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Good evening everyone. Thank you so much for joining us. Uh This is our first uh webinar series in the robotic assisted surgery uh series. We have got um a weekly uh uh webinar for you over the next six weeks today, we are, our focus is on the CMR versus, and we are really honored to have some distinguished speakers with us who will be live throughout the session. You've got a chat box to your right, please um put your questions into the chat box and hopefully we can answer them at the end of the session. Um I am Lilian Reza, the president of the Dukes Club. I have my VP chat saied with us this evening and Tana Shakir, who is the robotics rep and they will chair the rest of the session. So I will hand you over to them. Thank you. Thanks Lilian. Um So yeah, my name's Tana Shakir. I'm the er robotics rep for this year and thanks everyone for tuning into a, a week, as you said, weekly session. I got some great speakers coming in the future as well. Um But without further ado, let's kick off our first session which is CMR themed. Um, and I'll hand over to Gareth RND, who's the professional education manager for CMR for UK and Ireland. Hi, thank you very much, Taler. Ok. Um, yeah, as Tana says, so I II had a professional education for, um, CMR in UK Ireland. Um, so I'll just take you through a bit of an interruption to, um, what CMR is all about, um, the system and then we'll talk a little bit about uh our training. Um Just a general overview in a, in a sense. And then if you've got any questions, just fire them off towards the end. OK. So hopefully you can all see my screen um just shout if you can't. Um So I'll start with just a bit of an interruption about ourselves. So, who are we? So CMR Cambridge Medical Robotics. So essentially, we're, we're, we're a homegrown UK company based out of Cambridge um where we still really house our base of operations where we still manufacture our robots. Um And actually, we, we do a lot of our training from CMR still as well. OK. Uh It's was set up by a number of key individuals. Uh One was a robotics engineer called um Lucas and the other was a consultant gynecologist from Aden Brooks called Mars Luck. Um And Mark was really asking me a lot of questions about the current um robotics platforms in the market. You know, how can they be better? How can they suit his practice and so on so forth. Um And Luke was largely answering them and together they were able to conceive the, the versus um, and put the, the project into production and, and get it to where it is today. Indeed. Mark SLT is still our chief medical officer. Er, and Luke is still our chief engineer and still very much um run the country from the company, from their position. So just to give you a very brief uh I guess look of our evolution because we're not real at all. I mean, we, we, we were conceived in January 2014. Uh we've had a viable product since September 2018. By 2021 we were a official gold partner of the Paralympics GB. And by 2022 we did over 100 versus uh we've had over 100 versus systems installed globally. So we've had a whirlwind success with the system. Um and where we are today with over 10,000 procedures completed using Verus and we're meeting new milestones all the time. So we really are um we really are having a success with the system. So let's let's meet the system. So let's meet versus so versus for Versatile. Um So I spoke about Mark Lar asking some key questions about surgical robotics and one of his key concerns was that he didn't want to change his current laparoscopic practice. Um And that really fed into the design concept of the system. Um And the strap line that we, we've come to you so much is think laparoscopically operate robotically. So the design concept is around these freestanding modular arms that can move anywhere around the bedside. OK. So they will allow allow you to accommodate your chosen laparoscopic port placements to a large degree and preserve AAA view that you are uh so familiar with. So you're not reinventing the wheel. You're not having to relearn so many nuances about um Surg Cras. It's just fitting in with your existing knowledge and allowing you to do what you already do robotically. Ok. As well as that, it's small, it's really portable. So it's, it's the smallest robot on the market. So the each one of these arms is about 38 by 38 footprint, tiny. So they stow away, they'll fit in with any theater, fit in with any existing equipment. You've just got up to four arms at a console, ok. To manage which means they can go anywhere, ok, allowing robotic surgery to become accessible to more people around the world. So I'll just give you a bit of a, an idea of what that looks like um in the theater you can see here. Another one of the key benefit designs of our system is we have this small um open design console. Ok. So it allows the surgeon to sit well in the room. He's not boxed off, he's right there in the action and he's able to communicate very easily with um the bedside team doing his operation with a big 3d screen, that kind of immerses him in the experience right in front of him. And you can see the arms here. They, they've chosen to do like it was like a left or right hemi. So they're, they've been able to position their arms on one side of the table moving across, freeing up all that space for, for two assistance. So it's slotted in nicely to, to that operating environment. OK. So where are we? So we have this growing install base within the UK. So we're predominantly in the South still kind of radiating out around from the Cambridge. Um But we have a growing presence in the North. Um And I think overall we're up to about 20 systems UK wide. Um Some of those centers are now looking, have a second system and looking to grow. Um So really within the next five years or so you could expect to see a versus in some of the major hospitals within the UK and Ireland. So it'll be something that you as, as you, as you become, as you develop in your career you will inevitably have contact with. So let's have a look at the training then. So our training is robust, it's validated and it's accredited. Ok. We tend to train um teams of individuals. So, so surgeons and support staff we tend to start everybody with a theory. So we have um e-learning that we take everybody through to about 30 ee learning modules for the surgeons. We have our versus training, which is essentially our simulator. So um this forms part of the surgeon's metric based education. So there are 60 modules that the surgeon must pass to qualify. OK. So those modules are looking to assess hand controller efficiency, um hand eye coordination, things like that, that you need to develop to use the hand control as well. In adjunct to that, we also have virtual reality. OK. So we have VR headsets that we can give to our trainees. Um And these VR headsets um basically immersed trainee uh in an environment where they can get used to the versus um anyway, um and also they can perform a lot of their versus train modules on the headset. So a really, really good adjunct to that precourse learning that we offer then uh versus supervised practical training, which is uh in person training and that's conducted over two or three days depending on our uptake. But essentially, we concentrate almost predominantly on the technical nuances of the system. So if you remember that design concept, we're, we're not reinventing the wheel. There's nothing procedural that we really need to teach you. It's just the technical know how of how this system will slot in with our existing knowledge. So that allows us to be quite agile and it allows us to uh avoid having to use things like cadavers and, and, and, and wet labs and such. We can train you on site in your hospital. OK. Using, using simply Averse and a mannequin after that, it's into your environment. So it will be interreceptor first cases. So we would have a, a short dry run just a practice before we got into that. Essentially. Then you'd have your surgical preceptor sat next to you. OK. With that for any clinical concern to get you through those first five cases and, and two of those could be telemental. Um But essentially, after that, um fully fledged um on a way, I'll also mention here just our mentorship program, which is something that's really starting to take off. Um As we um as we have a growing in store base has a growing number of versus users in the UK. It simply makes sense to use those users to help train up and coming surgeons up and coming registrars as they come in through the hospital. OK. So we, we, we fallen back emotionally on perception to do that to date. But mentorship that personalized um relationship is always going to be the best thing to go for. And so many users throughout the UK now qualify for mentorships. That's something that we're looking to exploit more and more as we go forward. Uh Just a double mention for our virtual reality because this is something that we really are leading away with no other robotic platform offers virtual reality in the way that we do. Um Like I say, not only giving you that ability, that immersive ability to, to, to be introduced to the system, to build averse to even operate with the versus but also to be able to do those simulator modules on your headset is uh an amazing thing that, that, that we offer and these headsets are very, very accessible. So as trainees, it's something that we can bring to you and you can have that experience anywhere. I'm just gonna leave you on this slide, which is um our R CS accreditation accreditation that we got last year. So we're very, very proud of this. All our training now is accredited by the Royal College of Surgeons and I just had to put this plaque on for my last slide. Um and I will leave it there. I think I'm passing over to Joan. Thank you Gareth. That was a brilliant talk um in the interest of time. We'll leave questions to the end if that's OK. I'm gonna pass over to professor to who of course is president of the A CPT B and he's going to talk to us about low anti resections over to you prof thank you ever so much. Um I hope you can hear me. All right. Um Yes. Um My name is J talking. I work down in Cardiff uh and just up at the beginning. Uh Please make sure you come to the ACP meeting this year, 1st, 2nd, 3rd of July, uh in South Wales. It's gonna be amazing, er, at the ICC, which is next to Celtic Manor and Charlotte's just been there recently to scout it out. It sounds like, but I'm gonna talk for 20 minutes on um low anterior resection, er, and er, its relevance to the robot in particular to, to CMR and obviously, it, it is, it is hard to believe how far we've come in a, in a career uh in uh with regard to minimal access surgery. And literally, when I was a medical student, this is what you, this was laparoscopic surgery looking down uh a scope, uh usually to do a procedure called a lap and dye, uh which was for infertility where um the gynecologist would squirt dye up um through the uterus and you'd see if it came out of the fallopian tubes and this was considered very, very exciting. Um but robotics is unstoppable. It's, it's all around us. I haven't seen anything for a long time that's um accelerated a a at this speed coming to a hospital uh near you um within months. Uh I should think if it isn't there already. And uh there are the ones that you know about and there are more and more coming all the time and there will be Chinese ones, there will be Taiwanese ones. Uh There will be some, they are coming from all over the world and it's gonna become quite a complex area in, in order to uh work through how and, and what you do, how you become trained on multiplatform um multispecialty use and so on and so forth. We've been doing work now with CMR um for uh nearly a couple of years now. Uh And we chose it on uh for a number of reasons program across Wales, which I'll mention briefly at the, at the end, it's um gives us a bit of mobility and flexibility between mid easily between the, we've had great support from the company itself in trying to develop our program. And so how does that apply to low anterior resection? Well, there are the usual considerations. We, we can't go through the entirety of how to do a uh an anti resection but things apply to robotics exactly is the same as they, as they apply to anything else. Preoperative workup. And CPAP testing is, is routine part of our workup. Now, bowel preparation consent is an interesting subject on its own. And uh one of our uh research fs at the moment is doing some work about that and how we consent for new procedures, new technologies and how we describe that um to the patients. And this is an important, important point, particularly when you're first starting. It's really important to be part of uh recording your, your results er to understand what's going well, and this is one of the drivers I think for robotics is it gives you such a wealth of data, you can uh bring quality assurance to your surgery like nothing before. And we're putting all our patients into something called the Reinforced Trial, which looks at the um impact of the implementation of robotics uh on hospitals, the interoperative considerations, which we can mention as well if we have time with patient position, poor placement assistance in many ways, it's similar to laparoscopic surgery. And some of the things apply, you know, particularly with low anterior resection, making an early decision about whether you're gonna immobilize the splenic flexure fully. Uh and uh quite often that can be done in a hybrid way because the real beauty of the robotics is um definitely uh in the pelvis in colorectal surgery. So hopefully these videos will work. These were given to me by James Ansel, um who is uh one of my colleagues and on the left, um you will see Dave Larson, he's from the Mayo Clinic incidentally coming to the ACP meeting in July, I think probably doing his three or 4/1000 laparoscop um robotic um low anterior resection in a pretty slim patient. And here you see James Ansel on the right, I think doing his first or second um in a much fatter patient um using the CMR system and you'll see the very, very little difference in terms of mechanics because the robot is a tool. And what you need to do is you need to find a tool that works well for you and you need to work out the best way to use it. Um And we've been doing it now for, uh as I say, nearly, well, 18 months, really, we've done 75 major resections using it. Um So we don't consider our expert, ourselves experts, but we do do that on a background of a lot long history of doing laparoscopic surgery. So, so one of the things you have to consider when you're doing immobilization obviously is TM E or partial TM E. Er And so this is a talk on low anterior section. So we're doing a full TM E and the robot lends itself uh very well which you'll see in some pictures now, er to really skeletalis, the lowest part of the rectum in order to get a, a clean transition energy sources um are an issue. Although when you do open TME, we use diathermy all the way and that's exactly what we're doing now um with robotics division of the rectum and what height and what sta and technique is a, is something we can discuss as well as well as the functioning and things like ICG um er er technologies that are all coming. So these are, these are, this is the case I did this morning. Uh And these are just some stills from this and just to ill to illustrate what I think, er, are the really er useful things about robotics. I don't know if you can see my cursor but you can see the nerves here, the anatomy with the, with the view, you, you will never get a picture of it, looking at it, a video at a conference because until you've got the 3D uh uh and looking at it um, with it directly in front of you, you can't appreciate uh the quality of the picture. So you can see, you can see anatomy in greater detail, I think, than you can see it at laparoscopy. If you see even in this picture, um which has been distorted and taken on a phone and actually um er transferred, you can see strands and strands and strands of tissue, er, which allow you to know that you're in a plane. The optics are amazing at using the robot and that, that allows you to be in planes that sometimes you didn't even know existed. And here we have this is the vagina at the, at the front and we're just being able to come across this and dissect off and there's quite a deep pouch of in this leg and do some alternate technologies and I haven't seen a live uh full case done robotically without er, an assistant doing some retraction or the use of the suction. Er, and indeed, er, stapling is often needed um as we're doing in this case, er, right down at the pelvic floor and these are the things that, uh, II think that the robot has given us in terms of rectal dissection, um, a new appreciation of anatomy access to, to places using the optics that we wouldn't have had before plane, tissue planes, um, being actually multiple planes rather than single planes. Er, and, er, um, but you still need some, um, old and inverted commas, er, technology, although those things develop all the time and I think that um II really like this uh analogy. Um and ab about robotics and about different platforms is before the pandemic, we were all used to using that mask on the left. Uh And if anyone had given us anything else, we would have been, um we would have been, you know, not that keen during the pandemic, we all used the mask on the right. And uh it's funny now when we're being asked to go back to use the mask on the left, um uh how we wanna stick to what we, what we know as surgeons, um we like familiarity. Er, and it's clear that the more you do with one set of instruments or one tool, whether it's a robot or anything else, er, the more you, er, appreciate it, the more you get used to it. And so the question is really whether or not the evidence for this to be any better? Um The long term oncological data for robotics is is not strong in colorectal surgery. The rollout trial, which probably chose the wrong, um, er, er, primary outcome was looking at conversion was done by laparoscopic surgeons who were very, very good at what they were doing. And so it failed to demonstrate any advantage to robotics in terms of conversion. Uh, although once it was adjusted for learning effects, there was some suggestions, certainly in, uh, in, uh, mid rectal tumors in, in men that it could in fact do that. There is evidence coming and evidence coming all the time. This is probably one of the most recent ones. Uh over 1000 patients in, in China low or or mid rectal tumors. Uh and they stratified by center by gender by BMI uh tumor location and whether or not they've had chemoradiotherapy we're waiting for and now for the primary endpoint in terms of local regional recurrence to be published. But their secondary short term outcomes they have now published and that shows a better oncological quality of resection, less surgical trauma and and quicker recovery. And all these things down the right hand side were in favor essentially of robotics. And if you look at the apr rate, there are 16.9% versus 22.7%. Um So the jury is still out, I think, and you will always find people who are skeptical and there are um technologies that are constantly being developed. There are issues about costs which I'll mention in a second. Uh, and there's an issue about sustainability but just like that train, I showed you at the beginning, there's no turning back, I don't think at the moment, er, and working out how and where the robot robot sits, er, er, in your practice in your hospital, er, is, is, is an exciting place to be at the moment. These are very, very quickly. It's a busy slide matt mckanna, one of our, our trainees pulled this together just on our 1st 50 cases. Um because patients really shouldn't, shouldn't be subject to too much of a learning curve. Um which is why things like Gareth described in terms of the training program is really important for any robotic program. Um If you look at the bottom left hand corner, um the robotics in the those cases took us longer than our last 50 laparoscopic cases. But actually, if you look at the at the top left hand corner of your screen, you'll see already we were noticing a reduction in, in bed days. Now that's difficult. It may be just, we are very excited and we're checking everyone out early in order to prove to prove that it works. But actually what we're, what we're seeing is uh in the middle at the bottom, you, we're seeing we're getting a lower conversion rate to open in the robotic group compared to our preceding laparoscopic group. And this is just in our 1st 50 cases. It's really important to keep this data because um I think if we're going to improve cancer outcomes and we uh we need to be doing this all the time to maintain our quality assurance and this and this is a thing that um robotics offer. I think sometimes we're looking at the wrong things and everything else. Make a, make a difference. And value based health care is really important, equitable, sustainable, transparent use of available resources. And I think that you need to take a, a much wider approach to what robotics can do. It can be a catalyst to engage the public, it helps you attract and retain surgical staff. It allows you to real, really focus on cancer outcome improvement. And so when we went down the path of looking at um who we were gonna work with, uh in terms of robotics, we were really keen to procure a partnership for Wales, er, that, that linked up to these, these ideas. And in fact, I spend a lot of time saying it's not all about the robot, it's all about the things we can do because of the robot. Uh and uh and, and we can take that forward and, and I think that's, that's been the case. One of the things that you get reversed here, you know, is actually on your phone, the ability to see what you're doing when you, when you've been doing it, er, and er, the ability to your, your your videos from the surgery is automatically uploaded to your phone. Er, and, er, this is, I think, is a, a really helpful, er, way of keeping a track of what you're doing, er, and why you're doing it. And this has been a real, um, really useful in, in our practice. You can also recall where you're putting the ports and, and actually that everyone talks about the set up time in, in robotics, This is, it is minimal. Now, it's, it's certainly not the, um, the part of the procedure that takes a, a long time for us sometimes. Um I think to myself and I'm sitting there, sat there dissecting down in the pelvis. It almost feels like cheating. You're so comfortable that the way you're doing it and the anatomy is so good, but I won't pretend to you that, that, you know, a short fat Welshman with a total neoadjuvant treatment, mid rectal cancer is, is and a, and a pelvis that's really, really narrow. It's not still challenging whichever way you do it. And so I mentioned about um, financial um, issues. It's quite clear that um how much it costs when you buy the robot and how often you use it makes a difference. This is a really interesting paper um from last year whereby um, the table on the, on the left which tells you depending on how much you buy a robot for, uh how many procedures you need to do a year to offset the cost. And you can see a big difference between 100 procedures and 300 procedures. That's the extra cost per, per patient. And then if you actually um relate that to um the, you offset it against uh the potential improvements such as conversion, er positive margins, hospitalization. If you're a, if you're um got a robot, if you see the left hand column where it says effect needed a variable to compensate the additional cost of €1086 you only need to reduce your hospital stay uh by a day to make a difference like that like that. But actually if you, if it's costing you 4.5 €1000 the, the, the um the er column on the right uh you have to get into some crazy figures in terms of uh I improvement and, and the one I like particularly is the duration of the operation, which means effectively you need to have finished before you've started. And so, so price is important and cost effectiveness is important value for money is important but where the way the market is changing, uh therefore we're gonna see costs coming down and technology improving. And so this is my final slide really. And, and I, and I, and I think this is really important because I know there's a lot of trainees on the call. I don't panic about robotic training. It will happen for all er we saw it with laparoscopic, er, er, training. Um, absolutely. Um, er, came for everybody and, er, you know, being able to do a good open or laparoscopic, low anterior resection should be your priority. I think robotics is not going to be a subspecialty. Everybody's going to be doing robotics, whether you're a pelvic floor surgeon, an IBD surgeon, er, or a rectal cancer surgeon. And so, so robotics will not be a subspecialty in its own right. If it, if it, it happens in the way that I anticipate it happening, it will replace laparoscopic surgery. It's a tool. If you're interested in rectal cancer, you need to know your genetics, you need to know about the myriad of treatment options for colorectal cancer. And if you know how to do an open uh low anterior resection, er robotic training will happen and you will be a really good all round surgeon. So that's my sort of final message really is, is, is not to panic. So, um I hope makes sense when we get to it. Thanks very much. Thank you so much pro for an excellent, really insightful presentation. Um We've already had some great questions coming through. Please. Please do keep um messaging and we will refer to them. Um after our next speaker, which I'd like to introduce as Mr Adnan Qureshi. Uh he's a colorectal and robotic surgeon at the Milton Keynes University Hospital. He's also got a special interest in abdominal wall reconstruction and we're gonna hear how he performs this on the CMR. Thank you. Excellent. Thank you so much for uh giving me this opportunity. Right. I'm just gonna share my screen. Um So I hope one of you can see. Um Right. So let me start with the first slide. Um Right. So I am one of the colorectal surgeon. Yes, I've got a special interest in inflammatory bowel disease. I also perform abdominal reconstruction for people who don't know, key. It's a, it's a, it's a medium size D GH uh just at the outskirts of Oxford. And we are proud um user of C uh CMR. We've been uh one of the pioneers in the field and we started this about at the time of COVID. It's been three years and we use CMR for our colorectal resections for our IBD resections and for our abdominal wall and general surgery, even gyne even urology nowadays. So all five days are completely occupied with this robot. Right? So, um I've been talking to different um trainees, uh what they want to hear from this abdominal reconstruction uh topic. It's a very huge topic. I um I have just um try and give you any um particular uh anatomy and physiology here, but I have just avoided giving any um um literature review just to, just to stay in time. So we will discuss a brief anatomy of abdominal wall and nomenclature associated with that. We discussed what pre operative assessments and what are the standard structure report or an MDT discussion? How important is MDT and how we have established in emergent keys. Um And then some something about robotic in abdominal wall. And at the end, I'll show you a case of um abdominal wall reconstruction. So why is it important? Um at 300,000 hernias performed worldwide and uh about 30% of them are ventral hernias. Um So, um uh beside European Hernia Society, um efforts to bring this on on a platform where they can discuss all this. A CGP has recently taken initiative. So they form a subcommittee on abdominal wall reconstruction just because most of us who are gi surgeon are or who performed um uh emergency surgery and give ostomies to all our patient and these patients because of surgical site infection can develop hernias um which can be problem. Um And then we have to deal with them. So I think this is a very good initiative from AC GBI to start training and uh focusing uh the surgeons toward this huge topic. Um Before I go any further further, these are two papers everyone should read who want to do a who are, who is in tested abdominal wall. Uh The first paper is a very nice paper by j um um who has done a lot of work in this field. And second one is about robotic abdominal wall reconstruction um with some very nice videos in there, um and board placement and all these things um are included. So these two papers to, to, to read um abdominal wall, when we talk about there are multiple components to abdominal wall. Yes, there is a myofascial uh complex in the middle. But there is what we, what we forget is about the, the fatty layer and, and uh skin and subcutaneous tissue. This is one of my patient. Uh she came in, she had a surgery and she was thinking that she will be uh she is, she's going to have a tummy tuck and all this. Um Essentially, you just have to counsel your patient very precisely that this is just to do my official component uh repair and not a plastic surgery. Big huge um abdominal reconstruction unit do have plastic surgeons with them and they can perform appom in this patient, but particularly um uh for a small DZ or where you don't have a facility. This service is only uh to repair um the abdominal wall. Um So, anatomy of abdominal muscles, as we know, there are five muscles on each side of our abdomen. The bulk of which is rectus abdominis, um which give flexion and attention to our um um skeleton and then external oblique, a huge muscle in front which give flexion um and the thinnest of all this or the smallest of all this actually Transversus abdominis. But its function is much more wider than any of these, it, it, it, it is an abdominal corset. And um because all these muscle actually form an um a rectus sheath which is of interest here and the rectus sheath, anatomy changes above and um above the rib cage and also below the line. As all of us know the three lines which we should be really, really aware of is a midline, which is uh a linear alba and linear Seminis, which is this middle part, middle, middle picture here, how the sheet is formed. And what is the importance of this? Um I think we all should, we all should be aware of that. Um Then if we go in a bit more details, um what is tons abdominis muscle, uh which is the innermost muscle and between the tonsil abdominis and the internal oblique, the neurovascular bundle runs. Um and this neurovascular bundle is very, very important. Um and the abdomen is supplied by T seven to t 11. Um anterior remi of these um these nerves which run in the middle of these two muscles. And it's not only that they are supplying the lateral muscles, they are also supplying the rectus abdominis. And one of the main aim of uh functional abdominal wall is to preserve these nerves. And this is the basis on which the trans abdominis release um actually runs. Um So these nerves are very important posteriorly. We have got corus, lumborum and soar muscle. Um and the hernias in these in these regions are very complex and very difficult to repair. That's a completely different topic. But yes, essentially, you, you should know why this plane has been created. And what is the importance of this and what is the importance of um um preserving these nerves. So, function of abdominal wall is to support the internal organs to facilitate our daily routine. Um uh uh um daily routine stuff like um which involve a silver maneuver like um opening bowel and and micturation and all these things. It's also stabilized, the trunk, which is um the main reason most of these people come with back pain and has difficulty in in mobilizing. So, the nomenclature, all of us know about epigastric um blic span, hernias and lumbar hernias. But when they are associated with incisional hernias, the nomenclature should still remain the same like um one of the example is, is recti diy recti is where the linear elbow is more than two centimeter. Um But when it is uh present with um an incision, that um nomenclature is not actually of any use because now this diathesis is actually because of the incisional hernia and not the primary um um not, not the primary uh diathesis if that makes sense. Um E HS has done a very good class classification just to stand thing and we have got the location of the hernias um according to M one M two M three M four and five. which has been self described here and again, the lateral hernias, which is lateral to the l semi and then the lumbar hernias. One of the main thing when you are starting these hernias, you should, if there are multiple defects, please um combine them together and make the width and length of this. Uh so that how you're going to repair these hernias. Um There is a working hernia group classification for surgical site infection, which is very important before you consult your patient. And they are graded from grade 1 to to 4 and grade one has only uh a risk of about 8% as it goes to grade two. the risk of surgical site infection uh increases to 28% which is very high. So all these um uh complex abdominal hernias are um uh high morbidity operation and should be counseled to the patient. So the investigation which you need is very simple, straightforward. It's a CT which should be a non, which should be an IV contrast with no oral contrast. Unless you're looking for fistulas, it should be done without Filva to have uh uh uh reliable dimensions and Filva if, if you're not sure about the hernias. Um this is how uh a good CT scan look like. It should give you details of all two muscles, it should show you linear Claris and all. Please do not forget the intraabdominal contents. Um When you're discussing these cases in IBD um um meetings or in, in uh cancer meetings or in um hernia MDT. Um these are equally important as the muscles are. Um, so one of the two indices which all of us should know, which are validated indices now is um rectus to defect ratio, which is very important where we measure the, the length and width of uh the both recti and the side and divided by the uh uh widest defect diameter. That will um tell you if the index is more than two, then there's 90% chance that you would be able to close the defect without problem. But if it's less than 1.5 then you will need some kind of um uh procedure like a tar or an interior component separation to close. Then component separation index is also very important um which is made by uh this angle which is on a fixed point on the, on the most posterior part which is aorta and you take the width of the two recti. Um you calculate this angle and divide it by 360 to get the ratio. Um And that will tell you that can you do you use to need a mesh or not? So these are both validated um indices which all of us um uh who are, who, who do abdominal reconstruction should know um loss of domain. Very common term, very closing term. Most of the people do not understand that loss of domain is simply how much contents of the, of the um intraabdominal contents are outside the abdomen. And the significance is if this is more than 20% of the abdominal contents are outside. Um the myofacial um lining, then it it it becomes significant and these people or these patients will need some kind of advent treatment, either Botox or facia toes or um um uh progressive pneum uh which is beyond um the um um uh the, the, the, the talk today. But I think I can explain it. Um If, if somebody wanted to know about them, it's a structured report which should come out of the MDT should look like this. It should tell us the number of defects. It should tell us is it primary defect or incisional defect and self explanatory? And we should record all the uh rectus to defect ratio, the loss of domain if it is there. Um The subjective impression of muscles and its quality is very, very important. Um And so is the presence of uh um uh any other defect. Um So patient selection optimization is very important, obesity, tobacco, diabetes, malnutrition, they all play a role. They have got their significance. Um And the correct procedure should be discussed. Um um uh I A multidisciplinary meeting um and then skin edges should be given equal importance and then postoperative care with an ERP extended profile access. This is the only best chance and a gold standard operation should be done for these patients. Uh There are contraindications, absolute contraindications only when patient cannot go under general anesthetic or not fit for surgery, relative, uh smoking diabetes, uh BMI as, as it as it states, um uh should be all relative contraindication and you can optimize your patient um uh before any major surgery, uh any major abdominal reconstruction is done. Um And the pre operative the scene is mainly, is it feasible to do, is it feasible for me to do this particular operation? And what is exactly the patient need? Is it an interior component separation or a posterior component separation? Also called t um degree of central adiposity is very important. And we do ask patients to reduce weight but there are some, some areas where a patient is struggling or has presented with a small or large bowel obstruction. I don't have much time. One thing to note in emergency scenario, please do not try and repair um with any definite repair, just deal with the emergency and then uh the elective repair can be done later. So um there are different techniques, inter component separation, posterior component leaves topa. And we have all heard these words, there's been there, they, they've been validated in different studies. There are a lot of meta analysis out there. Um to read about every single um uh technique has got its own advantage. And the most common um technique nowadays uses a posterior component separation, also called trans seomin release. Um So basically, Reeve dopa was introduced in 1960 by Reeve and to where they, they created a retro muscular plane. And that changes the whole concept of hernia where a retro muscular space was used. Interior components separation fall out of favor way because of a lot of subcutaneous dissection which leads to choma formation. Uh Hardly anybody is using that. Uh Nowadays, uh posterior component separation um very, very common today. And the whole concept lies about where the transversus abdominis, where is a neurovascular bundle and you cut the transversus abdominis muscle to go behind the muscle uh on the top of the facial transversalis um as shown in the, in the figure on the right. Uh posterior component separation again can be done with open laparoscopic hybrid. I'm one of the favorite. I, I'm one of the one who who, who favor hybrid technique just because of the wall of the hernia sac. Um So aim is to get myofacial closure, functional abdominal wall and reinforced by the mesh and choice of the mesh depends upon the surgeon. Um So technique is to say to the abdomen, do all the analysis explore, expose the entire hernia um and then use mesh. So there are four major steps for doing abdominal reconstruction as explained in this picture. Um All units who start doing a little uh reconstruction. It is advisable to start with a uh with a complex hernia MDT and these are the core uh members. Um um more important in all this is a radiologist, um then admin support and then, and anesthetic preassessment. Um This is how our MDT runs. So once the patient has been seen in clinic CT MRI within the last six month and then we optimize them for their comorbidities and we decide what kind of surgery they need. Do they need any ADRS and, or do they need a CACS testing or not? So, robotics in abdominal wall surgery um is is quite new in 2015. Uh valles started using this um after Noski described the posterior component separation. And since then, it's been standard practice and the most um uh the the advantage of robotic is is dexterity with which actually um you can suture and you can dissect. Um And obviously, the vision is also very important. Um So the, the, the the trainees who are not aware of how many robotic system there are um three major robotic system, which should be, we should, we should all be aware. We only use master slaves active system or where there, where it all um um uh a already prepopulated like cornea. Um The, the like cornea surgery like LASIK and stuff like that where surgeon involvement is minimal, semiactive system where where uh some of the complements of the, of the surgical um of the surgeon are actually combined with uh autonomous uh part of the robot like cochlear implant surgeries and stuff like that. But in general surgery, it's all master slave. There are three major systems available in the market which are single card, multiple arm system modeler system and a single card single arm system, which is going to be the future pioneer. Yes. Um uh it was uh Davinci which is a single card, multi arm robotic system um as self explanatory. But what has changed the game is this model of robotic system and, and CMR um uh which is mainly has got its own advantage as, as has um highlighted the CMR is um um a quite small robot and it can be easily driven in and out of the theater. Um It has got its own advantages. Um This is the future and we're looking forward um to use them when they come out. Um I think the Da Vinci, Singam is already in the market. Um So robotic t can be done from top to bottom um or from bottom to up uh approaches. Um I am quite in favor of top to bottom approach because in the top part, the abdominis is quite bulky and you can divide the lamina and the muscles. Um preoperative planning is very, very important reading your CT scan, uh reading the defect size where your Seema uh uh uh uh se Lamar and how you're gonna wear that, how you're gonna mark that all these marking should be done before the Nemo is created. I normally put my two working robotic arms outside the L semi um and the camera even more lateral than that. That's the beauty. If you have done this with the, with the laparoscopic arm, your robot is exactly like this uh like laparoscopic arms as well. Um So this is one of our first studies where we, we um shown our implementation of robotic hernia surgery in versus system. And we have described this in literature. Um So this is a normal set up um where patient is tilted on, on, on one side. Um I normally break the table to give patient a bit of more extension. Um And I normally start with a simple laparoscopy to divide all the adhesions and then dock the robot. Um Let me show you a small video of uh how does this work. Uh And this was uh a 43 year old who is known Crohn's disease, midline laparotomy and she is, she was an immunomodulator like Azot. Um Otherwise, um she's been graded as grade two on um uh r hernia working group. Oh Sorry. Uh How can I go back? Right. So, yeah, so OK, as it goes through, this is the preoperative scan and you can see preoperative scan, I'm gonna measure the defects and you can see the divarication of recti right there. And here the incisional hernia starts and you can see uh in a second. So this is the defect um which is roughly made about 8.5 centimeter. So, and this is an showing that this is an M three hernia, which is a paralic hernia. Um And this was a structured report which shows a ratio of 1.37 which means I will need at. So, step one is a urethral muscular dissection um where you just go in a, in a urethral muscular space and, and dissect the posterior sheath. Um and then step two, obviously, once you dissector all this dividing the interior lamina of the, of the transversus abdominis muscle, you can see the nerve just behind on the back. Um And I'm just medial to this nerve and I'm dividing the belly of Transversus abdominis muscle. My camera is 30 up. So I'm struggling to see. Um but in a second, I will change it to 30 down position. Um And you will see that the view will completely change um dividing the belly of transversus abdominis muscle. Um And that is a very, very important step here. You see the transversus abdominis is divided. Um And you can see I have left the posterior sheet which is facia transversalis on the peritoneum. And you can sometimes dip down and can make rents which are sometimes difficult to repair. Um and try and um and that's the beauty of top down approach that the muscle is quite bulky and you can actually separate the muscle from the, from the facial transversalis. You have to do this dissection all the way down um and keep going down. And this is the step three where you go into the T plane and you lift the transversus abdominis from the facial transversalis, facial transversalis in the top part of the abdomen has got only one layer as you go down and cross um the the rate line, it, it, it has got two investing layer. So in the, in the lower part of the abdomen, um the transversus abdominis is quite neurotic as you can see. And I'm lifting the uh um transversus abdominis muscle uh from the facial transversalis, developing my T plane which should uh go all the way down. So I'm gonna go down a little bit more, lower down and divide at the quit line. I'm gonna divide um theis abdominis completely and go into the space of burgers. So you can see, I am just developing the plane more naturally and it can go, as I said, all the way to the anterior axillary line. This is space of bogus which is later to the inferior epigastric uh vessels. And so you keep dissecting and uh deciding how much myofascial advancement you need in the midline. Um And that's what I said. Um you can, it can go all the way down to the mid axillary interior axillary line as long as you can close the midline. Um So here you can see the transversalis um facia, the the, the superficial layer is still on the muscle. But as you go above, you see the muscle completely naked. Um and then you keep dividing, I'm now going more cranially. Um And um in a second, I'll show you where I actually go under the diaphragm. And you can see the diaphragmatic fibers dividing this muscle, this fat pad on the right side is the, is a distinction where you can, where, where, where, where you can identify that you are under the diaphragm. This is right under the diaphragm. And uh you do not need to do too much unless you re really, the defect side is really big and you have to close it. So one side, once it's done, you can um uh do the robot to the other side. You keep checking how much you have mobilized and then you close all this um um uh the posterior sheet uh with the robot, the interior, the anterior abdominal wall sheet I normally do is as a hybrid because II, like actually excising the hernial sac so that seroma formation is less. Um So once I've done that, um I put the mesh in the different way of fixation, uh fixing the mesh. And some people use transfacial suture. I normally use glue um to fix the mesh on the posterior sheet. I will put a couple of drains on the top and I've never used more than two drains which are ready closed system. And this is patient eight weeks postoperatively. Um So yes, uh CMR has changed um the way we normally operate in this patient. Um and it is, it is um equally compatible robotic system and I've been using it for a while and I think um the future is um the future is there, it is still evolving. Uh It is um it has evolved a lot over the last 3 to 4 years. Right? Thank you very much. Any question I'll be happy to answer. Thank you, Miss Qureshi. Excellent talk and thank you for the fantastic videos. That's all privilege. Thank you very much. Um So we are short of time. So the first question I'd like to ask and this is to yourself professor to if you're still there, what what would you say is the average learning curve for complex uh colorectal procedures on the robot or on the CMR specifically? So, for a low anti resection for abdominal wall reconstruction, all would you say is the average learning curve of what were your learning curves just for the audience? I think it's really difficult to answer that question because we three of us have started doing um in Cardiff, we're all pretty experienced laparoscopic surgeon and the transition to me as a very middle aged man um who uh teach old dogs new tricks and all the rest of it, it didn't take long because it felt very natural going from laparoscopic um to, to to robotic using the CMR system anyway, and I haven't got any experience on any other system, so I can't comment. So I think it does depend where you're starting. And I, and I think illustrative of that is, you know, the urology who went from open to robotic with no in between really and the the learning curve is, is different. So, um I think that, you know, and I hinted at that in my talk, I think the learning curve is significantly shorter if you operation laparoscopic skills actually is, is, is literally about learning how to use the kit. Thank you. Yeah, I think I, yeah, II think I completely agree. So um the new era of training is completely different and as soon you are exposed to the robotics, I think that that will decrease your learning curve. Again, it's depend upon the speciality as well if you're using in colorectal where you use minimally invasive surgery more. But in like abdominal wall reconstruction mostly done open, II hardly know. Uh few units. I think in, even in UK, we're doing robotics. So unless you've done 20 open abdominal reconstructions, I think it will be difficult to appreciate the anatomy with the robot, which can be really confusing. So, yeah, I think a nice follow up question to that is in the chat, take each operation take to perform. So you mean robotic reconstruction? Is it? Yeah, it can easily take up to four and 4.5 hours. So from that from that point report really give you an advantage that your, your ergonomics is, you know, uh, not that much compromised and you can take breaks in between as well. Um, so, yeah, easily 4.5, 5 hours profit. I II think again, it's, it's very variable and I'll be a bit careful because I know I can see a few of our, our, our trainees have been on the chat so they'll be, they'll be coming in screaming saying he's lying, he's lying, he's lying. But, but, but I don't perceive it to be massively longer than if we were doing it laparoscopically. I really don't. I think that, you know, there is this initial bit about, um, about set up, but you get over that very, very quickly. I don't think it takes as long to transition from the laparoscopic to the, to the robotic part of the procedure. And I, and I think that it, you can't generalize. I mean, the case I did this morning was a, was a woman who had any previous surgery before. It was a nice, mid, mid rectal tumor with a wide pelvis and a long sigmoid colon that's completely different to the guy who you've got to take down the splenic flexure to the middle of the transverse. It's really difficult to see where you're going. You've had radiotherapy. So I think you can tell which cases are gonna take longer. But, but, um, I, you know, we, we, we, the case we did this morning, which was a fully robotic case. We mobilized the left colon, but we didn't have to do the whole flexure. We did a low anterior section and defunction. We started at half nine. We were finished at half one. And so, um so it doesn't take all day, but that was a relatively straightforward case. Um And you, you, you cannot generalize, you've got, you've gotta really work out your list. And this is what drives me mad sometimes when we look at, looked at about how we utilize lists is that often the people who are looking at and measuring how you utilize your list don't realize that every, every right hemicolectomy is different. Every anterior section is different abdo and every abdominal wall reconstruction is different. Um And you, you, you, you get a feel for that, how long things are gonna take and you manage your list accordingly. How about trainee involvement in, in any of these cases? Are you sort of doing it as, as we know, traditionally parts of the procedure or, or is it sort of, you have to do your training first? Like what are the, what are the steps to, to trainee involvement in these cases? Yeah. I mean, that's a really good point and it's a really important question that we have to answer and get right. And there's no doubt that there's no doubt that that when we started, um we were, we were probably not giving trainees, you know, as good a shout as, as possible. II certainly try now because certainly if I, if the spine fractures gotta come right down, I'll do that laparoscopically and I try to get the trainees to, to do that bit. Uh I'm conscious of trying to give bits away and, and we as a unit have really got to take a big step. Now, in terms of making sure our trainees come through our aspiration in Wales is that we would have people that would finish training, being robotically trained. Uh you know, and, and that's not as crazy as it sounds because that's what happened with laparoscopic colorectal. Believe me, you know, I was there people were being consulted, were being trained how to do laparoscopic colorectal surgery. And now it's almost inconceivable for a trainee to finish training and not to be pretty proficient at most aspects of laparoscopic colorectal. And it will be the same for robotics and I think will be clear. Um Thank you. And one last question. So what advice do you have for enthusiastic trainees out there who are desperate to get robotic trained and desperate to start their robotic journey and go out there on their fellowships, any advice for them? Well, I would say absolutely do not panic. I you know, you will get robotic training. Alright. And, and you know, II wouldn't want to appoint a colleague who was just a one trick robotic, you know, Pony. I want to point a colleague who actually knew how robotics applied really well to the subspecialty of pelvic floor or IBD or cancer because they understood cancer. They understood IBD, they understood abdominal wall reconstruction, not that they were just turning up at the door going. I've got a robot and I'm gonna use it. So, so I robotics will not be a subspecialty in my view, you know, the subspecialties will be the diseases and therefore, and, and robotics will have a part to play in each. So I think that uh it's exactly the same as laparoscopic. Nobody says I'm a laparoscopic surgeon. It, it, you know, it is exactly the same. So I would say, don't panic, pick a, pick a, pick a subspecialty and work out how robotics is gonna apply to that. Uh And uh you know, and it will work out for you, you know, be assured you will get it. Thank you, prof um thank you so much wise words. And I think that's uh an excellent way to end this first uh webinar uh in, in our series, we are so grateful to all our speakers for joining us at this time of the night on a Monday and we've had over 100 and 20 unique uh attendances today live, which is great, which just shows you how enthusiastic trainees are about robotics. Um I'm uh just going to sign off by saying that we've got uh CMR um uh leading the way in terms of training this Friday. They've uh they've, they're presenting a free course for our trainees. All the dos club members are getting opportunities to go on the CMR uh course. Um And in September, there will be another one. So there will be more opportunities to go on these courses for free, completely for free, led by CMR. So we're very, very grateful and proud of that collaboration. Um The Dots Club weekend is in September in Leeds this year. But prior to that, we will see you hopefully every week over the next uh six weeks, the next one being on the 15th of February, uh with E SCP, you'll get to uh have a chance to speak with uh the proctors in E SCP and uh those who are running the Call Robotic of Fellowship. So hopefully, see you then. Thank you so much. I'll sign off here. Thank you to our speakers. Have a great evening. Thank you. Thank you guys.