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.
Background: Procalcitonin (PCT) may support decision-making in abdominal and emergency surgery when infection is difficult to distinguish from non-infectious inflammation. Its interpretation remains challenging because clinical settings, sampling schedules, and proposed thresholds vary. This WSES position paper examines the evidence across six clinical scenarios to provide a practical framework for PCT-informed decision-making. Methods: A structured literature review covering January 1980 to December 2025, with targeted updates through August 2026, informed six PICO-based clinical questions. Evidence appraisal drew on selected GRADE domains, including consistency, directness, and precision. Recommendations were developed through iterative expert review and consensus. Results: The panel formulated six conditional recommendations addressing intra-abdominal infection diagnosis, antibiotic discontinuation after source control, suspected source-control failure, infected pancreatic necrosis, infectious complications after trauma, and postoperative anastomotic leak. The panel's qualitative assessment rated evidence certainty as moderate for antibiotic discontinuation and the pancreatitis domain, and low for the remaining domains. Serial PCT trends may complement clinical assessment in selected patients. Evidence for reduced antibiotic exposure with predefined PCT algorithms is more established than evidence that PCT-informed imaging, reintervention, or discharge decisions improve patient outcomes. Conclusions: PCT-informed decision-making in abdominal surgery may contribute to a more individualized approach to emergency surgical care and precision emergency surgery. When interpreted as part of serial assessment and integrated with clinical judgement, organ-dysfunction trends, microbiology, imaging, and evaluation of source-control adequacy, PCT may support individualized antibiotic discontinuation, potentially earlier recognition of an unfavourable clinical course, and more timely diagnostic and source-control reassessment. Current evidence does not support universal thresholds or routine serial testing in all surgical patients. Biomarker kinetics should strengthen, but not replace, surgical reasoning or independently determine antimicrobial, imaging, or interventional decisions. Future research should validate setting-specific thresholds and sampling schedules, establish whether PCT provides actionable information before clinical deterioration, and evaluate the clinical effects and cost-effectiveness of PCT-informed pathways.