Telepresence-Assisted Robotic Common Bile Duct Exploration Using the da Vinci 5 Platform: A Novel Application of Real-Time Intraoperative Telementoring

Surgery has long been a craft of hands-on training, where a surgeon learns by watching a master, then practicing under close supervision until the skills become second nature. This is especially true for complex procedures involving the body's plumbing, such as the bile ducts that carry digestive fluids from the liver to the intestine. When a patient has gallstones, the standard operation is to remove the gallbladder. However, if a stone has slipped into the main bile duct, the situation becomes more complicated. Traditionally, surgeons might stop the operation and refer the patient for a separate procedure later to clear the duct, or they might attempt to remove the stone immediately if they have the specific expertise to do so. Doing it all in one session is often better for the patient, reducing hospital stays and the risks of multiple anesthetics, but it requires a high level of technical skill that not every surgeon possesses yet.

In a recent report, a team at the Mayo Clinic described a new way to bridge that gap between a surgeon's current skill level and the expertise needed to handle a difficult stone. They utilized a fourth-generation robotic surgical system, a machine that allows a surgeon to operate with tiny, precise instruments through small incisions while viewing a magnified, three-dimensional image of the inside of the body. This specific robot, known as the da Vinci 5, includes a built-in feature that lets a remote expert join the operation in real time. This is not just a video call; the expert sees exactly what the operating surgeon sees, including the live video from inside the patient and any X-ray images being taken, all on the same screen. This allows the expert to guide the surgeon's hands and decisions without ever stepping into the operating room.

The story began with a patient in their fifties who arrived at the emergency room with severe abdominal pain caused by gallstones. The medical team planned to remove the gallbladder using the robotic system. As is standard practice, they took a special X-ray picture of the bile ducts during the surgery to check for hidden stones. The image revealed a blockage: a stone was lodged in the lower part of the main bile duct, preventing fluid from flowing freely. The surgeon performing the operation had experience with the robotic system and had done similar procedures before, but this specific type of stone removal was a skill they were still mastering. Faced with the stone, the surgeon had a choice: stop the surgery and send the patient for a separate procedure later, or try to remove the stone right then and there with help.

Instead of stopping, the surgeon activated the robot's built-in connection to a remote expert who was highly skilled in removing these stones. The two surgeons connected through a secure digital link. A key part of this setup was a picture-in-picture display. On the surgeon's console, the main view showed the inside of the patient's body, while a smaller window displayed the live X-ray image of the bile duct. Crucially, the remote expert saw this exact same combined view. This meant the expert could see the stone's location on the X-ray and immediately understand how it related to the physical anatomy the surgeon was looking at, without needing to switch between different screens or describe the image in confusing words.

For nineteen minutes, the two surgeons worked together. The remote expert provided only verbal guidance, talking the operating surgeon through each step. They discussed the best way to approach the stone, and the operating surgeon followed instructions to gently flush the duct, pass a tiny wire through the blockage, and use a small balloon to widen the opening slightly so the stone could pass. The expert watched the X-ray and the surgical view simultaneously, confirming that the stone was moving and that the duct was clearing. Once the stone was gone, they took another X-ray to confirm the duct was completely clear. The stone had been removed successfully during the first operation, and the gallbladder was then removed as planned.

The entire connection lasted just nineteen minutes, and the total time for the surgery was two hours and fourteen minutes. The patient woke up without complications and was sent home the same day. No further procedures were needed. The report highlights that the success of this case relied heavily on the ability of the remote expert to see the X-ray and the surgical view at the same time. In the past, remote guidance often required the expert to look at a separate screen or rely on the surgeon to describe what they saw, which could be slow and prone to misunderstanding. By integrating the X-ray directly into the surgeon's view and streaming that combined image to the expert, the team removed the barrier of distance and visual confusion.

This single case suggests that this technology can make complex, single-session surgeries accessible to surgeons who are still building their confidence. It allows an expert to be present for the critical moments of decision-making without needing to travel. While the authors note that more study is needed to confirm how well this works across many different hospitals and surgeons, the result here was clear: a patient who might have faced two separate procedures and a longer recovery received a complete solution in one operation, guided by a remote expert who could see everything the surgeon saw. This approach offers a promising path for expanding high-quality surgical care to more patients, regardless of where they are located or how experienced their local surgeon is with a specific technique.