Remote robot-assisted surgery raises liability questions

In a world-first, surgeons in Dundee and Florida have successfully performed remote stroke surgery using robotic technology: a significant development that could redefine emergency care for millions.  

Professor Iris Grunwald, consultant diagnostic and interventional neuroradiologist, performed a mechanical thrombectomy on a human body which had been donated to science. The procedure uses catheters and wires to remove blood clots on the brain after a stroke. Traditionally, a surgeon would be situated in the operating theatre with the patient, but in this procedure Professor Grunwald operated from Ninewells Hospital in Dundee on the cadaver located in a university facility across the city.  

Hours later, neurosurgeon Dr Ricardo Hanel used the same technology to perform a similar procedure from his location over 4,000 miles away in Florida.  

The procedures used robotics from Lithuanian firm, Sentante, to mimic the surgeons’ movements, who were guided by live X-ray imaging and ultra-low latency connectivity supported by tech companies, Nvidia and Ericsson. 

How robotic stroke surgery works 

An ischaemic stroke occurs when a blood clot blocks an artery supplying the brain. A common treatment is a thrombectomy, where a specialist threads a catheter through an artery (often from the groin) up to the brain to physically remove the clot.

In the robotic setup:

• A patient is admitted to a local hospital for surgery.
• At the local hospital, a robotic arm is connected to the same catheters and wires a surgeon would normally use.
• A local medic attaches the wires to the patient.
• The hospital is connected to the remote surgeon at another location.
• The remote surgeon uses instruments in their hospital, and the robot replicates those movements precisely in real time on the patient at the other hospital.
• The procedure is monitored via live imaging, allowing the remote surgeon to guide the catheter and remove the clot as if they were physically present. 

This innovation could greatly improve access to stroke care, especially in rural or under-served areas where there may be fewer specialists. Further, every minute counts in stroke treatment, and this technology could eliminate delays that can cost lives. It could also reduce the burden on overstretched healthcare systems. 

Legal questions in a robotic world

Professor Grunwald described the procedure as “the first glimpse of the future”. But it brings with it a series of legal and ethical questions.

As we move toward clinical trials and live patient procedures, key concerns will include: 

1. If something goes wrong, who will be liable? 

• Is it the remote surgeon, the local team, the hospital, or the robot manufacturer?
• What if harm results from a connectivity issue, software glitch or mechanical fault? 

2. How do we prove causation?

• In traditional surgery, causation is linked to a surgeon’s direct action or inaction.
• In robotic procedures, responsibility may be distributed across multiple actors, including hardware, software, and network providers.
• If a patient suffers harm, how do we trace the source of the error in a system involving real-time data transmission, robotics, and human oversight? 

 3. What regulatory and legal frameworks apply? 

• With a patient in one country, a surgeon in another, the robot manufacturer and software provider elsewhere, which legal framework would apply? 

A call for thoughtful regulation

Careful thought will need to be given to regulation. Policymakers, insurers, and medical bodies will need to work together to: 

• Define clear liability protocols for robotic procedures. 
• Ensure transparency in robotic system performance and decision-making. 
• Develop cross-border standards for remote surgery and patient safety.

Conclusion

Whilst the Dundee experiment is a triumph of science, connectivity, and vision, it also raises considerable questions about patient safety, consent and liability. Patient safety must always be at the heart of technological advances, and clear liability protocols would help to resolve any questions arising from these internationally connected medical devices. It is important for innovators to work hand in hand with regulators to ensure that both patient safety and innovation are given the importance that is due.