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Good evening everyone. Um Thank you so much for waiting uh with us uh while we had had our technical issues um sorted in the background. I'm sorry for the delay. Um This is our second episode in the robotic assisted surgery uh series with uh E SCP this time round. And we're incredibly excited to have uh uh some distinguished guests amongst us who will be talking to us about called robotic uh fellowships within Europe. And we are very, very excited to hear from past fellows who have gone abroad um to master their craft. So without further ado uh just some house rules, you can see the chat on the side if you have questions, ask questions on the chat box and we'll answer them right at the end, you'll be sent um a form to fill in for feedback and you'll be receiving a certificate right at the end of the, of the uh session automatically. So Charlotte Sai is the VP for Dos Club this year and she'll be sharing with Andrew you who is our secretary. Thank you. Thank you Lillian. So, uh as Ly said, we're extremely excited, we've got uh two fantastic consultants from the E SCP Robotic Working Group. And first of all, I'd like to introduce you to um Mr Gomez Rou, who is part of the robotic steering group and is a proctor and he's talking to us all the way from San Santander Spain. So, over to you Mr Gomez Rou. OK. Thank you so much Charles for this uh kind introduction. It's a big pleasure for me to be uh here with you this, this uh evening. Um I will try to share my screen, let's bla bla bla so hopefully working now. Yes, we can see it. Perfect. So, yeah, uh uh as already mentioned, it's just uh a big pleasure to be with you this evening to speak about Chlorotica uh which is uh uh well, the, the, the colorectal robotic surgery training pathway that E ACP has established uh for the last few years and which is uh already uh working and already training surgeons across Europe. So, uh I think something which is already uh real and, and we will just, or I will just try to, to well comment on what it is, how it looks like and what is the experience we have had so far? And I'm very happy to answer any questions or, or listen to any comments you, you might have the the problem of this uh training pathway is that when, when any new technology is introduced in, in, in health care therapy concerns that arise uh regarding safety regarding clinical benefits. And we are all very much aware about the the Bristol case in laparoscopic surgery, the no uh or even uh in the robotic field, the the Newcastle case. So this is something that uh concerns us and this is something that, that is real life. Uh New technology has its issues while introducing it. And most of them are related with the uh training of surgeons on how to do those techniques or use that technology. The um mm OK. The, the lessons that we learned from, from laparoscopic surgery, from T AE surgery and its implementation is uh that that for sure patients uh shouldn't be uh at risk to CRS uh and the outcomes uh should be as good as possible for for our patients. Uh The evidence suggests that formal training shortens learning curve for surgeons and also makes the the learning curve of uh these uh surgeons safe for the patients. Therefore, standardization of colorectal surgery and, and surgical uh training uh is a key element in in robotic training. We have uh been uh doing training as uh probably in, in a way which is more like a hand craft way in which uh surgeons are trained uh in a very uh basic way in which surgeons are trained usually in a 1 to 1 interaction uh by other expert surgeons. And we think that that uh probably it's time for us to, to move forward to what we could call industrial revolution in in surgical training. Uh trying to standardize training, trying to assess uh training, trying to measure training and trying to do training in a way which is uh easily reproducible and scalable. And probably that's one of the good things that robotic surgery has that uh it allows us to, to probably set up this uh industrial revolution. This is why we think that the, the has to approach of C 1 to 1 T one is no longer acceptable for us, for our patients mainly. And that uh surgical bodies have the responsibility to embrace these new technologies and incorporate them into surgical training. This was uh our, our message uh while publishing this uh correspondence letter at Coral Disease uh five years ago uh in February uh 2019. So it just uh in few days, it will be just five years ago when we were sending out this message. It's uh our responsibility uh to do training uh in a, a standardized way, in a structured way uh in a safe way for our patients. And, and we also, they were sending out the message that probably uh we need to collaborate to work together with manufacturers but not uh let manufacturers run uh those uh surgical training activities while uh speaking about uh procedural training. This is the group of, of people that uh has made uh all this possible. And I, and I think it's very important to uh have them uh on, on, on stage to have them uh here in this slide because without the, the amount of work that all these people has done and, and many others that are not here in the picture, uh uh I think this would have been just uh an impossible, never setting up uh a structured training pathway, setting up. Uh all the components that training pathway and delivering the training pathway is just AAA huge endeavor and it's nothing that uh few people could do. So this is what I would say. It's really uh called robotic, the, the people that is behind it uh under the umbrella of the, the European Society of Ology, regarding the methodology that we can use to standardize. Uh well, uh we, we think that that first of all, uh standardization of these surgical procedures is the first step uh towards uh standardization of training. Uh We have uh learned how to use a based uh progression training method uh in order to, well, to describe a way to perform a, a surgical procedure and also to describe potential uh associated errors uh which we can call metrics and also to train surgeons in a structure way, which is really what our training pathways. Uh It is key to assess the progression of these surgeons during their uh curves. Uh because this is the only way we can learn if what we are doing is uh the best way to do. Uh this training. And also if it is working. And uh well at the end of the day, this will also lead to uh build uh probably high tech training tools like uh simulators or uh developed uh real time tools we are going to speak now about how the the color training pathway looks like. Uh As we said, it's a very structured uh pathway, it has different components and all of them we think are key are very important. The idea is to train uh a number of trainees which is uh based on the resources that E CP has. Uh And these resources come uh from the, the collaboration with uh with uh in this case at the moment, with Intuitive Foundation, which is the one supporting uh this training pathway. Uh The idea at the moment is to start training uh already uh special surgeons, which can be called different ways across Europe uh colorectal surgeons, physical surgeons, general surgeons uh and the origin of these surgeons or these surgeons will be coming from uh what we called geograph Europe. Uh This is uh something that wants to cover uh all uh the European continent and the UK and also uh to be able to, to well uh train surgeons from different locations across Europe. Uh to be able to train the surgeons. There has to be an agreement uh in between the E CP in between the training and the and, and the training institution. And there also even has to be a, a committee approval uh for data collection. There is a uh I would say uh uh a very low fee per surgeon uh which just uh is uh in place just to, to try to make the surgeons commit to, to the training process and uh to uh show from their side the commitment. But I can imagine all what we are going to, to tell you in a few seconds about training, by the way, is not something you can cover with €500 per surgeon. And also the good news is that E SCP uh I accepts non ES EP candidates to uh well apply for this uh training pathway and and is happy to train uh non E CP uh members. Uh Although uh the idea is that, you know, they, they, they might be interested to approach society and be part of it. So this is the, the, the way the the uh training pathway works. And, and this is probably a, a slide that summarizes all the, all the process and all the, the thoughts we had behind uh building this training pathway. Uh We understand that there is a basic training which is uh driven by manufacturers, which is just what uh we used to call in the past ology, which is just how the the the system, how the machine works. But this is not something that uh color robotic is, is designed for what color robotic is designed for is to do procedural training in the colorectal field. Uh And this is why we, we have this component in uh and this is why also we are uh collecting clinic uh clinical uh outcome data. And, and uh all this is done by uh trainers which are also standardized. So a standardization is uh kind of like the the backbone of everything uh within the the the train pathway. the different small components of robotic are e learning. We will speak about them uh in a couple slides, uh simulation, case observations and, and workshops. And uh the last one is is proper. And as you can see in this slide, we have uh different assessments uh after every uh each, each of these components. So the idea is that uh uh trainee starts with e-learning, that's the assessment uh of the knowledge, uh the assessment of of that ele moles. Uh this, this is followed by a simulation. So the, the trainee starts uh learning or showing that is able to do uh uh some uh skills to, to work at the, this is ap assess followed by a caseation and a and a workshop with real uh tissue. Usually it's a cat out what we use again, some assessment of those skills. And then is when we think that that treaty is ready for pros or even teary, these are the, the emos that Tica already has in place. Uh We have uh two mo two emos which we consider general concepts, which are uh well, one is general concepts in robotic surgery. So this includes uh well basic uh i ideas on how to use the system, uh how, how to use the energy, uh how to even interact with the trainer in terms of how to uh follow the, the guidance of some indications of the, of the trainers while uh running, for example, a pro. Then we also have a new mole. Uh speaking about uh enhanced recovery after surgery, which we think is key for our patients to have uh optimal uh clinical outcomes after any kind of procedure. And uh we have 34 specific uh procedural uh emos which are V neop sigmoid resection, low arterial section and right Emy uh which is presented uh including CM E and Ocran stenosis. This is in an L MS platform uh which has a standardized approach for procedures and which has assessments which are following th that standard, a standardized approach for each procedure. This is, for example, the, the L are mod metric phase uh which is uh validated and published. We have here uh an example of uh what uh includes uh this uh emo this is just one of the steps of uh LA R. Uh we include the, the, the steps of the procedure of this particular uh step. We include uh some anatomical references. We can uh jump into how it looks like when we are talking about the posterior plane, uh this is presented before presenting uh the, the uh step uh tell how, how to do. And we can see, for example, here how the in the A model, we have indications anatomical references and how to use the different instruments while doing this uh uh part of this step of the procedure, uh where each instrument should be is also mentioned in the, in the mole. And how different uh uh steps of the procedure uh are done is uh well uh according to the, to the voice over, you can see here how, how the the different instruments are presented for different steps of the procedure. And for example, another step while doing the, the lateral uh dissection, doing the TM E uh we have another reminder of landmarks uh in this case, for example of the protium including uh uh a lateral uh uh middle rectal artery. And then we have the, the video of the step. Uh And we have here again uh an indications on how to use the system to have this this view and how to do this is a step with the different instruments in place. So this is how comprehensive the the A modules are uh for the different four procedures. Uh We, we mentioned earlier once the, the uh this step is done, uh the trainees are assessed and we uh move forward to simulation simulation is something that some of the trainees that uh are in the pathway already uh have done. And if that is the case, we just um ask them to provide evidence of, of scoring already. If not, we have to do or go uh around this 12 exercises and then provide evidence of having done this uh the or or arrive to, to this scoring. Case observations are done by, by uh trainees uh in um trainers uh institutions uh they are interactive and usually one or two correct procedures are done. The trainee travels to the trainer institution and observes one or two procedures in which at least we usually uh uh prefer to, to have one LA R or at least one high interior section. And this is again, followed by another uh assessment to understand if the trainee really understood what was happening there. R and, and that understood that approach that is used for this uh procedure. Next step is workshops, workshops is again something that we usually do with uh institutions that are collaborating with the S EP in this uh E RA or C or uh HPV. And uh those uh uh workshops are uh for four trainees with two trainers done at this institution and usually with a carer lab uh going uh along uh L er and right AOM. So they practice in a uh anatomical uh high theoretic model. Uh These two procedures uh A are as on how they do these two procedures before moving to the next step, which is property drugs are done at trainee uh hospital training site uh depending on on the availability. One or two cases are scheduled for the day and the trainer visits, the trainee and guides the trainee uh through the the the procedure. And again, another assessment is done and clinical data is collected on, on how these uh patients involve and, and which are the clinical outcomes of these, of these patients all along this. This uh proctoring uh the non technical skills for surgeons are used to assess also uh the uh well, the way the the the surgeons interact with the rest of the team, how uh they uh behave with the, with the rest of the team. And this is something that is also uh very important I would say is uh unique uh for a training pathway like this. Uh uh In, in, in your video assessments are the last step of the of the training pathway. It really has to submit to videos to be assessed by trainers before signing off. At least one of these has to be on a layer. So again, another assessment which is the final assessment uh which uh is what we use to, to certify or to sign off uh the techniques. This is the kind of of uh videos we can see and, and we have the metrics and we want to collect if there were any, any errors or critic errors during those uh videos. So this is for example, one of the of the phases, phase five step 44 is im exposure and ligation here. Uh We see uh sub optimal uh performance. Uh And we see that well, the space in between hemos, for example, is not going to be as we uh train the surgeons in at least around one centimeter in between hemos. So we will say that this uh trainees making an error here and might uh be performing sub sub optimal. So this is the the kind of detail we we want to go in and we are going in. So so far, we have a structure training program for a colorectal surgery developed and led by a scientific society uh which is accessible for anyone, not just for us SD member members provided that the uh the the criteria are fulfilled. It's a, a multilayer activity based on, on the team. Uh that, that is uh behind all this project. Uh It has some strengths which is uh uh I think uh already well established and structured uh training program. Uh I think a unique experience probably worldwide uh with a coordination through an admin team. And here we have the, the pictures of, of some of the a team members and which is already collecting uh this uh clinical data. We have had so far 100 and 19 applications. Uh only uh 30 I think four of them. 32 of them have been uh accepted and the rest uh maybe have not been accepted because of, of not being in geographical Europe, not having a robotic system, which is another of the of the uh uh well requirements. You can easily check those at uh E SCP uh website uh looking into the robotic uh training pathway, robotic training pathway and, and the different uh requirements are, are mentioned there. And this is what we assess while assessing each of the applications that that uh we receive the progress so far is well, you see the the the degree of participation of the assessment pass rate. Uh also the the learning hours that uh the trainees have had so far. And also uh how long the training pathway is taking, which is uh a bit more than one year for, for some of our trainees, but around one year for, for most of them, some clinical uh outcome uh data to share here. Well, we see that the the kind of procedures that most of the trainees are doing during their training pathways, high interiors and low interiors and right colectomies as expected. For example, we have had uh no uh conversion uh throughout the the learning curve in this uh trainees and no positive uh well suppress resection margin in oncological cases. So, well, we we think that uh these are the kind of of outcomes that we want to see while a trainee is is uh in training. And uh we think that they are, they are uh being quite positive. So something which is uh rewarding to see that, that this is uh been a safe uh uh pathway for for our patients. Also, we are facing some challenges and, and sometimes uh professionals uh might feel less uh comfortable in this uh structured approach. Uh sometimes uh being assessed is, is difficult for some of them. But I think that it's a, a key element for the for the training pathway. Uh We think that right now, uh this training pathway is only for one robotic platform. And uh the, the, the society of course, would love to have AAA pathway which uh is uh uh open to different uh platforms probably because of the, the momentum we are living in robotic surgery is still too early for that. But we, we have opportunities to measure to, to reproduce to the scale and to evolve. And we think that the next steps is of course, uh having the, the metrics for the different procedures uh and train more trainers like we did on December last last year. Uh We, we increased the number of trainers so we will be able to train more trainees and, and, and run in the future. Thank you so much and again, very happy to answer any, any comments or, or questions you might have. Thank you, Mr, go in in the interest of time. Um We'll just carry on with the next speaker. Um So I'd like to introduce uh Mr Santi, who we all know as a consultant from da also part of the E SCP Robotic um workforce Group. And he's going to be talking to us about uh ES CPS approach to a low anterior re section. Thank you over to you. OK. Can you see the screen? OK. Uh Yeah, yeah. Uh um My talk is, is gonna be a bit uh uh uh short, hopefully would be OK. Uh uh First of all, thank you for the Dukes Club and uh uh colleagues for inviting er Marcos and myself and part of the co rob uh and a lot of the talks been covered by uh Marcos. And uh so these are my disclosures and I think for the past decades, we've been uh looking for ways to improve uh patients uh with colorectal cancers um as you know, the optimizing surgical techniques and use of adjuvant neoadjuvant therapy, uh the uh minimally invasive surgery and enhanced recovery. Now, this um editorial er was written by Professor John Nichols in 2014. 1 of these last uh couple of editorials, he summarized uh the rectal cancer treatment over the last 30 years and uh AAA lot of uh OK. So I can hear, can you hear me now? Yes. OK. Changes, sorry, I just heard some noise. Um um I in addition, uh centralization and high volume centers are reported to have positive impact on patient outcomes and there are emergent uh evidence suggesting uh surgical skills to affect uh patient outcomes, um um evidence from the er bariatric HPV gastric urology and also in colorectal. So, the focus now is to ensure the training would provide um uh surgeons to improve their skills to attain proficiency. You saw this, uh we don't want it to happen again and that's the er backbone of the er colorectal Robotic Training program for the ES EP er, as you can see, we want to impart on knowledge and skills and there are er assessment in each step to ensure that the trainees attain proficiency before moving on to the next stage. And the European School of Coloproctology was a set up to benchmark uh uh uh training and robot caloric for surgery programs. Uh uh is one of the uh program and the index procedure. Uh one of the index procedures is low anterior resection. Now I saw John L in a lo a locker today. He uh his mantra is um uh no training today, no surgeons tomorrow, but that's actually more to that uh because it's not every surgeon's a good trainer. And um uh I think uh there's a way to learn just AAA short click. Yes. Now this uh uh slide showing the er global assessment scale, we are quite familiar with it in the UK, er, because labco used it so you can see um the assessment in different areas of the uh operations, exposure, vascular ligation, mobilization, anastomosis, and overall performance. And they er they ran er 126 ones being not performed by the trainees and had to be done by the trainer. 26 fantastic proficient performance. Um There are issues with the like a scale, it is easy to use. However, the limitation is the uh the interrater reliability and this article was published some years ago and for uh assessing a couple of uh examiners looking at the surgical procedure and only 26% of the inter reliability is more than um 0.8. And also the, you know, one, you know, uh number 1 to 6, uh they are not really instructive in terms of um providing training and also uh giving feedback to the uh trainees for the procedure. So we want it would be a performance measurement would be something that objective, reliable, make comparisons, set benchmark and suggest improvement. And we uh found uh Professor Tommy Gallagher, uh who's a psychologist um specializing in uh training and education. And what he proposed is the performance metrics. And there are numbers can give us the important information about the performance and this is the definition of the performance metrics that M mark was covered uh a little bit earlier. So the methods, we went, uh we set up a team and we developed the index procedure uh M metrics er for the robotic er lower interior section. So we looked at uh they published guidelines, teaching materials and looked at uh more than 10 unedited uh videos we analyzing and uh starting a de deconstruction process. And after that, uh we um draft different faces within the robotic law interior section with errors and critical errors involved. And we went through um AAA modified Delphi process with a panel of expert colorectal surgeons uh all over Europe. And we published this in year 2020 for the metrics of the robotic low anterior section. There are 14 faces with 100 and 29 steps. The number of errors and the number of critical errors they're different because in the pelvis, male and female are different and you saw bits of it uh during Marko's presentation, as you can see for the splenic flexure immobilization, there are uh uh 10 steps, the circled area. You can see uh they instructive. In fact, we um uh did a case today and uh you can see the traction will expose the, the, the clip uh like like uh uh mesenteric vein. And also it gives you the information about the assistant forceps to facilitate uh going to a lesser sac. And this light showing the example of the errors and critical errors. They are unambiguous. As you can see, the dissection here, dissection is not in the embryological plane and the rectal uh dissection and transection in female patients. Uh There are nine steps. He and he again uh showing you the uh instruction, you know, how far do you go down for the uh TM E plane? Now, um the following, after the modified D process, we um did a study uh which is a, a construct validity. What it means is actually these uh metrics can differentiate between expert surgeons and the novice surgeons. Um a little uh a short clip um er from Santander Marcos team. This is Lydia. Um You can't really do it better than, than her describing. I'm just showing you AAA phase five of the I MA dissection. Yes. OK. And thank you again for the group that uh participated in this study. Um So this is a website for our uh uh training program. Um uh Please do visit and, and look at the information there and also we've recently uh submitted and, and got accepted for these er ES EP guidelines. And uh Marcos is here, Christina is here and a lot of people have been helping for this project for the last two years and do visit our our website and thank you. That's great. Thank you very much, Mr T. That was a really interesting presentation. So our next speaker is er MS Christina Fleming. She's a consultant colorectal surgeon at er University Hospital Limerick. She's also the ES EP program committee and National Rep for Ireland and er did her ES EP fellowship at Chu Bordeaux in France. Thank you, Andrew and thank you also for kind of sharing my slides as I could do in advance Robotic Fellowship. I couldn't seem to master that this evening. So, and you can hear me ok. The audio is ok. Great. Thank you Christina. Perfect. So, um just I guess thank you so much for inviting me to speak tonight. Um As mentioned, I'm consultant in the southwest of Ireland and I am a past fellow of the ACP Robotic Colorectal Surgery Fellowship, which I completed and professor in Austin bordeaux. So I'll just go through a little bit of my robotic surgery journey, I guess, um a little bit about the fellowship and then maybe a few tips and tricks with regards to getting on the fellowship and um getting the most out of it. So let's just go to the next slide, Andrew, please. So I was very fortunate to start my robotic surgery journey in T six when I came to work in this hospital. Um with two of my colleagues, Professor Calvin Coffey and Mr Colin Pierce, and they were the first hospital in the country to introduce robotic colorectal surgery. Um and they were quite an advanced stage of their program when, when I started here. So during that time, I had the opportunity to take part in simulation, go on some courses, um complete the first assistant element of the program of training and start on some early console work. Um as they had, I guess, quite developed practice at that time, there was also opportunities for research. And whilst in my next training, I didn't have any access to robotic surgery. You know, I could tell II was quite interested in it and thought as an important part of my future practice. So I did continue on with, you know, seeking out opportunities for simulation courses and research. And then, you know, finished off my surgical training in Dublin with Professor An Brannigan and Mr John Connely, um where we had, you know, weekly or twice weekly access to robotic surgery. And the real focus of this was on console time and developing as you know, I guess more of an independent robotic um robotic surgeon. So if you could just go to the next side, Andrew, please, um you know, from the point of view of doing a fellowship, I guess what I was looking for is very much something that push, push me outside of my comfort zone. And I fell doing something along the lines of complex pelvic surgery, particularly focusing around accentuation um and applying minimally invasive surgical techniques. So that would really suit what I would envisage my future practice to be. But also my personality and the way that I would like to practice in the future. So I was very fortunate to join Professor Con on in November 2021. Um and I stayed for a 12 month period. The fellowship was 8020 meaning four days a week were spent in the theater and then one day for clinical activities and research, this, I mean, there was a significant volume of operating, I'll go through some of the numbers and shortly, but um Professor Duo himself would operate, you know, on about 200 rectal cancers per year and was a regional referral center for um pelvic accentuation for a population of about, you know, 8 million people. This allowed me specifically to build on those real basic, you know, robotic skills that I have and bring them to the next level. Um And it also gave me an opportunity to develop into a trainer role as when I could, you know, complete a particular element of a procedure, you know, competently, then, you know, there was an opportunity to teach the more junior trainee to do that. And I think that was very important for transitioning into consultant practice. And obviously, you know, working in such a prestigious unit like this, there was significant opportunities for research and international collaboration as well as leadership opportunities with regards to guidelines and other activities in robotic surgery as well. And next slide, please. So I've come full circle back to Limerick and I commenced my consultant post in 2022. Um And from a robotic surgery point of view, I guess some, you know, exciting things that have happened since starting here is we're now developing, you know, multiplatform practice in robotic surgery and expanding into our general surgery procedures as well. Um As Sam mentioned, I had the opportunity to take part in developing the guideline or training in robotic colorectal surgery with the CP. And I recently started as a general surgery lead for robotic surgery curriculum development in CS. I and I suppose all of these things are only probably possible by the opportunities that I had on fellowship to develop specific skills and both operative and non operative and the various I guess, networking and leadership opportunities that were available as well. So, next slide, please. Yeah. So I suppose, you know, when considering the ACP robotic called Rectal, well, why should we, why should we consider it and how should we prepare? So, I suppose, you know, this is a very prestigious fellowship. Um It's recognized, it's structured, there's specific learning agreements and you know, parameters that are laid out that should be achieved by the end of the fellowship. And this is very important because I think, you know, in the UK and Ireland, we're very used to having a lot of structure around our training and having very clear targets. And certainly that's something a kind of system that I work very well in. Um it also provides um you know, a significant amount of funding which is very important um particularly if you're, you know, living in a different country and there's travel or language skills that need to be developed, you know, the costs can tend to gather. Um but I suppose, you know, probably one of the most important things is you do become part of a community. Um And certainly I have reached out and leaned on a lot of the other a robotic fellows that I've met through the journey and other, you know, social and networking events that we've had kind of subsequent. And they've been a significant support to me in my practice in various ways with regards to preparing, obviously, there's an application and interview which I believe will be discussed shortly. But I think the things you can do to make sure that you are a competitive applicant or, you know, really avail of any practical experience that is available to you in your training. Um you know, go try and get experience of all steps even if it's just very basic, if you have opportunity to do any courses or research, you know, say yes. Um but also have a very clear vision of your learning goals. Um because that way you'll, I guess, you know, align yourself to probably the fellowship that best suits what you need. And ultimately, that will have the most positive impact on your career. Um Here are just some of the numbers with regards to the, you know, my year in fellowship and I did spend a year there. Um And, you know, as you can see from a robotic point of view, you know, there was a very significant volume from the point of view of developing proficiency. Um So next, I um so obviously, when people go to bordeaux, it's mostly to look at the vineyards and the beautiful architecture. But this is kind of the thing that things that I was looking at every day while I was away. So firstly, as you can see on the top left, there's a screen that has a lot of French words on it. So that was something that I obviously had to get to grips with to be able to commute my fellowship there. Um In the top writers, two very important individuals, Benjamin, and they, um you know, worked very hard as part of the colorectal surgery team, both clinically and academically. Um and certainly, um made my fellowship um far more, I think, productive and from the point of view of doing research, but also from opportunities for training and education as well. I have some specimen along the bottom panels. Um And I suppose the fellowship was very much focused on rectal cancer and the entire spectrum of rectal cancer management from, you know, non operative watch and wait local excision right up to pelvic accentuation. And I really think that breath of exposure, I wouldn't really have had the opportunity to do that in my training. And I guess that's what your fellowship is for. It's for learning new and complex skills that you may not have had the opportunity to develop. To that point. Next slide, please. A very significant um you know, whilst, you know, these specific, a lot of the resections were performed robotically, a lot of the reconstructions I guess were also were quite novel to me. And maybe not, you know, things that I had seen a lot of in my training. So, you know, had developing experience and a breath of different reconstructive methods with regards to GI anastomosis. Um So here seeing a TTSS and a delayed colo anal anastomosis in the top, right, a robotic construction um on the bottom left, enter vagina plasties, small ball to reconstruct vaginal vault, post exenteration and on the right um eye gap flap, which we routinely performed at the end of a pelvic accentuation and again, performing these procedures and, you know, a high volume is certainly not something I would have had a, you know, opportunity to learn had I not gone on the fellowship. So, next slide, these, so I think, you know, if I were to pick out one further specific area of robotic surgery that I felt really benefited from, was looking at how do we push, you know, all the parts of a specific robotic surgery procedure across multiple domains, you know, into pelvic exenteration. Um And you know, I had the opportunity to work on this with um when I was in the unit and building work that Dina Hardy had done the previous year. So, next slide. So um I guess robotic pelvic exenteration is really in its infancy Um But having the opportunity to work in a unit where we're actually developing the procedure and applying it in this way, um was really exciting. It was very inspiring and I think I learned a lot of skills about how to introduce new technology or apply technology in a different way that will undoubtedly be very useful in my consultant practice. Next slide, please. Obviously, this meant getting a really good grasp of the ideal framework which we should all be applying. And we introducing new techniques. Next slide, please. Um We can just skip through the next few slides. Actually, Andrew, just to the recommendations in the interest of time, we can skip through that one as well and skip through that one. So I guess, you know, just some tips that I would say, you know, with regards to exploring fellowship opportunities and preparing. I think it's really important to have a clear idea in your mind. What are your learning objectives? Where can these learning objectives be achieved? What's your personal situation? Do you have family? Are they going to travel with you or not? What are the logistics around that? How much is it all going to cost because the bills still need to be paid and sometimes the mortgage needs to be paid even when you are living in a different country. And then I guess really preparing yourself in advance of the fellowship so that when you arrive day one that you can get the most out of this next slide, please. I think this is really important. You know, sometimes we're obsessed that the only way we can prepare is by operating, but there's lots of other opportunities for preparation when you're not operating, you know, participating in simulation, get involved in research, collaboratives, any education opportunities that are available and leadership opportunities as well with organizations like Dukes Asset and E SCP. Next slide, please. Um I think this is a very key message as well. Don't fear the machines. I remember the first time as an sc six and Colin priest told me to sit on the console, immobilize the left colon. I mean, I had a bit of panic attack. I think I was like, oh my God, am I going to be able to do all of this? But actually, you know, new technology isn't to be feared, it's to be embraced because undoubtedly it usually makes our life much easier. So that's it. I hope there is some helpful information in that and of course, the questions at the end of the session. Thank you. Great. Thanks very much. I mean, that was really good talk. Um Let me OK here. So um our next speaker is Mr Kapil Saran. He's a consultant colorectal surgeon at Saint Mark's Hospital, er and an honorary senior clinical lecturer at Imperial College, London. He did his ES EP fellowship at Val De Hebron Hospital in Barcelona. Hi, thanks very much. Can you see my slides? Yeah, perfect. Cool. So look, I've got 10 minutes and all I'm going to focus on is convince you to do this. It's amazing. The ACP intuitive color Robo are all at your disposal. Literally the world of, well, Europe is your oyster and I'm going to talk to you today about how I prepared initial training, how I developed, what happened within my department, what we achieved and the thoughts for the future. So I chose Barcelona as a city because it does a high volume number of resections. They had four Da Vinci systems. The trainers were credible and good and Barcelona is amazing when I prepared, I was one of the ECB candidates who had never actually done any robotic operating at all. So the first time I operated on a system was, was in Barcelona. So I spent some time at the intuitive Business Park at the dry lab. I did simulations. I spent a whole weekend just with one of the intuitive reps, just going through things and then my evenings and the weekends on the console at ST Mark's just skiing up as needed. Professor Espin sent me his videos. So I knew exactly how he set things up, how he did things. And therefore I was able to take that on board. And of course, you might also have opportunities to learn from other avenues kind of robotic as we saw being a brilliant opportunity for you as well as some of the American surgeons who youtube, a number of their videos, I did not speak Spanish. So we had Spanish lessons and I think that's really, really important if you want to integrate and work well, within the department, I think you've got to take the time to do that. So prior and still now I'm still on my du lingo and I think that's very important for us to consider when we venture to other countries. So when I first got there, this is the screenshot of me leaving London and me arriving in Barcelona, I knew that I had to make a good impression. So it's the same thing that we do here. So I turned up earlier than everyone else. I prepped the cases the night before with the residents, I arrived early before everyone. I set my simulator up. I gave myself about 40 minutes just practicing on the simulator before we even started anything. I was involved in all aspects of the theater set ups. And when I started, Professor Espin wanted me to start as you would expect at the bedside to learn how the system works in Barcelona, how the srp nurse interacts all of these various kind of non technical skills. And this is pictures of me doing exactly that. Um And this is a picture that I always love to show, but it's how my Spanish surgeon showed me how to orientate the head from the toes and in this case, they used a phus so operative rehearsal. So this is a factor that I think is really important. This is looking at that radiology beforehand, attending the MDT planning and understanding each move that you're going to make. We moved through my development as a kind of genuine amateur with single quadrant operating, working with two arms with the pro having the third then doing multiquadrant operating and using every opportunity that was given to me. So this is a picture of a retrorectal cyst being taken out robotically, which I had never done ACOP let alone um robotically. And this is how far we managed to go as a trainee before, before the proctor took over. So that's a good example of every case, having an opportunity for the trainees to get involved in. Um it's pastoral and I think that's really important. This is a new system. It is a new skill. It uses another part of your brain. You are distance away from the patients. There are a number of arms you're controlling. So you will get tired. And I think that kind of conversation we don't tend to have as surgeons, but it's important to have when learning this new skill. So often I would, I would find myself exhausted and tired and my trainer would know this and, and he would remind me to take a break for five minutes. He would do a little bit and I would come back refreshed as I developed, they were great in Barcelona, they kind of helped me work a system out to deal with complications. So what happens if mid operation of the Da Vinci system crashes? What happens if we have bleeds? And we had a lot of opportunity to practice that in real life with a kind of safe structured setting with the pros around. As I progressed to my training, I started to um train some of the residents on the system through basic parts of the operation, which is brilliant. Um And this is really that key slide that you must think about before you start any fellowship or learn any technique. This is the slide that hangs up in the New York Fire Department. So it's all about training and this is the work that we can do prior to attending that hospital and attending that theater. I think this is crucial. So my aim was to give more to the unit than I took. So I trained the residents eventually in robotic surgery. I did a lot of the laparoscopic operating with them, the extractions from the perineum and also they were not robotic operations. I was around as an assistant and as a trainer for them to go through basic laparoscopic cases. So as a novice, I achieved 54 receptions, I published, I wrote book chapters and papers and I have the opportunity of understanding another healthcare system. I think when you consider an E CP fellowship, you need to have the basics. So you need to understand the operation. How do you do that open or laparoscopically? You need to find the right robotic mentor for you. You have industry who support you and of course that could be attending the Business Park in Oxford intuitive or simply chatting to your rep about what opportunities they have, understanding the training resources that are available and how you might kind of skill up on that nice and early and appreciate that modular learning such as that, that has been exemplar by color robotic is the way to achieve most of the things we want to. This is a lovely slide for maturity and that really kind of homes, all of the kind of aspects that they are working on in the context of how you skill up for surgery. So through remodeling case reports, intuitive learning, so learning from other people telepresence and how you collaborate with pros even now that we do, sometimes it's marked with proctors around the world, record your videos and watch them, especially those that go well and the ones that don't go so well. They're really good for your M and M post hoc analysis. Um We haven't done this yet, but there will be future opportunities to use machine learning algorithms and track your progress. How much better are you getting and what happened in case number 60 that was different from case number 59. So things to consider there is no clear training pathway before attending that I found. But that could a robotic offer that you need to get access to the um to the system that is different from consultants versus trainees. So you do need to find your opportunities um after a fellowship such as this, you need help from intuitive in achieving your certificate of equivalency, something that you need when you start as a consultant and then converting that into the formal intuitive scheme. And there is heterogeneity across all of the ACP centers. So, Professor Shape and Ellie Rudge will talk about this, but of course, you can speak to previous fellows ask them which is a good center. Why would you go there? And this is kind of crucial before you decide which hospital you like to spend six months at. So in conclusion, it's a really great opportunity the work starts before you arrive and it's a final chapter and a really, really long training pathway. So do enjoy it. And again, this is a couple of slides. I bought my family and my wife and kids out there as well. And that's something I'm very happy to talk about if anybody wants to talk about that. Thanks for listening. Thank you so much. Cap. That was brilliant. Really great to hear experiences from previous fellows. Um I will be uh asking questions um at the end of the session. So um next up or next speaker is Professor er, Sha Sheikh. He is a consultant general and colorectal surgeon at Norfolk and Norwich Hospital. He is also um chair of the ES EP Robotic er, er correct fellowships and obviously a proctor. So it's brilliant to have you on online with us professor. So I will to you. Yeah. Can you hear me? Yes, we can. Yeah, thank you. Thank you. Sorry, I joined late because there was some technical issues. So finally I've joined through like just uh hotspot and Wi Fi using my Macbook somehow due to firewall, I'm not able to use my hospital computer. So, uh I think we've got slides with Andro. So we'll start from there. Um Pretty much Kapil has covered um everything about uh ESB fellowship. I've taken over this fellowship lead role in last 23 months and currently we are going through an interview process. So, um let's uh obviously, you know, I, I'm one of the surgeons at Norfolk no hospital and uh um we do run a intuitive fellowship and we are a host center as well. So can you go next light, please? And OK. Uh And for next one. Yeah. So uh when I asked the ACP team to give me some idea about their fellowship programs, I'm in charge of Robotic Fellowship, but other fellowship generally come under me, but it is managed by the, the team or the, the admin team. So what they told me was they've got six robotic fellowships and some Functional Disorder fellowship in different different units uh across Europe and two week observations which is on hold currently and, and some traveling fellowships as well as, as they are on the slides. Uh Next one, please. So the, the coming back to Robotic Fellowship, uh it's a six month fellowship. It is, there are about 10 to 12 host uh centers and um it is expected that um it comes with its own funding. It's not huge amount as um uh normal um uh ST eight or fellowship salary, what you would get in the UK. Uh This is more of uh €16,000. It comes and you, you need to submit your receipts and, and claim that. Uh but if you're going outside UK, I think it's pretty much all right in that way to uh have the fellowship and, and, and, and, and meet the living uh cost. Um depending on which units uh you end up in, you got a decent amount of experience. Every unit is uh will provide you broad experience of all the common procedures like left sided resections, anti resections and low intersections and right colectomies uh rectopexy. If, if they doing some rectopexy type of procedures like um if it come to my unit, we tend to do extended um uh resections in pelvis, like pelvic lymph lymphadenectomy and exam patients as well on top of it and, and on block resections, like for example, this afternoon I was doing a um s sorry. Uh right colon cancer with en block uh gallbladder and liver capsule and liver vag resections. And my fellow got to do something, some bits of that as well, but they will get that exposure. So, but bly, you will get a right uh antis and, and sigma. So next one please, the eligibility criteria is um uh I've been shortlisting the first batch as a as a lead for this. Um We have got nearly 40 to 50 applicants. Generally. What we look at is post CC is preferred or ST eight fun levels because um if somebody is coming to say I'll give my own example, somebody's coming to come into my fellowship and I tend to do routinely to resection this morning. I did a partial mi excision, a cancer at about 15 centimeters. So we did that and afternoon we did uh the case I mentioned. So, so you need to be a, have passed the exams uh for this exam. I there's not nothing outstanding in your training program to wait for, to get accreditation. You're basically ready to go on fellowship and you have got across length and breadth of experience. So, so I think all host centers are pretty much similar because if you come to come my list and if you don't know, or if you're still learning how to dissect pedicles and flexures, you need to know in and out laparoscopically. So you'll learn better. I think you get more value and more uh training out of it. But um generally, uh all plus are welcome, minimum 5 to 6 years of experience, the five years criteria we have put in because uh because this is an European Fellowship and their training program is different as opposed to ours. Ours is a six year and their is five years. Um And uh on the ACP, they are quite hard on that. You need to show a demonstration of that. You are, you have got an interest in color. Um And you've done a prefer if you prefer, if you done a basic exams that will add definitely value to your uh application and research and publications in chop pa. We, we need to find, we need to be able to differentiate uh because all apply look pretty much similar in basic criteria. So that's the one is there. So next like place the, this is the the three months functional fellowship uh which um again, E SCP runs is primarily for uh pelvic floor disease or inflammatory bowel disease. Um um There are few centers in the Europe you can have and I think this comes with 8000 point funding because this is I think in to it. So this come funding come from ASAP, the ES AP the Robotic Fellowship. The funding come from in two. Hence it is 16,000. So next door, please. So how you go about with your application form. So that's the website you go into. So next one and these are the host centers you'll find. So I'm not aware any more new centers has been added or not. But these are the whole centers you'll find uh because you got to choose three centers preferably uh in, in, in terms of your preference. And um the E ACP is keen on like a cross um uh country uh fellowship programs. Um If, if you are UK trainee, they expect you to go outside UK, for example. And um uh if you are outside UK, they tend to come to UK. But you also need to look into say, for example, if you're going to go to Spain or France, the language and your registration processes, what may be the uh issues you might face because all that needs to be sorted out. Now, I'm currently sorting out two fellows fellowships which has been awarded last year. They were not able to start their fellowship uh because of various different issues. I suppose it's mainly registrations and visas and languages. So next one, next one placenta. So how do you apply? There's AAA clear form you need to fill, fill in and then we would expect you to supply the logbook uh of all your experiences. And if a letter of support will definitely help us, um uh it should be quite a good letter in a way that you have done so many procedures. Whether you are independent or not in certain procedures and what, how the fellowship will add value to your training and your experience and to your future consultant experience. Um And uh II understand that some of the places you may not get the robotic or simulator experience, but uh pretty much uh uh almost all hospitals in, in the country has got robot and all robo da robot. They come with the simulator. So I would strongly recommend in order to um uh improve your success in this improve process. If you got a logbook attached that you've done simulation, because you, you will get numbers from the simulation program. And there's something called online Da Vinci community. If you log into that website, you can do some online models as well. All those things help you to show that you are interested in robotic programs. So next one, um uh obviously this year's application from November, sorry, October 2024 take is now finished. We are in the process of shortlisting. So obviously, you'll have to wait for the next year's application. So the last application uh it finished only in January the last day. So 2425 should be coming at the end. But keep in mind this is subjected to um funding from intuitive as well. And, and moreover, uh in the UK, we have started new uh fellowship programs too and there are four post for ACP GBI approved fellowships. Next slide and this is the application form. Um uh you, you who was my previous trainee and she was successful in getting this fellowship. Uh Currently, she uh she, she did complete her fellowship in Barcelona, like uh uh like uh Mr Han. And she, I think she went uh after him and she is currently uh completing her fellowship in Edinburgh as well. And she's on panel too. She might an able to answer some questions, But this, this is her application form. It's mainly about your current experience, your logbook experience. And um uh uh and um what that is so small there. So you can see what is that? Let me see my screen. Yeah. So uh one more thing, important thing you got to be ASAP member. We were not able to shortlist to two or three people, uh candidates, good candidates because they were not ESP members. If you are keen to apply for a SP fellowship, I would strongly recommend ESP membership. I know it's a, it's a financial issue maybe. Uh there are three types of memberships available. One is online which is quite cheap. I think it's 40 or 50 quids. Um Other one is a, 100 or you can take a three year one as well. So we go to the next like list. So again, this is the application process. So you can see on the left hand side, it say which country you you're from because I did not know that. But I think when they started this fellowship in uh in E SCP um for, if you, if somebody has done medicine M BBS or M RCA training in Eastern Europe, they seem to get one extra point. Uh uh Honestly, I do not know the details. Perhaps they need more training. I don't know their exposure, but that's, that's the reason they ask where you had done your uh medicine. And Mr that's uh on the left hand side, you can see but rest all pretty standard questions. OK. Next one, please. Uh And that's the application form again. OK. This is pretty much a CCD logbook. So I will not go in details of it. And um the more you supply information is useful for us to uh shortlist. So next one um same your logbook again, uh your chot experience because uh some of the units they don't not only do robotics, but they also they may have some extra like uh chop type of cases at the end of the robotic list. So we expect you to have some sort of chop experience and then then you'll be able to do them independently as well that will again add value to your experience. Next one, please. So in terms of your supported document, uh we already mentioned that a supporting letter from your department concerns are useful. Um And, and you need to write a robust to your letter as well, so that why you want to have this fellowship. And what's your plan if somebody is already lined up a consultant post or if you already have a consultant post, where as soon as you finish your fellowship and you're able to get into a job where you can get on the robot that will certainly add value to your application form. So next one place, the interview process um uh is an online interview. You will be invited about two or three weeks before. Uh The admin team will check your references and uh all your eligibility criteria, they take all those boxes and then um uh so the uh for example, if it is my trainee, I'm not supposed to ask any questions other panel members will ask. I've, I've done three or such interviews. There will be usually eight or nine primarily the lead robotic surgeon from the host centers. They will be interviewing you and next door, please. Um They usually it is a standard entry format. First one is tell us about yourself um and your robotic experience and your simulation experience and those, those questions next one. Um And um the uh we ask uh one or two management scenarios. Uh you need to be prepared. This is where your experience or color experience comes into picture. These are not tricky questions at all. These are like standard questions. Like if I want to give an example, we may ask you that you have fired a stapler and the stapler has misfired and there's a hole in the rectum. How do you manage that? Or? Um, you've done a, a right hemicolectomy and you find that there is a damage to, uh, right ureter. What would you do? Or, or I'm just asking randomly, uh, or there's a bleeding in pelvis. How do you manage those sort of questions? It's a standard color sort of questions. Ok. And, uh, then we might ask you some controversy, robotic surgery and evidences, some latest latest literature. Just go through last few question, last few public papers and publications and some meta analysis. Just to arm yourself. If there were to be any academic questions you can answer next one, please. Um And uh what depression you want to have. Uh the, if you're selecting host centers, please just know about the host centers. Perhaps it's a good idea through your trainer or directly or by attending E SCP meetings um to contact the relevant host center. If you can meet them, that certainly increases value and it shows that you're interested and also know about that center, then you can answer better uh in the interview and also know about yourself what you need and what job you're going into. Um uh say, for example, if you've already taken up a pelvic floor job somewhere, you're not going to do resections, then I don't strongly recommend to go to a cancer unit, perhaps find a unit where we do rectopexy and endometriosis and that sort of thing. So, knowing yourself and what you need and then matching national, please. Yeah, then yeah, that that's it. Really. So uh Elle, do you want to add anything? Um my uh my colleague and currently she has done, do you want to add anything that she, you've been successful last year? Yeah, just I mean, can you hear me? OK, by the way? Yeah, perfect. Um Yeah, just to say that the, the interview um is, is a very quick process and so you really need to um prepare very well for it. Um Practice what you're going to say, practice saying it into your webcam. Um because it's, it's, you know, fairly um different interviewing into a webcam versus in, in, in a room in real life. So keep practicing that. Um And um yeah, follow this advice and um hopefully you'll be successful. That's it. Really, I think you've covered everything else. Thank you. Oh, well, pri you prepare the lights. That was fantastic. Thank you so much. Uh Professor Shake and thank you, Elle. Um I'd like to invite every everybody, all our speakers on to this stage. Um Thank you so much for being with us. I'm very conscious of the fact that we've kept you far longer than we had imagined we would. And I can see that there are no questions from the audience. Um The, the talks were incredibly uh useful and I, and they'll be available on demand. So um the the audience can look back. Um So we've got one question that's just come in. Which month does the fellow do the fellowship start? Do we have a specific time where the um for example, I only taken over the last 23 months and we are in the interview process now. So I'm hoping to do the interview start the interview in March early April and I'm told that the starting date will be October. So similarly, from next year, I'll streamline it better so we can make it October, October, that sort of thing, but it's a six month fellowship. So some people um may want to start from April like if you given six fellowships. So it, but we have got funding for one year, but it's a six month fellowship. So usually we're hoping to start in October and um uh Marcos is there. So, hi Marcos. He, he has done, he had previous EB fellowships. U usually, we are quite flexible. I think we try to, to uh set the, the starting month with uh the, the fellow and depending on, on each fellows, uh we, we've been starting the, the fellowships for different months. So we've had three so far. We, we are right now with the third uh E CP fellow uh visiting us and, and she folks up in October and we'll finish in March. But yeah, it depends, I guess that each center, each fellows have different uh cans and uh I think that that's quite, yeah, I think the only um as far as I know requirement that is in place is that the fellowship has to start during the year uh for which the fellow has applied, but not on a specific month. Christina. Where are you going to add? Yeah. So I think that's really important because um a lot of the centers I think like you to start their natural um kind of change over. So, for example, I started my fellowship in November because that's when they changed over in France, but finished my training in July. Um So there's just a little coordination with that. And obviously, if you were coming to Limerick to do the fellowship, we prefer it was in January or July, which is a natural change over as well. But I think everyone's willing to work around it whatever suits everybody, you know, um mutually, I suppose. Um Is everybody another interesting question we've got is can a trainee apply for both a robotic and a functional fellowship or would you rather they, they went one stream? Yes, both. Yes. OK. Right. Um I had a question. Um What sort of case volume is expected when you return? What would you advise trainees uh to hope to get per week? For example, when you return back home to maintain your skills and develop them, maybe Kapil may be able to answer this question. I think she has done it. I think you, yeah, that's a really, really good question. I don't think there's a set answer and there's nothing that you can do about it. If you're a trainee without a de post or a consultant post lined up, you have no idea what you get. I came back to three months at a district General Hospital and I did three of those operations in three months. So that was very different from three theaters a week. Um So there is a degree of skill f but there's not much you can do about it. Um Ideally you would seek other opportunities elsewhere. So go and see another unit going to another trainer, try to do your very best to keep up, but I think it's too varied. Ok. All right. And is there uh just, just from a practical point of view, are there any sort of uh support available for trainees when they are moving perhaps with their family to know exactly where, where they'd be placed and how to get accommodation, et cetera? Is there, are there any uh mentors or support system on the ground? I think months living. My understanding is that uh it comes with a 16 K Euros package and I think it's within that they have to manage in terms of their funding. I'm not aware of any additional funding available. I'm sorry to say that. And then in terms of support. So the team will support you in terms of logistics, right? And this and that. But uh but you can also be in touch with host center. I don't think there's a massive kind of uh 1 to 1 support. Is it pretty much you will have to make yourself? Uh uh just final one question are the case volumes rec center published online or available somewhere. Uh As far as I know it's not available, but you could always ask USP admin team, they should be able to reply because when we apply for host center to be accredited, we have, we, we would have given average number of cases people do or not do. So if you can directly ask u they should be able to supply. Ok, lovely. Thank you. I think I will um end this uh session here today. Um Thank you so much all for joining us. I'm sorry that we've been delayed um and taking so much of your evening, but this has been immensely helpful. Uh We've had over 70 live attendances to this. So you can see that people, people are very, very interested and excited to hear from you, which is great. So thank you so much for being here. This will be available on demand and our next webinar is next week actually on the 19th. Um and we'll be talking about uh IBD and uh robotic surgery. So thank you everyone. I will