BITS: A Blockchain-driven Intelligent Scheme for

Telesurgery System
Rajesh Gupta, Student Member, IEEE∗ , Urvish Thakker† , Sudeep Tanwar, Member, IEEE‡ ,
Mohammad S. Obaidat, Fellow of IEEE and Fellow of SCS§ , Kuei-Fang Hsiao¶
∗†‡ Department of Computer Science and Engineering, Institute of Technology, Nirma University, Ahmedabad, Gujarat, India
§ Collegeof Computing and Information, University of Sharjah, UAE, King Abdullah II School of IT,
University of Jordan, Jordan, University of Science and Technology Beijing, China.
¶ Department of Information Systems, University of Sharjah, UAE and Department of Information Management,

Ming Chuan University, Taiwan

Email: ∗ 18ftvphde31@nirmauni.ac.in, † 17bit115@nirmauni.ac.in, ‡ sudeep.tanwar@nirmauni.ac.in,
§ m.s.obaidat@ieee.org, ¶ kfhsiao@gmail.com

Abstract—Intelligent Telesurgery (TS) system with 6G-enabled
Tactile Internet (TI) based on the blockchain has tremendous po-
tential to deliver real-time and intelligent ultra-responsive health-
care services remotely with high quality and reliability. It would
be significantly beneficial for the society in the prospect that high-
quality medical service could be delivered to deprived areas and
a highly promising surgical diagnosis could be achieved. However,
the state-of-the-art TS systems have security, privacy, reliability,
latency, and high-cost blockchain-based storage concerns, which
limit the applicability of TS in surgical operations across the globe
in the near future. To mitigate the aforementioned issues, we in this
paper propose a novel approach named BITS an intelligent and
blockchain-based TS framework. The issues pertaining to security,
privacy, and lack of trust could be resolved through employing
a smart contract. The issues related to the cost of data storage
could be resolved by employing the InterPlanetary File System
(IPFS) protocol. Moreover, we incorporate Artificial Intelligent (AI)
algorithms for training of surgical robots. The proposed scheme
also prevents the execution of malicious commands transmitted
by an intruder to a great extent. The 6G communication channel
significantly mitigates the latency issues in exchanging surgical
commands. Finally, we highlight some issues of the state-of-art TS
systems and how the proposed BITS will be beneficial to combat
those issues.
Index Terms—Blockchain, Healthcare 5.0, Security, Privacy,
Anonymity, Telesurgery, Artificial Intelligence.
I. I NTRODUCTION
Healthcare is a paramount factor in discerning the quality of
living standards for a particular region or country. Healthcare
industry is an aggregate and incorporation of industries within
the economic structure that offers products and services for
therapeutic, preventive, curative, rehabilitative, and palliative
treatments of patients. An efficacious healthcare structure may
lead to a noteworthy contribution to overall growth, a burgeon-
ing of the nation, and bolster the country’s economy. Access
to accessible, and reliable healthcare facilities are essential for
health promotion and sustainability. Disease prevention and
control, mitigation of trivial impairment and premature death,
and accomplishing health equity among all citizens are prime
concern for any country. Healthcare industry has witnessed
various revolutions such as 1.0 to 5.0 [1], [2]. Healthcare
1.0 consisted of maintaining physical manual records for data
related to the patient and was considered to be surgeon centric.
However, in Healthcare 2.0, the manual records were restored by
electronic records and were sought after as technology-centric.
It is worthy to note that Healthcare 3.0 was patient-oriented,
but was incompetent to manage real-time large scale data while
Healthcare 4.0 was able to overcome the disadvantages of prece-
dent revolutions. Healthcare 4.0 employed Electronic Health
Record (EHR) to store patients data and envisions wearable
devices to track and monitor patients unrelated to the location of
patients [3]. However, the exigent need for intelligent healthcare
systems resulted in Healthcare 5.0. Artificial Intelligence (AI)
and Automation are at the pith of healthcare 5.0 [2]. In the
present era, the healthcare industry is focusing on the develop-
ment of smart and intelligent healthcare equipment. Moreover
automating the mundane surgeries which might compensate
for the dearth of quality doctors faced today. It also aims at
enhancing the reliability of such automation procedures.
Conventional treatment procedures were manual, so patients
ought to reach the hospital and address their health compli-
cations with surgeons. It would be a quite expensive, intri-
cate, and time-consuming procedure. Subsequently, the pro-
liferation of communication technologies enabled surgeons to
proliferate their services remotely in a newfangled manner
called telemedicine [4]. It has been sufficient to be efficient
in extending the reach of dexterous healthcare treatment to
remote areas, incorporating remote management of specialized
care units, and facilitating services to international patients
[5][4]. The most intrigued applications forte in the domain of
telemedicine is Telesurgery (TS) [6]. It is a procedure in which
the doctor can perform medical operations from a distant place
employing a robotic arm controlled by the doctor sitting in the
operating room. It enables doctors and clinical practitioners to
facilitate real-time surgical procedures remotely over wireless
communication channels (WCC) and with the aid of surgical
robots. It mitigates the long-distance traveling time, expenses
associated, and compensates for the lack of quality surgeons
to perform surgeries [7]. It pledges to enable the skills of
sophisticated surgeons to be accessible to patients globally,
especially in underprivileged areas; obviating the need for
patients to transit beyond their local hospital. This is precisely
beneficial in scenarios when the condition of the patient is
critical and the transfer of patients may have its own adverse
effects. Furthermore, facilitating systematic medical care to the
mobile military troops can be facilitated through employing
TS. However, issues related to latency of the network, i.e.

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the delay in the communication medium, which affects the
time-lag between the doctor’s movement and its appearance on
the dashboard, the chances of cyber attack over the network
and leakage of sensitive information due to hacking or other
unethical practices are prevalent challenges in the real-life im-
plementation of TS. Also, the cost of setting up the infrastructure
for enabling TS is a major area of concern, especially for the
developing nations [8].
In TS systems, both patients and doctors are at distinct
places connected through a public network, which leads to
many security risks. As TS is a safety-critical application, where
security attacks might result in loss of patient’s life. Thus,
security and robustness are important aspects of the TS system,
as they ensure protection against probable security attacks.
Many authors across the globe have presented TS systems such
as Lee et al. [9] proposed a secure Interoperable Telesurgery
Protocol (ITP) to meet the security requirements of TS systems.
They defined their framework for communication among the
TS robots and surgeons controls the same. An open-source
software tools were employed to develop the secure ITP. Fekri
et al. [10] proposed a novel approach to enhance security
in TS system by employing Deep Learning (DL) techniques.
The commands given by the surgeons were used to train the
DL model, which then used to differentiate the instructions
given by a surgeon or malicious intruder [11]. Their proposed
novel approach enabled the protection against probable security
attacks on the TS operations. Iqbal et al. [12] presented a system
called SecureSurgiNET to ensure security and reliability of TS
operations. Their system employed various full-proof reliable
communication protocols. Also, telesurgical authority, database
server, and identity management server were incorporated in the
system to enhance the efficiency and security of TS environ-
ment. However, the present solutions were inadequate owing to
lack of trust in the system, lack of privacy, and security concerns
for sensitive information related to the patients. Furthermore,
the solutions are based on centralized architectures which may
lead to misuse of power by central authorities. Thus, there is
an exigent need for more efficient and reliable solutions for TS
procedure.
The adoption of blockchain technologies is a feasible solution
to the aforementioned challenges of conventional healthcare TS
framework. It is a distributed ledger, i.e., a sequence (chain)
of blocks that preserves transactions and keeps them safe. It
ameliorates the maintenance costs and enhances the consistency
and security of the information. This has various benefits in
healthcare systems over conventional such as seamless inter-
operability, quicker exchange of records, catastrophe recovery,
error tolerance, immutability of data, traceability, cost-effective,
prompt access to data, and data protection [13]. Gupta et al.
[14] proposed a blockchain-based TS system named HaBiTs,
employed a private blockchain network. It facilitates only vali-
dated users to access information from the blockchain network,
which ensures the security of patients personal health records.
The data in a block cannot be altered once written due to
bolckchain’s immutability characteristics. If one block is altered,
then all subsequent blocks becomes invalid. It is relatively easy
to track who tried to manipulate a particular block’s information.
However, the HaBiTs framework uses a 5G network which
has the end-to-end delay of < 5ms that is not suitable for
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complex surgeries, where multiple surgeons are involved and
can cause the death of a patient. Thus, there is latency, reliability,
and interoperability (due to private blockchain) concerns in the
HaBiTs framework.
To combat the issues prevalent in the present solutions of TS
systems, we propose BITS framework, which employs 6G as a
communication medium and incorporates Artificial Intelligent
(AI) algorithms in the TS procedure to predict the disease
pattern. If the system gets hacked and manipulated by the
malicious user, the AI-based algorithms facilitate to identify
the commands which might be generated by such intruder and
stop the further execution of the same. In addition to AI, we
incorporate 6G as a communication medium that mitigates the
time lag between the doctor’s movement and its execution by the
robotic arm significantly ( probably less than 1 microsecond).
Thus, BITS framework is capable to combat the challenges of
the state-of-the-art TS systems.
A. Research Contributions
Major contributions of the paper are as follows:
• We highlight various security, privacy, and communication
challenges of the state-of-the-art telesurgery systems.
• We present BITS, a blockchain-based intelligent and effi-
cient scheme for the telesurgery system.
• Finally, we present how the aforementioned security, pri-
vacy, and communication challenges of the state-of-the-art
systems can be eradicated with the proposed BITS scheme.
B. Organization
Rest of the paper is organized as follows. Section II describes
the system model and the mathematical framework of the BITS.
Section III describes the proposed blockchain and AI-based TS
system called BITS. In Section IV, we evaluate the performance
of BITS. Finally, Section V concludes the paper.
II. S YSTEM M ODEL AND P ROBLEM F ORMULATION
Fig. 1 shows the blockchain-envisioned AI-focused intelligent
TS system called BITS, which consists of various remote entities
such as surgeon/doctor, patient, caregiver, and healthcare center.
All the remote entities in BITS are communicating with each
other via Ethereum blockchain network after satisfying the
smart contract conditions over the 6G communication channel.
Blockchain maintains the coherence between the entities during
the surgical procedures for the betterment of its result, whereas
6G enhances the network performance parameters such as
latency (10 − 100µsec) and reliability (99.99999%). BITS
Control Commands
Robot Training Robot Testing
Surgeon Smart Smart Patient
Contract Contract
Haptic Feedback
Fig. 1: BITS system model.
considers the entity set {ξD , ξP , ξH , ξC } ∈ ξ, where ξD is a
doctor entity, which comprises of same specialization multiple with facilitating qualitative healthcare services and enhances
1 2 n
doctors {ξD , ξD , . . . ξD }, entity ξP is a group of m patients the efficacy of the system by employing the InterPlanetary
1 2 m
{ξP , ξP , . . . ξP }. Both ξD i
and ξPj need to tie up with the File System (IPFS) protocol for storing of data. The various
1 2 h
specialized hospitals {ξH , ξH , . . . ξH } ∈ ξH for their surgical components that have been incorporated in the presented BITS
k 1 t c
procedures. Each ξH has t caregivers {ξC , . . . ξC . . . ξC , } for framework have been discussed in subsequent subsections. Fig.
taking care of the patients. The relation between ξD , ξP , ξH , ξC 2 depicts the proposed architecture of the BITS framework for
entities are subject to the following constraints. TS procedure.
{m, j} ≥ 0 (1) 3D Video Monitor Audio, Video, Velocity, Force Feedback
Slave HD

{h, i, n, k, c, t} > 0 (2) Controller Camera

Slave
Sensors
, ξPj , ξC
i t k Manipulator
∀{ξD } ∈ ξH (3) Surgeon
SC
Patient
SC Video Compressor

th
Any i doctor i
ξD operates over ξPj
in an hospital A k
ξD . i
ξD Position
Sensor Base Base
Haptic
Feedback
Station Station
can operate multiple surgeries over different ξP . Thus, ξD and Patient
Feedback
ξP have one-to-many (1:m) relationship, i.e., F(ξD → ξP )1:m , Self-Observation
Surgical Videos
likewise each ξD is tied up with diverse ξH for their surgical Manual Data Feed
Simulations
procedures, i.e., F(ξD → ξH )1:h . However, one ξP must be Reinforcement Tech.
Demonstrations

associated with only one ξH for treatment, i.e., F(ξP → ξH )1:1 .
All entities ξD , ξP , ξH , and ξC can communicate with each
other via blockchain (BEtherium ) network to preserve the
security and privacy of the TS system for its smooth execution.
Each block (B) of an BEtherium consists of the following
components.
Curr P rev
B= {BHash , BHash ,N,T , BN o. , BV er , MRoot }
Curr P rev
where BHash and BHashare the hash values of the current
and the previous blocks, N is the nonce value, T is the
block timestamp, BN o. is the block number, BV er is the block
version, and MRoot signifies the merkle root value. Each entity
associated with the BEtherium network can have their respective
wallets {ωD , ωP , ωH , ωC } ∈ ω for communication. Each ωl can
have the following fields.
ωl = {KP rivate , KP ublic , %, Tω , GV al , Mω
Root }
where KP rivate and KP ublic are the private-public key pairs of
the ξ for secure communication, % is the hash value of the data,
Tω is the wallet timestamp of an ξ, GV al is the total gas value
of the ξ, and Mω Root is the merkle root of the ω. All these
communication can be executed over the 6G communication
channel to improvise the network performance parameters for
the TS procedure. The properties of the 6G communication
channel are as follows in comparison to the other 4G and 5G
communication channels.
L6G (< 100µsec) ≪ L5G (< 1ms) ≪ L4G (< 20ms)
R6G (99.99999%) ≫ R5G (99.999%) ≫ R4G
In view of all the communication and security parameters
mentioned above, the goal of BITS is represented as follows.
O = max(T S{Accuracy,Reliability} , P atientSecurity
M edical Data ,
ωSecurity ) + min(LCommunication , T SErrors ) (8)
III. P ROPOSED A PPROACH
The subsequent section describes the functioning of BITS,
a blockchain-based secure TS architecture. BITS is a secure
TS framework built on a public blockchain and employing
the Ethereum platform. It is secure and obviates the need for
involvement of intermediaries to build trust among the patients
and surgeons. It also mitigates the conveyance cost associated
Surgeon HSI
Trained Robotic
Arms
Surgeon Layer Transmission and Training Layer Patient Layer
Fig. 2: The proposed architecture of BITS [14], [15]
A. Supervision and Controller Layer
The supervision and controller layer consists of surgeons who
(4) monitor the TS procedure and have an active involvement in
it. Surgeons controls and supervise the robots actions occurred
at patient layer during the TS procedure is via Human System
Interface (HSI). The 6G-enabled Tactile Internet communication
medium is employed to facilitate the transmission of commands
through HSI from surgeons to robots. To ensure the trust
between various entities involved in TS, (i.e., surgeon, patient,
and caregivers) and coordinate the commands a digital Smart
Contract (SC) needs to be enforced among them [16]. The
(5) SC ensures the integrity and reliability of the TS procedure.
Various components of supervision and controller layer that
aid in the TS procedure includes a master controller, proximity
sensors, foot paddle, haptic devices, master controller, 3D tissue
monitoring, video decompressor, microphone, and speakers.
Surgeons can communicate with SC for TS requesting and
initiating via Ethereum clients. Patients approve proposals from
the surgeons based on their present reviews of results provided
by the previous patients [17]. During the submission approved
by the patient, the surgeons can activate the TS procedure (S-
State = Active) and update the IPFS-storage record of patients.
(6) After completion of the TS process, the S-state is updated
to Completed status. Post surgical procedure, the patients are
(7)
entitled to review the surgeon based on their functioning.
B. Communication Layer
This layer facilitates the communication between the surgeon
at the supervision and controller layer and robot at the patient
layer of the BITS for transmission of commands and data. BITS
employs WCC as 6G-enabled TI for facilitating secure and
reliable, real-time transmission of the procedural commands.
Furthermore, it is worthy to note that AI-based intelligent
services such as 3D Tissue tracking and kinematic modeling
are embedded in the system employing machine learning and
computer vision algorithms []. Moreover, as the SCs are over
the public blockchain and shared between various entities, the
maim of the TS framework is to secure the SCs as well. IPFS,

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6G-enabled TI, and ESC are some prime components of the
communication layer.
IPFS Protocol: The conventional blockchain frameworks di-
rectly store the data in the blockchain, which can be significantly
costly, i.e., about 550 USD for 1MB of data. IPFS is an im-
mutable and distributed protocol that would be ideal for solving
the aforementioned issue as there are no charges associated with
storing data in it. Also, it is worthy to note that it is distributed
and has no single point of failure [18]. It also accelerates the
procedure of downloading by hosting the portion of the data
to other peers utilizing minimum bandwidth. Moreover, it also
prevents replication of data as it renders the same hash value
for the same data.
The above-elicited reasons are the driving force to employ
IPFS protocol, a peer-to-peer distributed protocol in BITS
framework. Moreover, it strives to deliver high-performance
throughput and low data latency in access. Data is stored
in blocks of a specific size, that constitute a generic Merkle
structure of the directed acyclic graph when IPFS protocol is
employed for storing of data. When a file is stored in IPFS, a
hash key is rendered and transmitted to the associated entity.
Also, the hash key can be used when we want to access data
through the IPFS gateway. In this manner, traceability in BITS is
beneficial in spotting the loop-hole in the system in case some
issue arises.
Algorithm 1 AI-enabled procedure for robot training.
Input: κ is the number of data entries in the training dataset Υ with maximum N entries,
ΥV id and ΥImg are the multimedia datasets for robot training, ΥDoc Exp is the manual
information feed by the surgeons
Output: Robot training.
procedure ROBOT T RAINING(κ, ΥV id , ΥImg , ΥDoc Exp )
while TRUE do . Loop for surgical robot training.
if (Υ is NULL) then
Return (”Enter data feed for robot training”);
else if (κ > N) then
Stop Training (Surgical Robot);
Ready for testing data;
else
κ = κ + 1;
Apply CNN(”Training using multimedia data”)
Fetch Next Record (ρ, κ); . ρ is record.
Continue;
end if
Surgical robot is fully trained for the surgery.
end while
end procedure
C. Training Layer
The Training layer embeds the AI algorithms employed to
accomplish tasks such as kinematic modeling and cooperative
modeling. Moreover, the sensors data is aggregated here to
facilitate the surgeon at supervision and controller layer with 3D
tissue tracking cooperative controlling. Also, the robots would
be trained using various AI techniques such as reinforcement
learning and DL, so that the overall efficacy of TS procedure
gets enhanced. Training to robots are provided using specialized
TS videos. It also be due to live demonstrations of surgeries
and customized data given as input by the surgeon, as shown in
Algorithm 1. Moreover, the reinforcement learning algorithms
will be employed so that robots learn from their own past
experiences of performing surgeries and owing to it the efficacy
of robot gets enhanced with every surgery it performs. Here,
we propose to use 6G enabled TI network as a communication
medium. However, the communication medium is open, so, the
chances of being hacked is increases. Thus, the commands that
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are transmitted by the surgeon may get altered by the malicious
intruder and if that gets executed, it may prove fatal for the
patient. Thus as it is a safety-critical application, we need to
adhere to the maximum possible levels of security. Thus, we
will employ machine learning and deep learning algorithms
that will be trained on a custom dataset consisting of instances
of commands which are authorized by surgeon and commands
which are malicious in nature. The model after training will be
able to predict whether a command is veritable or is specious,
as shown in Algorithm 2. The integration of the model will
mitigate the chances of execution of malicious commands and
boost the reliability of the system. Thus, with BITS, we propose
a novel smart TS framework based on blockchain.
Algorithm 2 AI-enabled procedure for malicious TS command
detection.
Input: ζ and δ is the number of data entries in the legitimate and non-legitimate training
datasets Υ with maximum M and K entries respectively. ΥLeg Cmd and ΥnLeg Cmd
are the datasets with legitimate and non-legitimate TS commands.
Output: Surgical robot trained with legitimate commands.
procedure M AL C MD D ET(ζ, δ, ΥLeg Cmd , ΥnLeg Cmd )
while True do
if (Υ is NULL) then
Return (”Enter data feed for robot training”);
else
Robot Training (ΥLeg Cmd , ΥnLeg Cmd );
if (ζ > M or δ > K) then
Training Finished (Surgical Robot);
Ready For Test (TS Commands);
else
M = M + 1;
K = K + 1;
Find Optimal Weights (Genetic Algorithm);
Apply Ensemble Learning(Surgical Robot);
Fetch Next Record (ρ0 , ζ, δ);
Continue;
end if
Robot is trained with ΥLeg Cmd and ΥnLeg Cmd
end if
end while
end procedure
D. Patient Layer
It consists of a surgical robot known as a teleoperator that
executes the command provided by the surgeons at the supervi-
sion and controller layer. The surgical robot sends and collects
haptic data in real-time, employing haptic feedback tools. The
various other components, such as haptic devices, HD cameras,
sensors, video compression, and controller, are also incorporated
in the patient layer [19]. Besides the surgical robot, patients and
caregivers also are associated with the patient layer domain. In
BITS, patients are entitled to give feedback, post the completion
of TS procedure. This would aid other patients in choosing
appropriate surgeons based on the feedback data associated with
the surgeon. Moreover, it would be a motivating factor for the
surgeons to perform all the surgeries with adequate enthusiasm.
IV. R ESULTS AND D ISCUSSION
This section discusses the performance evaluation of BITS
using the following performance metrics: latency, throughput,
and storage cost.
A. Latency
Fig. 3a depicts the latency difference between the BITS and
the state-of-the-art approaches called HaBiTs and AaYusH. The
communication channel considered in the BITS as 6G, whereas
4G and 5G were in traditional TS systems. From Fig. 3a, we can
notice that the processing latency in BITS is quite low compared
to the traditional ones.
 (a) Latency in TS instructions processing. (b) Throughput in TS data access.
Fig. 3: Performance evaluation of BITS with parameters latency, throughput, and storage cost.
B. Throughput
Fig. 3b presents the throughput comparison of BITS with the
traditional HaBiTs and AaYusH TS systems. The communication
network deployed in BITS is 6G, which has a latency of
< 100µsec and reliability of 99.99999%, whereas HaBiTs
and AaYusH deployed 4G and 5G communication channels
respectively. From Fig. 3a, we can find out that the throughput
(in bps) in BITS is extremely high compared to the HaBiTs and
AaYusH.
C. Storage Cost
Fig. 3c deals with the comparison of data storage cost of
BITS with respect to the HaBiTs and AaYusH. From the figure,
we depict that the storage cost in HaBiTs is quite high and the
costs of AaYusH and BITS are comparatively same.
V. C ONCLUSION
In this paper, we propose BITS a novel intelligent TS frame-
work based on blockchain to enhance the efficacy of state-of-
art TS systems. We facilitate with comprehensive insights into
the cloud-based and blockchain-based smart TS framework and
highlight the security, reliability, privacy, and high-cost data
storage issues. We present how incorporating AI techniques
could be highly beneficial for the TS system. Moreover, we
propose how blockchain-based data storage employing IPFS
protocol guarantees privacy, reliability, security, and is cost-
effective as it obviates the need for third-party verification.
Furthermore, we emphasize that how 6G enabled network would
improve the present TS system, which uses 5G as a communi-
cation medium by mitigating the delay in the communication
significantly. Then, we also highlight the effectiveness of the
proposed blockchain-based smart TS framework. In the future,
we will implement the proposed framework to identify its
challenges and issues for real-life applications.
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