery setting (a) andquestionnaires after suturing in
the virtual setting (b)separated by approximately 30 km. A leased-line with 10
Gbps of bandwidth was provided by Chubu Telecommunications Co., Inc. (Nagoya, Japan) and dedicated for thisstudy during the operation. The network system for thistelesurgery consisted of this dedicated fiber-optic networkand local devices, including the hinotori Surgical Robot
System and information processors (Fig. 2). Video data
was processed using H.265 codec. Latency time, including
the telecommunication network delay caused by the delivery between the two locations (transmission path between
network switches at each site; shown in blue color) andthe local information process delay caused by compression or decompression of the video image and audio signal(transmission path between surgeon cockpit/operation unit
and network switch at each site; shown in red color) were
measured (Fig. 2). In addition, the fluctuation of latency
time attributable to unstable network connections was also
evaluated. The real-time image and voice in the operation room were shared with the remote meeting software(Teams™, Microsoft Corporation, WA, USA) using astandard internet connection. In addition, to inform theconsole surgeon of the arm position, the real-time threedimensional illustration of the arm position was createdat the operation unit side and sent to the console surgeon
using a standard internet connection (Fig. 4a).

Telesurgical gastrectomy
Two gastric surgeons who had performed more than 100
robotic gastrectomies (I. U. and K. S.) participated in thisstudy as console surgeons. As the first step of the actual

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telesurgery, each surgeon performed gastrectomy on a synthetic training model for gastrectomy [12] (Fasotec Co.,
Ltd., Chiba, Japan) (Fig. 4b). In each case, the dry gastrectomy model and surgical robot were located at Fujita
Health University. By contrast, the console surgeons werelocated at Okazaki Medical Center. Using the aforementioned telesurgery setting and following the dry gastrectomy model, we performed robotic distal gastrectomy
with D2 lymphadenectomy and intracorporeal Billroth-I
anastomosis in two porcine models, the anatomical aspectsof which are similar to those of humans (Fig. 4c, d). The
details of this procedure in a human patient were describedin our previous reports [13, 14]. Two females 41.7–42 kg,
10–13-week-old WL specific pathogen-free porcine (ZPP,
ZEN-NOH, Tokyo, Japan) were purchased. All animals
were kept in a controlled environment with a 12-h light/
dark cycle and 20 ± 5 °C room. The animals were fasted
for 12 h before anesthesia to control the vomiting, otherwise were able to eat and drink anytime. Midazolam 15 mg/
head (SANDOZ, Bavaria, Germany), medetomidine 1.5 mg/
head (Kyoritsu Seiyaku Corporation, Tokyo, Japan), butorphanol 7.5 mg/head (Meiji Seika Pharma Co., Ltd., Tokyo,
Japan) was injected intramuscularly for premedication andwere weighted. The animals were induced with isoflurane(Pfizer, NY, US) by mask and were intubated. The vital
sign of porcine was captured and shared at both ends using
a standard internet connection. First, five trocars, including
one port for the assistant surgeon, were placed at the upper
abdomen, and pneumoperitoneum was started. The operation unit was rolled in from the right side and set up thearm arrangement targeting to the left shoulder to prevent

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Fig. 4  The real-time threedimensional illustration of therobotic arms (a), telesurgicalgastrectomy using a gastrectomy model (b), and the operating surgeon (c) and the surgicalrobot (d) during telesurgicalgastrectomy in a porcine model

extracorporeal collision between the robotic arms. Positioning of the forceps during procedures was determined basedon the monitor quadrisection theory to avoid intracorporeal
collisions [14]. Maryland Bipolar Forceps (Medicaroid Inc.,
Kobe, Japan) or monopolar curved scissors (MedicaroidInc., Kobe Japan), which was connected to a AUTOCON™
II 400 Electrosurgical Unit (KARL STORZ、Tuttlingen,Germany), and Universal grasp (Medicaroid Inc., Kobe,
Japan) were used with the operating surgeon’s right hand(i.e., the third and fourth arms of the robot, respectively),
whereas Croce grasping forceps or fenestrated bipolar forceps (Medicaroid Inc., Kobe, Japan) was used with his left
hand (i.e., the first arm of the robot). Then, dissection of
the D2 lymph nodes, including perigastric lymph nodes andlymph nodes along the celiac trunk, left gastric artery, common and proper hepatic arteries, proximal splenic artery,and portal vein, was performed. After transection of theproximal duodenum and proximal stomach, Billroth-I anastomosis using linear staplers was performed intracorporeally [15]. The console surgeons performed all procedures,
excluding port placement, clipping of vessels, and transection of the stomach and the duodenum, using linear staplers.
All procedures in porcine surgery were performed under theapproval of the Institutional Animal Care and Use Committee at Fujita Health University (APU19076-MD3). The careand handling of the animals were in accordance with thepolicies promulgated by the Regulations for the Management of Laboratory Animals at Fujita Health University.
Each animal was under the care of a veterinarian (T. H.)
at all times. The porcine model was monitored during thegeneral anesthesia and euthanized immediately after thecompletion of each procedure.

Statistical analysis
A latency time was expressed as a total round-trip delay
in milliseconds. Continuous variables were expressedas the mean and standard deviation. One-way analysis
of variance with a post hoc Bonferroni correction test
was used to evaluate the continuous variables. P < 0.05
indicated statistical significance. All analyses were conducted using SPSS 28.0 (IBM Inc., Chicago, IL, USA).

Results
In the virtual telesurgery setting, the suturing time increased
as the delay increased; 74.6 ± 20.0 s in the latency of
25 ms, 84.6 ± 21.3 s in 125 ms, 104.1 ± 24.4 s in 225 ms,
156.5 ± 38.6 s in 425 ms, and 215.1 ± 74.1 s in 625 ms.
Although a longer time was found between 25 and 125 ms,
the difference was not significant (p = 0.247), whereas significant differences in time were found in the other comparisons (Fig. 5a). Additional suturing time measurements
under the latency time of 25, 50, 75, 100, and 125 ms did
not show significant differences in time between any pairs ofsettings (see Fig. S1, Online Resource1). Every suturing wasappropriately performed without any failures. The questionnaires revealed no apparent cut-off in the feeling of delay,
stress, and smoothness of the procedure. In all questionnaires,

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Fig. 5  The suturing time (a) andsurgeons’ answers (b–d) undereach virtual delay setting

43%–57% of surgeons answered moderately delay/stress andpoor smoothness (score ≥ 4) under a delay of 125 ms or less(Fig. 5b–d). This virtual telesurgery study suggested that thelatency time threshold was less than 125 ms.
Then, in the actual telesurgical setting, we performed thegastrectomy in the dry gastrectomy model. The latency timein the dry model surgery was 27 ms, including 25 ms for
information processing and 2 ms for data communication.
Following this dry model surgery, we conducted telesurgical gastrectomy with lymphadenectomy and intracorporeal anastomosis in two porcine models in May 2021, andthe procedures were successfully completed (Figs. 6 and
7). The intraabdominal procedures are presented in theattached video (Supplemental Video). There was no unexpected event, including trauma to adjacent structures suchas the major arteries and pancreas during the operation.
In each case, the actual latency time was also 27 ms, andalmost no fluctuation was observed during the operation.
The local information process delay comprised 25 of the
27 ms of delay. In the two cases, the total operation times
from the skin incision were approximately 173 and 237 min,including console times of 160 and 225 min, respectively.

Fig. 6  D2 nodal dissection in the telesurgical gastrectomy in a porcine model. Division of the left gastroepipoloic artery (LGEA) (a),division of the left gastroepipoloic vein (RGEV) (b), dissection at the
suprapancreatic area and left gastric vein (LGV) (c), division of theleft gastric artery (d), nodal dissection along the proper hepatic artery(PHA) and portal vein (PV) (e), and dissection along the right gastric artery (RGA) (f). CHA, common hepatic artery; PV, portal vein;
PHA, proper hepatic artery; LHA, left hepatic artery13

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Fig. 7  Intracorporeal Billroth-I
anastomosis using linear staplers (a–d)

Although the console surgeon and assistant surgeons at thepatient side communicated smoothly on the leased line, live
room image and voice using Teams™, vital signs of the
porcine, and the real-time three-dimensional illustration,
which were sent on a standard internet connection, reached
the other side later.

Discussion
This study found that the latency time threshold was lessthan 125 ms in telesurgery. In addition, we successfully performed telesurgical porcine gastrectomy with D2 lymphadenectomy and intracorporeal anastomosis using the hinotori
Surgical Robot System and a leased fiber-optic network. The
actual latency time was 27 ms with no fluctuation. To ourknowledge, this is the first report of such a procedure andthe use of this new Japanese surgical robot in the gastroenterology field.
As reported in previous studies, the latency time is critical in telesurgery, and the acceptable upper limit has beenreported as 100–450 ms limit [1, 16–18]. The threshold of
the latency time in the virtual telesurgery study (125 ms) was
within this range. In addition, the latency time of 27 ms inthis study was much better than those reported previously [1,
16–18]. Although it may be difficult to shorten the telecommunication delay further because an optic-fiber is currently
the fastest communication line, it is vital to reduce the delayin the information process, mainly composed of encoding
and decoding the data. The information process delay of
25 ms in this study was shorter than that reported previously (70–126 ms) [1, 2, 8]. This difference could be attributable to the up-to-date information process system including encoder and decoder in the hinotori Surgical System,suggesting that this system is appropriate for telesurgery.

Regarding the telecommunication delay, 1 ms with no fluctuation for one-way was superior to other networks reported
previously [1, 2, 8]. The optic-fiber network is widely andcommercially used across the nation in Japan. Therefore, we
believe that we can theoretically secure a sufficiently shortand stable network delay (nearly 2 ms for the round trip)
under the optic-fiber network even if we perform remote surgery between places separated by longer distances. However,in this study, we sent supplemental data, including the live
room image, vital signs, and the three-dimensional illustration, using a standard internet connection due to the technical limitation, which caused the delay compared to theprimary data using the leased line. As these are essential
information, the system is expected to be updated to send
these data on the same line as the primary data.
This study revealed the feasibility and safety of short-distance telesurgical gastrectomy from a technical standpoint.
Because of technical difficulties, the rate of surgical morbidity in laparoscopic gastrectomy was reported to be lower
in high-volume academic centers than in low-volume community hospitals [9, 19], which may indicate the importanceof not only telesurgery but also surgical training, including
observation and mentoring in community hospitals. Our
telesurgical system enables patients with gastric cancer toundergo high-quality robotic surgery at hospitals near theirhome. In addition, our telesurgical system can provide benefits to surgeons as well as patients. In minimally invasive
surgery, including robotic surgery, in which all participants
share the same operative screen, telestration with an audio
system and augmented reality (AR) has been applied [20],and its usefulness in improving learning effects on surgical
techniques was reported [21]. In addition, AR mentoringwith three-dimensional instructions reportedly facilitated thesurgical learning effects [22]. Also, telementoring in humanlaparoscopic colectomy with the fifth-generation wireless

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network has already been reported, and it was safely performed with 146 to 202 ms of latency [7]. The latency of
our telesurgical platform is well below those values, whichindicates our system is applicable for such telementoring.
Furthermore, our system enables experts to join the actual
surgery if needed as well as give advice, which could guarantee the operative safety, although ethical, legal, and financial issues should be reconciled [23].
Although two RCTs recently showed benefits in short-term
outcomes of robotic gastrectomy over laparoscopic approach[24, 25] and we also reported the oncological benefit ofrobotic gastrectomy [26], the benefits of robotic gastrectomy
over conventional laparoscopic approach are not established.
Most studies considered the higher cost of surgical robots
problematic [27]. Despite this situation, many companies
have accelerated the development of surgical robots, indicating that massive surgical data obtained from robotic surgery
attracts developers. The short-distance telesurgery system inthe present study can efficiently collect such large data, which
could be transformed into surgical intelligence using artificial
intelligence, leading to advanced surgical training and subsequent improvements of surgical outcomes and cost-efficiency.
Since 2019, the pandemic caused by the SARS-CoV-2
virus has limited our free movement, and the importance of
remote outpatient clinics and prescriptions has been emphasized [28]. Therefore, the development of this telemedicine
system, which features a telesurgical system, has the potential
to play an important role in the near future after the pandemic.
Furthermore, considering cost-effectiveness and sustainability,
this telemedicine system could provide better efficacy even in
the short-distance setting, such as that in this study (30 km),than in long-distance settings such as transcontinental surgery.
This study had several limitations. First, 125 ms of threshold of the latency found in this study might be specific inthis system and cannot be treated as a general value. It isneeded to re-assess in other surgical robots and transmission
system. Second, this was a preclinical study using a porcine
model, and thus, validation in humans is needed. Third, we
did not establish metrics because this was a pilot study. Further research under several patterns of distance and type ofprocedures is required.
In conclusion, this study found that the latency time
threshold was less than 125 ms in telesurgery using thehinotori Surgical Robot System. Meanwhile, this study represents the first case of telesurgical gastrectomy with D2
lymphadenectomy and intracorporeal anastomosis in a porcine model and the first use of the hinotori Surgical Systemin the gastroenterology field. Our telesurgical platform using
this surgical robot and a leased optic-fiber network is feasible and safe.
Supplementary Information The online version contains supplementary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00423-0​ 22-0​ 2710-6.

13Langenbeck's Archives of Surgery (2022) 407:3783–3791
Acknowledgements We gratefully acknowledge Yusuke Oi of Sysmex
Corporation (Kobe, Japan) for the contribution to this study.
Authors’ contributions Masaya Nakauchi, Koichi Suda, and Ichiro
Uyama substantially contributed to the study conceptualization.
Masaya Nakauchi, Koichi Suda, Tsuyoshi Tanaka, Susumu Shibasaki,
Kazuki Inaba, Tatsuhiko Harada, Masanao Ohashi, Masayuki Ohigashi, Hiroaki Kitatsuji, Shingo Akimoto, Kenji Kikuchi, and Ichiro
Uyama contributed to data acquisition. Masaya Nakauchi, Koichi Suda,
Masanao Ohashi, and Ichiro Uyama contributed to data analysis andinterpretation. Masaya Nakauchi drafted the original manuscript. All
the authors reviewed the manuscript draft and revised it critically on
intellectual content. All the authors approved the final version of themanuscript to be published.

Declarations
Competing interests Tsuyoshi Tanaka and Ichiro Uyama belong to anendowed chair by Medicaroid Inc. Koichi Suda was funded by Sysmex, Co. in relation to the Collaborative Laboratory for Research andDevelopment in Advanced Surgical Intelligence, Fujita Health University. Koichi Suda has served on advisory boards for Medicaroid Inc.
Ichiro Uyama has served on advisory boards for Intuitive Surgical Inc.
and has received lecture fees from Intuitive Surgical Inc. and Medicaroid Inc. Masaya Nakauchi, Kenichi Nakamura, Susumu Shibasaki,
Kazuki Inaba, Tatsuhiko Harada, Masanao Ohashi, Masayuki Ohigashi,
Hiroaki Kitatsuji, Shingo Akimoto, and Kenji Kikuchi have no relevant
or material financial interests to disclose.
Conflict of interest There is no funding support to be disclosed in thisstudy. Tsuyoshi Tanaka and Ichiro Uyama belong to an endowed chair
by Medicaroid Inc. Koichi Suda was funded by Sysmex, Co. in relation to the Collaborative Laboratory for Research and Development inAdvanced Surgical Intelligence, Fujita Health University. Koichi Suda
has served on advisory boards for Medicaroid Inc. Ichiro Uyama hasserved on advisory boards for Intuitive Surgical Inc. and has received
lecture fees from Intuitive Surgical Inc. and Medicaroid Inc. Masaya
Nakauchi, Kenichi Nakamura, Susumu Shibasaki, Kazuki Inaba, Tatsuhiko Harada, Masanao Ohashi, Masayuki Ohigashi, Hiroaki Kitatsuji, Shingo Akimoto, and Kenji Kikuchi have no relevant or material
financial interests to disclose.

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