Objective  To explore the practical application, challenges, and potential advantages of remote surgical robots for complex grade IV procedures such as liver cancer surgery.

Methods  This study retrospectively analyzed all cases of remote robotic-assisted liver cancer surgeries conducted under supervision at Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, between August 2024 and July 2025. A total of three cases were included, all performed using the remote four-arm laparoscopic robotic system. The surgeries were carried out across different distances: intercity (from Hangzhou, Zhejiang to Jiangshan, Zhejiang; Case 1), interprovincial (from Hangzhou, Zhejiang to Alar, Xinjiang; Case 2), and international (from Strasbourg, France to Hangzhou, Zhejiang; Case 3). These scenarios encompassed three distinct geographical and network conditions, preliminarily validating the clinical feasibility of this system in assisting with liver cancer surgeries across diverse environments. All three patients were male, aged 52-80 years, with a body mass index range of 21.3-26.2 kg/m². Preoperative diagnoses were malignant tumor of the right liver, diffuse regenerative nodules with elevated alpha-fetoprotein (AFP) (with one suspicious malignant nodule), and recurrent malignant tumor in segment II of the left liver. The procedures performed included robotic right hemihepatectomy with cholecystectomy, robotic partial hepatectomy, and robotic left lateral lobectomy with adhesiolysis.

Results The operative times for the three cases were 200, 282, and 160 minutes, with intraoperative blood loss of 100, 50 mL, and 20 mL, respectively. No significant lag or delay occurred during the procedures. All three patients developed Clavien-Dindo grade Ⅱ complications (hypoproteinemia), which remained manageable and improved after symptomatic treatment. Postoperative hospital stays were 8, 8, and 6 days, respectively. Postoperative pathological examination revealed hepatocellular carcinoma in Cases 1 and 3 and a cirrhotic regenerative nodule in Case 2. As of August 2025, none of the three patients reported discomfort, and follow-up examinations showed no major abnormalities.

Conclusions This preliminary study demonstrated that remote surgical robots were feasible and safe for using during complex procedures such as liver cancer surgeries. Remote surgical robots are a potential tool for optimizing the allocation of high-quality medical resources, enhancing the diagnostic and treatment capabilities of grassroots hospitals, and fostering international collaboration in remote healthcare.