An estimated 160 million additional surgical procedures are required annually to address unmet surgical need globally, with the greatest deficits occurring in low- and middle-income countries. While telesurgery has re-emerged as a feasible model for delivering remote operative expertise, its broader implementation remains constrained by unresolved technical, ethical, regulatory, educational, and governance challenges. We aimed to develop an international multidisciplinary consensus framework to guide the safe, equitable, and scalable implementation of telesurgery and remote surgical education. A Society of Robotic Surgery (SRS)-supported accelerated Delphi consensus process was conducted between February and March 2026. Candidate statements were generated through a comprehensive literature review and refined by a multidisciplinary working group of clinicians, engineers, industry representatives, regulators, and healthcare leaders who convened at a telesurgery conference in Orlando, in February 2026. A three-round electronic Delphi survey was performed using a 7-point Likert scale across nine predefined domains: (1) Global Need, Ethics & Humanitarian Rationale; (2) Technical Infrastructure, Connectivity & Network Performance; (3) Cybersecurity & Data Protection; (4) Surgeon Credentialing, Training & Skill Maintenance; (5) Safety Protocols, Human Factors & Team Dynamics; (6) Clinical Indications, Case Selection & Procedural Scope; (7) Regulatory, Legal, Licensure & Liability; (8) Economics, Administration & Reimbursement; and (9) Industry Responsibilities, Research & Global Roadmap. Consensus was predefined as ≥ 80% agreement (Likert scores 5-7). A total of 153 international experts participated in Round 1, including surgeons, engineers, industry representatives, hospital administrators, and regulatory stakeholders. Participant retention was 79.1% from Round 1 to Round 2 and 90.1% from Round 2 to Round 3. Of 86 core recommendation statements, 83 (96.6%) achieved consensus after three rounds. Consensus was strongest in cybersecurity, safety protocols, clinical indications, regulatory governance, economics, and industry responsibilities, where all statements reached agreement. Three statements failed to achieve consensus, relating to procedure-specific latency thresholds, dual-site credentialing requirements, and telesurgery as a preferred intervention when alternative treatments are available. Four additional terminology statements defining telesurgery, tele-mentoring, tele-proctoring, and tele-preceptoring achieved consensus after a single Delphi round, providing provisional standardized definitions for the field. To our knowledge, this is among the first multidisciplinary consensus frameworks to integrate clinical implementation, remote surgical education, cybersecurity, regulation, economics, and governance within a single Delphi exercise. The findings position telesurgery not only as a model for remote operative care but also as a platform for global surgical education, mentorship, workforce development, and equitable access to expertise. The framework provides a foundation for specialty society guidance, institutional implementation, regulatory development, and future international research.
This framework from the Society of Robotic Surgery offers best practices for safe, effective, and ethical telesurgery. It is based on a comprehensive literature review, Delphi consensus process, and an international meeting in Orlando, Florida, in February 2024, involving experts from a variety of domains including surgery, engineering, telecommunications, hospital administration, law, and regulatory affairs. Key areas covered include the global landscape and new models of remote surgical care, technological needs like connectivity and cybersecurity, safety standards, training and credentialing for surgical teams, and scalable implementation models. It also addresses legal and ethical issues, clinical indications, and regional and international regulatory comparisons. This framework aims to be a key reference for institutions, surgical societies, policymakers, and technology developers to promote safe, equitable, and sustainable telesurgery worldwide.