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Good evening, everyone. And welcome to the third episode of the Dukes Club Robotic Assisted Surgery series. And today we have a really exciting episode with uh three great speakers, Alison Rowan, Ala Patel and Katie Adams. And we are incredibly excited to be collaborating with intuitive. Uh So you'll get to hear about intuitive in uh robotics um and IBD. And then you'll get a fantastic uh a to a few talks on wh how, how, how do we do robotic surgery um in patients with IBD. So thank you for joining us. We have uh as usual, just some ground rules chat box. Is there just asking questions into the chat box? Some of our speakers may answer them straight away and at the end, we might take some of those uh questions and uh start our discussion right at the end. So, uh without further ado Charlotte, Sai, uh the VP for Dukes Club will share with Andrew Yu, who is our secretary. Thank you. Thank you, Lillian. So, starting off, we have Alison Rowen who's from intuitive and she's gonna talk to us about the Da Vinci training pathways and just give us an overview of of what we need to do in order to get trained by intuitive over to you, Alison. Thank you. Thanks very much. Let me just share my screen. Ok. Hopefully everyone can see that. Yes, Jessie. Fantastic. So, as Charlotte mentioned, uh I'm Alison, I'm one of the Gynae managers for intuitive. My specialty is actually Gynae neurology. But what I'm gonna share with you today is very much um reproducible across the whole specialty cos it's all about our training pathway. So, and I'm absolutely delighted to be with you this evening. Thank you very much for the invitation. And I'm gonna give you a little overview of intuitive and also more importantly, the training pathway that we tend to follow a little bit about intuitive very briefly. Now, our mission is very much about trying to increase access to all to minimally invasive care because we do believe that minimally invasive care is life enhancing. So we continue to increase our focus to make sure that our surgery in terms of da Vinci robotic surgery is benefiting all patients moving on to what this actually looks like. We do believe as a company that we want to support the development of world class training, focusing on what we call the quadrupling, improving outcomes, lowering the total cost of care, making it a better experience for not only the care teams, but more importantly, your patient as well. This aligns to the NHS tripling. We work with trusts around the UK and in Ireland to help them achieve their desired outcomes. What does this mean? Well, we see demand annually for indications expanding in programs and also demand for the Da Vinci systems as well. And with over 12 million procedures performed by tens of thousands of fully trained Davinci surgeons. We're more passionate than ever to make sure that one minimal invasive care is still at the forefront of technology. But also Da Vinci is accessible for all the experience we have now is not just all about how many procedures we've done, how many systems are out there in the field, but what's behind those numbers in terms of the the quantified experience of training surgeons on the Da Vinci technology is where we're focusing. As of last year, over 66,000 surgeons globally have been trained on Da Vinci on our various platforms. That's across 82 training centers across Europe and the world. Just to give you an insight, this is looking at growth over the last 10 years. Bearing in mind, this is three years out of date. This is pre pamic figures. And it's interesting once I have the updated data, I can share this with you, but it's really good to see the adoption over the years is definitely lifting off with general surgery, having a real surge in where we are in the market at the moment. So what does this mean for you? And for learning, we know that Da Vinci is more than capable of giving you a tool to perform perfect surgery. However, we also have various different things in terms of pre op planning, interoperative guidance and POSTOP analytics, which enable us to support you become that expert in your Da Vinci robotic procedures. But also to ensure that you're continually learning, we don't want to just sit still and we don't want you guys to sit still either. We want to make sure that we can grow with you, listen to your feedback and in and take that all on board so we can develop the next better Da Vinci system all because of your input as well. Intuitive learning is a tool that is available for all. Whether you're a reg an ST 34 or a fully fledged consultant, we are not limiting this to just consultants. If your sister, your hospital has a SIM. Now, if you're allowed access, jump on there, the best way to learn the tool is to jump on the tool and use the simulator to practice, practice, practice, practice, it's the only thing that's gonna make you better of what you're doing. There's various other things in here as well. And one key factor is the mind choose of that again, accessible for all it means you can log and track your procedures, your times your instrument, choreography, you can refer to it later on if you need to look at what you did and why you did that and it also aids you with training others as well. How did I do it? How did I improve on doing that? We have the beauty of the dual console. Now, this enables you to work side by side. You have a consultant already there doing da Vinci dual console enables you to see what's going on, exchange instruments, passing that control. You have the 3D HD vision, you have the safety with having a fully fledged Da Vinci surgeon next to you. And therefore the reproducibility of what it is you're trying to achieve telepresence is where you have the option to have others outside of your theater view, what's going on and to give you guidance with instruction, there's various different ways of doing this. Um and this is technology that's readily available. Now, the app, I've already mentioned a great tool for learning your cases and to, to really improve on what your your outcomes are. It's all very warming saying about all of this technology. How do you get to use it? How do you get on there? The training pathway starts with us having this full accreditation. We are so proud as a company to be the first Da Vinci, the the first robotic company to achieve this accreditation. But it also means that we've received that recommendation that what we are doing is really addressing the education that is is desperately needed across the systems for surgeons, hospitals and teams, hospital teams and patients that accreditation gives assurance that training on intuitive technology is being provided in a safe and standardized approach. Globally, we have a training pathway which is specifically designed dependent on your specialty. And this is why I say earlier, it's very much uh reproducible process across the board. So is the whole learning process is anchored by the technology. And this phased approach helps you to develop the knowledge and the skills necessary behind the intuitive technology. So the four phases, you have phase one being the introduction to intuitive technology. Phase two is the actual technology training. Phase three is your initial case series and phase four that continuing development. Please keep in mind these recommendations are the beginning of the learning process and that self directed study and practice are still required to become proficient with the technology. Brief overview of what that journey looks like and it's not five minutes, it does take time and it does take commitment. So you need to be sure that you want want to go down the da Vinci route, you have access to it and you're willing to put in the effort as well, which I'm sure that's not even questionable. Surprise for any technology training. What we would ask you to do, spend time at our Oxford office or whichever office is closest to you, get some test drives in, get hands on in a safe environment, go to case observations, see others doing the procedures that you're going to be doing. We'll give you an inservice into the system, telling you what bits do, what we'll prepare you for that technology. We'll look at all the logistics in your hospital and the functional logistics as well. We'll move on to technology and then we'll move on to case series as well. This is just at a glance and it's simplified to the lead up to your technology training in more depth and again, reproducible across all specialties. We start one. So there's low level complexity procedures. This is where you can gain your insights into instruments. What instruments does, what how do you put them in? How do you remove them out? And at all times your cases will be Procter during these sessions, you then move on to what's next. So you're gonna start with your, your simple, moving on to your midlevel and then to your higher complex procedures as well. And all of this is detailed for you. This is documentation that you're seeing here that is readily available for you to have your hands on as well. Moving on to level three, that high level of complexity. So what does this actually mean? There's a lot of words on here, I'm not gonna read through all of them, but what it means is you're starting off on your tl 100. So this is the entry level where you'll do hands on in a, in a lab, you'll get to understand the system, what it does, the skills simulator and then you'll move on through surgeon led training, Proctor, supported training and eventually getting all the way through to being a master's training where you'll go onto those complex anatomy procedures and you'll have new technologies and things to really get your teeth into as well. You're never left on your own. You're always fully supported by an intuitive member of staff throughout your whole journey and continuing throughout your whole robotic use as well. We are never far away. We're always there to support you. That's a very brief run through. There's an awful lot more that I can go through, but it's a very top level. So you've got various resources available, the intu of learning, you can access this system yourself online, it gives you various videos and simulation performances, learning plans, et cetera. You've then got the in service overviews and then for those trainees that are not, are not quite at the higher level, we do have residents and fellowship training as well. Um follows a very similar path and it also means you get a um certificate at the end of that to say you have reached an equivalent of stages one and two C TL 102 100. We talk about Da Vinci as being the robot. We wouldn't be where we are today if we didn't have input from surgeons and the like, and it also means that we have this wider ecosystem. So it's not just about the hardware. We also have the training and education behind that and the support and analytics teams that work behind that as well. We do class ourselves as a big family and we will always welcome anybody into that Da Vinci family as well. Any questions you do have? That's my email. Please do reach out to me with the questions you have. If you want to get involved, if you want to speak to your local rep, just reach out to me and I can put you in contact with them. Thanks very much. Thank you, Alison. That was an excellent talk. So Alison's gonna stay with us until the end of the session. So if anyone's got any questions on to how to navigate their intuitive training or how to get in touch with intuitive, uh You'll have an opportunity at the end. Um So next, I'd like to introduce you to, first of all, fabulous IBD surgeons. We've got er, Miss Abby Patel, who I've known for a long time. Now. Uh He's a consultant, colorectal and IBD surgeon from University Hospital Commentary, Warwickshire. Uh and she is also the vice president of Ey CN and she's going to give us an overview of IBD surgery in robotic assisted surgery over to you, Abby. Thank you. Uh Thank you, Charlotte. Um uh I hope you can hear me. Um or I guess you can. Yeah, I can hear you. Great. So thank you for to talk about robotic surgery in inflammatory bowel disease. Um, it's something that's very close to my heart. So I'm going to talk a little bit about some of the generic principles regarding IBD surgery, how the robot fits in with that. And then there's a couple of videos and some practical considerations regarding do s and don'ts when it comes to starting up robotic IBD work. So I think everybody would agree that IBD surgery is technically challenging and there's lots of different reasons why that is the case. I think at the heart of it though, is some of the decision making regarding when to operate and how to operate. And these are often young patients who are having a chronic incurable condition which often affects them at key milestones. So whether that being higher education, whilst having Children having their first job. So there's lots of different factors aside from just considering the burden of disease, which makes IBD as a surgical specialty challenging. So I think that the key when you're thinking about IBD patients is timing, timing of surgical intervention, I think is very crucial in determining the course the patient will have. And often you're faced with a patient who's very sick, who's really unwell and there's at patient to dive in and try and fix them. And actually, I think these are the times where you might want to take a step back and actually look at the global sort of situation and also assess the patient. And this is sort of my checklist of things that I think about when I'm looking at a patient with IBD. And aside from sort of controlling sepsis and nutrition and looking at medication, whether it be steroids or biologics, I think that the most important thing for a surgeon who's potentially considering a minimally invasive approach is actually going through all the scans and looking at the anatomy. So looking at the anatomy of the disease, looking at whether they've had any previous surgery and really mapping out where you're going to operate and how you're going to do the operation. And as I speak to more and more IBD surgeons, I become more and more aware that a lot of us will really meticulously map the anatomy before we dive in and do an operation. And often surgeons will have a plan A A plan B and even a plan C because often you find things are not quite what you thought they were going to be. So, minimum invasive surgery in inflammatory bowel disease has got an established role, particularly for subtotal colectomies and iliorenal pouches and primary ileo colic resections. And I think we all understand that there's short term advantages and long term benefits. I think though sometimes it's difficult when it comes to Crohn's patients who may have more complex disease and often are presenting with their second or third presentation. So minimally invasive surgery in IBD with conventional laparoscopic equipment is quite challenging to do. And if you think that there's an inflammatory mass and you're using two straight laparoscopic instruments, it's like rolling a ball with two chopsticks. It's not really going to work. And most surgeons, even if they are enthusiasts for minimally invasive surgery will try their very best to try and address the pathology and often will give up and convert or won't even try the next time. It's also difficult to reach down little nooks and crannies, particularly in patients who are having redo surgery. It can be quite difficult to divide adhesions to get your laparoscopic instruments down where they need to go. And the most cynical people will sit there and say IBD surgery looks terrible. Anyway, why would you even bother trying to make it look beautiful with laparoscopic instruments? And I would question them. These are young patients who have quite morbid conditions. And if there's anything we can do to minimize that morbidity to the patient, it will have far reaching consequences for the rest of that patient's life. So I think the robot really hones in and comes in. It's an element when it comes to doing complex inflammatory bowel disease surgery. And I think with the fourth generation robot, it's really opened up the doors. Um There's a wider surgical field so you're not confined to one quadrant. It's more versatile, you can move it around, you can get to different areas and technology So, um you know, the energy devices are much better and more confident reason and aren't so afraid that it's going to bleed. Um And there's like anastomosis. So use ICG, we'll sort of reassure you that the two ends about that you have got good blood supply by without you being, having to exteriorize them and look at the. So also it allows you to do things that you didn't think you would do before. So this is an intercorporal anastomosis, which is being performed and then the colo enterotomy is closed primarily. So this becomes possible with the robotic instruments. It is also possible with laparoscopic instruments, but you have to be much better technically and often you can't get the same angulation and maneuverability. You can with the robot. Similarly, you can get to the anti abdominal wall. So this is actually a hernia operation, but it illustrates the point that the robotic instruments enable you to divide adhesions that are stuck to the anti abdominal wall. So you are much more able to do redo surgery which you potentially would struggle to do laparoscopically. So our robotic service has increased steadily because of the expansion um of uh robotic practice across different specialties. But also within the colorectal field, we have five colorectal surgeons, all trained. The first two who essentially did rectal cancer surgery with the si robot. And as the XI and the X have come into the fore, we are now doing, we have surgeons who do robotic Tami, robotic abdominal wall and um myself who does take IVD. So it allows us to subspecialise into areas where robotic surgery wasn't conventionally considered. So this is a reflection of my practice at the moment. Now, it didn't look like this at the beginning. And I think over the course of the last three years, I've seen the pendulum shift from sort of open procedures to robotic procedures. So I rarely now do laparoscopic work and I tend to do it in the emergency setting if patients present with acute colitis or if there's a primary ileocolic resection to do and I have no access to the robot. I think there are clear indications where you would consider an open approach without even trying minimally invasive surgery. And that tends to be in patients who have more complex Crohn's presentations where there are multiple segments of disease and you actually need to exteriorize the bowel to understand whether you need to perform a small bowel resection or a stricture plasty. And in that situation, I don't think there is any sort of surrogate that you can do minimally invasive and patients who have had multiple laparotomies before who have dense adhesions in multiple areas. I think you would consider an operation going back to the robotic side of things. Patients who have a need to dissect in the pelvis will benefit tremendously from using the robot. But also as experience has got better, I've become more confident, taking on more complex fistulated disease, applying it in patients who've had previous open or laparoscopic surgery and also taking on interoral anastomosis in patients with Crohn's, particularly those who need reversal surgery. So my IBD robotic practice has expanded steadily over the years, training for robotic IBD practice. Um So there is a very, very nice defined pathway for training cancer surgeons to do robotic surgery. And I was Procter initially by cancer surgeons who have very set operative steps and a standardized approach to most operations in IBD. Unfortunately, it doesn't always translate. So Katie will know we set up a whatsapp group at the beginning of this journey and we shared practice to understand if there were better ways of doing things that were different to what we were told to do in cancer patients. And I think that training in robotic IBD could follow a similar pathway to cancer surgery. So you start off with single quadrant surgery um in primary settings. So no redo surgery and you do simple things like ileocolic resections, you do an extracorporal anastomosis. So you don't have the stress of performing an intercorporal anastomosis in a patient who may be high risk. You do pelvic dissection, which is again, single quadrant and you do proctectomy and you become familiar with using the robot and how it handles. You then move on to multiquadrant surgery where you may have to change the way in which you do things in terms of putting in ports, you might have to try different docking positions. You might have to adapt the way in which you operate from the standard practice in order to reach all four quadrants in the abdomen. Um And then you move on to redo surgery where things are distorted more. You have fistulas and abscesses. So the anatomy is not as predefined and you have to understand how you're going to address any variation that you are faced with. And I think then the ultimate step is crossing the bridge and going on to, to doing interoral anastomosis. So I've always been fairly conservative. Um And I think it's about changing your mindset. Um I remember sitting in the audience when somebody talked about intracorporeal anastomosis in a robotic setting for IBD patients. And I couldn't ever think of doing that because of the risks involved and the need to be able to feel and see and squeeze and do anything you can do to an anastomosis to make sure you confident that it was intact and it was going to heal. But actually, as time has gone on, I work with surgeons who are more earlier doctors who are visionary who have helped to change that mindset. And I think it's important that we challenge our existing surgical doctrines and learn from others so that we can change the way we do things because ultimately, it will have far reaching consequences for the patient. So other things to consider when you're thinking about the patient and whether you should do a robotic operation or an open or a laparoscopic operation. I think the length of disease is not as important as how many segments of disease are there. So if it's a long single segment, you'll probably be fine doing it minimally invasive. If there's multiple small bowel segments or there's uncertainty about it, it will become quite important to, to sterilize the bowel and actually visually inspect it or even put down foley catheters and make sure there's no upstream stitches. And that's not really possible to do in a robotic setting. So those patients, you would opt to do a laparoscopic or a hybrid approach, either with or without the robot. The anatomy of the disease is important organs. Are you going to take that first? Five or 10 cases? Did you do? Probably not means you're gonna have to repair another organ that's going to stay behind in the patient. So you really need to be confident about your suturing ability and your ability to understand the tension you're applying with the robotic arms and be confident that you can repair organs safely. Similarly, we do surgery becomes quite challenging, particularly if there is scarring and adhesion, it might mean that you're not able to put the ports where you want to be able to put them normally. So you might have to change how you address this. Um Usually in cancer operations we will, our practice is usually to do a fan and steel and do a pneumoperitoneum safely. That way, I think if you're doing redo surgery and there's uncertainty about whether you're going to finish this operation with a midline incision or a fan and steel incision, you might opt to do the pneumoperitoneum in a different way. So I will often do a various needle at Palmers point and then I'll do a vi port with my air seal fairly laterally um to try and get safe pneumoperitoneum and safe entry of the first port. The other thing to consider is theater access. So essentially robotic surgery is reserved mainly for cancer operations. So how can you as an IBD surgeon get in there and offer it to your patients and if you or like myself, I do some cancer and I do IBD, you have to learn to manage the cancer patients as well as the IBD patients and somehow decide which ones are going to get the robot and which ones are not. And some of that is managing caseload. Some of that is becoming better at recognizing patients who you are going to be able to do successful robotic surgery on and some of it is accessing wider areas. So looking to do extra lists and I think Katie and I both have done that to try and get access to the robot for IBD patients. And I think the final thing which is probably close to most of your hearts is training and, and I do know surgeons who do a hybrid approach between robotic surgery and laparoscopic surgery so that the trainees are able to do some of the operation. And we've really tried to move away from that and we tried to become as open as possible and allow our surgical trainees and fellows access on the robot so that they are able to pick up, they do their simulation work and they are able to do some of the operation robotically. And I think that's increasingly how we should be moving. So patients don't all come in the same size. I think the top diagram shows a patient that I've never seen. Really, most of my patients don't look like that, but that's the standard sort of for robotic port set up that is described for most colorectal resections. And in a patient who is more obese, you might want to spread the ports out more, you might struggle to get down into the pelvis if the port is too high. Um in a skinny patient, it becomes also challenging because the ports have to be 6 to 8 centimeters apart. And it might not be possible to do that in a patient who is very narrow. So those are some of the considerations that you might have to think about when you're doing surgery for these patients. So I'm just going to talk through a simple operation. I know Kate is following. And she's probably got some more videos of more complex procedures. But this is just to highlight one way of doing a robotic subtotal colectomy. So this was a 36 year old lady. She'd failed two biologics and actually opted for surgery even though she was offered a third biologic and underwent a robotic subtotal colectomy. And this operation can be done in many different ways. I tend to use a similar approach to what is described for cancer surgery and have adapted it for a subtotal colectomy. So there's two docking positions. The first docking position is with a robot from the left and aimed at the rectosigmoid. And we do the left side. And then when you get to mid transverse, we flip the robot still from the left, but we target up towards the right upper quadrant and we do the right side. So I'm going to just see if I can come out of this because this video so just bear with me because its video is glitching a lot more. So we start from the left side. I hope this is projecting and probably hopefully it's running better than the on the power point. Um But I tend to keep it quite simple and some, some surgeons will say that they do this operation like a cancer operation. I tend to not do it like that. I tend to do all the lateral mobilization. Um and then go right the way up to um splenic flexure get into lesser sac. So the splenic flexure is completely mobilized, then divide the and create a window between the knees entry and the and the bowel so that able to staple across and divide the rectal stump. And then this allows you to retract the colon up and you can do a close colonic division of the me and tree and fairly easily zip up along it towards the splenic flexure and divide up all the way around to the transverse colonic mesentary. Um And then this is again, still in the same poor position, not redo at all, the omentum has been taken off and there's a nice view into the lesser sac and then you basically carry on going around. Then this is once that's done we undock and I redo again and, and this is um taking off um you know, uh omentum and pulled um medially to umbilicus. And you can see that the entries has been divided and the duodenum is behind um and then web uh the lateral attachments to the right colon um and uh follow it around. Uh and then you can staple inside and retract uh and remove the bowel through um through uh a fan and steel. And similarly with um fistulas, uh I might just have to run this from the beginning, apologies. So this was to illustrate the point that it's possible to resect um fistulas. Um And this is a gentleman who had a co vy fistula, um, not an IBD fistula. Um, but essentially the point is the same, um, you're able to detach and retract the sigmoid mass of the bladder and repair it with robotic instruments safely. So, in terms of do s and don'ts, I think it's important that you do perform robotic IBD surgery as part of that. I think it's important that you remain meticulous in how you approach the patient and that's really paying attention to all the other things that I've talked about. Not just how you're going to do the operation, prepare your patient and yourself for what's going to happen next, which is the operation and don't be afraid to learn from others. I think that there's a lot to be gained from sharing practice, learning what works and what might not work and, and developing new ways of doing things don't dive in. I think if you can take a step wise approach to robotic IBD practice, it will get you there, but it will get you there in a much safer manner and you will become more confident with how you approach the operation as time goes on. Don't give up. It can be quite challenging. At times, there have been times where I've sort of questioned myself and thought, why am I doing this to myself? And actually, what I've realized is over the three years, I've increasingly been able to do more and more complex surgery, particularly inter purple anastomosis and C os anastomosis. So I think if you can do all of those things in the end the journey and some of the pain is worth it. Um Don't be afraid to try new port positions and docking positions, try something out and see if it works for that patient. If it doesn't, then think about how you might change things for the future and the next time. But you do need to be able to have a degree of Seril to be able to deal with the different scenarios that you may face and the ability to think around some of the problems that you might have with clashing or changing the poor position or the camera or the way in which you have your assistant. So what are the unknowns? I think there are still some unknowns I think that we have at the moment. Um and some of the retrospective case series and Katie's recent paper, all actually highlight that IBD surgery and the robotic platform is safe and it's feasible. Katie talks about trying to standardize the approach, which I think is very welcome. And I do think that we need to look at ways in which we can do this across the board, particularly if we are in the market to try and translate this and adopt it on a larger scale. We do need to have ways in which we recognize this operation is done best in this way. What we don't know is what impact it has on the patient. We have some rumen data in terms of length of stay and recovery. But what effect does it actually have on the patient? And particularly regarding the long term impact on that patient for their foreseeable journey with inflammatory bowel disease. We don't really have an understanding of that and we'll probably fair way off trying to get that. The other part of this, which I think is important is the impact on the surgeon. As most of you will know if you are in the pelvis deep down trying to do an open operation to remove a big fistulated mass. It is not only physically but emotionally draining. And when you do it on the robot and you can walk about, you can have a cup of coffee or tea and you can take it at your own pace. It definitely transforms the experience for the surgeon. And that's something that we are in the sort of early stages of really understanding cost is always highlighted as one of the negative aspects of robotic surgery. And I'd sort of argue that we know the cost of using the robot. What we don't know is the cost to the patient of not using the robot. So that is something that we need to address. I think where it gets really exciting is all of the other things around digital technology and artificial intelligence. And I think that it will question how we do surgery. We will learn more and more about the human robot interaction. We will have artificial intelligence technology to be able to help us learn and get better at learning and we will also be able to think and change how we do surgery. It certainly has for me. So I'm going to end there. I'll stop sharing and then um you can go on to uh Katie before we take questions. Thanks very much, Miss, that was a, a really brilliant talk. Um I can see some questions already coming through. So a quick reminder to our audience um to please keep them coming in the chat and we'll, we'll get to them after um the next talk. Er, so our next speaker is Miss Katie Adams. She's a consultant, colorectal surgeon and lead for gastrointestinal surgery at Geiser Saint Thomas's. Er, she's on the ACP GBI IBD and External Affairs committees and is a past president of the Dukes Club. Thanks very much. Thanks, Andre. All right. I'm gonna equally see if I can share screening, screening screen. Um So thank you. Thank you for the invitation. Um It's always lovely to be able to talk to the Juices Club. Um And you know, having spent years there myself, I know how passionate we all here feel about training. Um We also feel about our patients, we feel about the future of surgery. Um And I don't think there's any denying that robotic approaches used safely and used well, um, really are the future of, of sort of where we're heading in terms of our surgical practice at the moment. Um, Abby's giving you an incredible, you know, breadth of vision in terms of IBD surgery, um, with robotics. And I would agree with absolutely all of that. Um, a lot of my messages will be absolutely mirrored to her, um, about starting within your limits, um, planning your operations out, optimizing your patients. Um And then I'm, I'm here to sort of be a bit more of the bad cop about. What, what about when things go wrong? What if it's too hard? Um And are there certain things that you shouldn't do? So, I've been asked to talk about redo surgery, tips and tricks and troubles troubleshooting and I try and keep you guys to time. So I think if we look at redo surgery, so we know that sort of, you know, about 20 to 30% of our Crohn's patients will require further surgery. Most of our patients with ulcerative colitis don't have the luxury of a one stage operation. Most will have at least a two stage. Um and more commonly a three stage. So when we're looking at these patients, often, their anatomy isn't how they started out. So it's so important to think about how is the anatomy different to your standard set up? We've heard from intuitive about, you know, the sort of capabilities of the technology that's there, the different generations of technology that's coming through, but nothing will get you around. The fact that each patient in front of you will be different. Now, in cancer surgery, that is slightly different because most patients will have, first of all, a normal bowel, um, with a pathology within it, as opposed to IBD surgeons who have an inherent disease within, if not some of their bowels, sometimes an awful lot of their bowel and particularly if they've had surgery before you need to know where you're going. You know, the roadmap is completely different, but also the priorities are different. This isn't about a high tide, this isn't about nodal clearance. This is about either, um, you know, sort of bowel preservation in the case of Crohn's or bowel sacrificing in the case of ulcerative colitis. Um, so you don't really want the same approach that you would for cancer. So, radiology is definitely your friend within this. So what does the radiology tell you? Where is the bowel going to be? Where are the vessels going to be? What are the challenging parts of the operation going to be? And even before you start planning what you're going to do with the bowel once you're in, how are you going to get in? About 45% of my patients will have had surgery before. So I'm kind of split now between about, you know, sort of half, first timers and half coming back for recurrent surgery and most of those will have had previous open surgery. And whilst initially, that was a contraindication actually, over time, it, it now isn't, um, there will be some patients who I sometimes might regret that decision. Um But with time and patience and training and expertise, you can translate the benefit of robotic surgery to patients who previously would not have been considered. Having said that your standard approaches for getting into the abdominal cavity, seeing if there's a peritoneal cavity or creating a peritoneal cavity do require some thought. Are you going to try and go in through an umbilical incision? Are you going to do what Abby does and put a ve needle in? Um what if you can't find a plane? You know, what are your options? Then? I think also it's so important to think about. Not every, it's not all or nothing this is not about. Could I do this really hard operation robotically often that may not be a full benefit to the patient, the patient will have a longer and longer operation and at what point does that benefit? Stop. So you've got to think about actually what does give benefit to the patient when we're thinking about open operations for a patient, it's the upper abdominal incision which causes most pain, respiratory complications, splinting of the diaphragm. So, can you do something to improve that patient's recovery whilst at the same time improving both your expertise, your robotic skill whilst keeping that operation safe. So many of your patients, if you're doing IBD surgery will come to you with a stoma or you'll have created one previously. What are you going to do that? What are you gonna do with a stoma? So often say, for a patient who's having either a completion, proctectomy after a colectomy or they're having a pouch surgery, leaving the stoma in place is ideal. It will keep the small bowel out the way. Often. The contrary is true for patients with Crohn's in that the stoma is your friend and it is an access into the abdominal cavity. That means you don't have to go through their previous often open midline incision. So this is sort of a characteristic of a patient of mine where unusually for Crohn's, the patient has got a higher BM I, but we're using the stoma as the first port of access. Now, bowel control is really important. So it's important as early as possible to get the end of the bowel closed. I prefer to use a stapling device to make that as safe as possible as soon as I've got a significant length of the bowel. And you can see that I'm currently unfolding the end of the loop pile ostomy here. And once it's unfolded, I'll be able to staple over the absolute end of this bowel. And that will mean that you preserve as much length as possible. You can then follow that down into the intraperitoneal cavity and with a stapled over end, that bowel can be returned to the abdominal cavity. You can use a, a Lexus wound protector or another wound protector with a cap which you can then either use for insufflation. You could initially use, you know, for your optical port. You can even use a robotic port there if it's in an ideal place for your use. So when we're looking at previous open surgery, I'll take you through a patient here where you know, you have your standard set up for a right hemicolectomy. And it will be easy to think because this is my favorite set up for an ileocolic resection in a Crohn's patient. And actually, that might be completely wrong. So this is a patient who's had three previous open ileocolic resections, they've now got new distal ile stricturing disease. They've had their standard preoperative workup, which for us is the IBD MDT. And obviously, after discussion with the patient about their wishes and their options, um they'll go ahead and do a preoperative optimization diet, including physical exercise and an elemental nutrition and an MRI for planning and it's the planning that's important. So here this is my standard set up for an E colic or EOC cecal resection, particularly a first timer, it's completely perpendicular often to what you'll see for a standard, right Hemicolectomy. And that's because it's often the EOC cecal junction itself, which is most inflamed. You might have adhesions it might be attached to the sigmoid um as opposed to doing that cm plane where people are really trying to go up as high as possible over the duodenum to get as many ileo um sort of colic lymph nodes as possible. But if we look at their MRI, what you can see is that the previous ileocolic anastomosis from this third sort of previous resection is actually now on the left. And what you can see is you can see that there is the ileocolic anastomosis almost in the left iliac fossa. You can see then that you've got the small bowel here, which is all thickened and you can see the large bowel and this is actually the distal transverse colon going up into a very high splenic flexure. So for this patient, the challenges are their previous incision, the new stricturing disease, the abnormal anatomy of the anastomosis being in the left fossa, but similarly, needing access to the splenic flexure to mobilize the bowel to do a repeat resection. So only by looking at the radiology beforehand, would you have realized that your original set up would have been completely inconsistent with the surgery that you've got to do? And for this patient, actually, he actually already had a small umbilical incisional hernia, which in this case turned out to be fortuitous because we used that for our initial insufflation. And he actually ended up only with a small extraction port despite the severity and recurrence of his disease. So on his fourth operation, he's ended up with the smallest incision and actually the recovery then for him was completely transformed from something that would previously keep him in hospital each time for about 10 days, for something that got down to about four days. So if we think of the tips and tricks now, a lot of this, you've heard from Abby already and I'm not gonna go over it again, but start simple. There is no benefit to trying to do your most complex patient robotically initially. So do first time surgery, do patients who've got limited disease in a well optimized patient. This is absolutely about operating safely and giving your patient benefit with added benefit to your next patient. And by that, I mean, say that you are not ready to do mesenteric control during your operation, you're not ready yet to either take on dividing it all with an energy device or my preference is often to individually ligate vessels say with a hemolock. Um and you may even not feel comfortable separating the bowel doing a bowel division and certainly not doing an intracorporeal anastomosis. But what if you mobilized all of the bowel? So that that patient could have a smaller incision or even a an incision that might be the same size due to the size of the mass you need to get out, but it's lower down the abdominal cavity. And that will mean their recovery will be less painful. So either by sort of inferior your incision or reducing the size of it. And this is very much about safety over determination to do it all robotically. But even having said that even if you're a patient, you feel gosh, I only did the mobilization robotically, you know, and I'll often do the same as Abby in that I might start laterally. You might do all of your lateral mobilization. Even if you did that, that patient will receive benefit from your extra skill that you've learned and your next pa patient will certainly benefit as well. Now, it's not all about me. This is also about my colleagues and my trainees learning to do robotic I PD surgery as well. And there isn't that much exposure. It's not really part of the curriculum robotics isn't, you know, sort of included in the case mix yet, although it should be. So how do we take people from, say, either new to robotics completely or new to IBD surgery? And this is all about using the capability of the system. So we know we've got simulation trained, we know we've got dry lab training. So here we've got one of my trainees who much better than me and this is slightly speeded up. I apologize. Um Going through her dry lab steps of making sure that she's got the manual dexterity needed to do intracorporeal work on a live patient. Then we took it one step. Further. And we said, right, your next step is to learn to do an interpore anastomosis. So we made a jig for that. So we created a sort of pseudo small bowel and we started training and we started doing it again and again at the end of cases. And what we found is then we've actually got the trainee doing the operating here in the pink hat. Um And then we've got one of our more junior trainees in the blue hat at the back and I'm walking around trying to keep my hands in my pockets because you're doing such a sensational job. So that is more challenging. When you're talking about IBD surgery, there are a lot more unconventional steps but the conventional steps still exist. So I think part of our role as a trainer is to say before the operation, what can we do? We can learn from planning. So where are you going to put the ports? Why are you going to put the ports there? Let's learn from the radiology together. And then how am I as the training trainer going to identify which steps might be suitable for training? And that's where collaboration is so important. My trainee and other trainees who come in will have different goalposts of what they want to do robotically. Some will say I want to use one arm and hold a bit of bowel out the way. It's my first time after doing all my simulation training, I just sort of want to start getting my hand in. And others will say actually, I've done everything except the intracorporeal anastomosis. You know, this is all the training that we've done together. Let's do that and I'll go great. Well, I'm gonna retain your mental reserve. I'm going to do a lot of the other steps so that you are as fresh as possible when we get to that step because I think the days of start and see where you get to, you'll only ever start. You know, it's the middle parts which are so challenging, which you can learn the most. And also you might be able to convert a harder operation into a simpler operation, particularly for my redo patients. I might do a lot of the adhesiolysis. So then my trainee who will be sitting with me on the dual console will be able to say right, I'm ready now to do this part because I can see the pedicles that need ligating the mesentary that needs dividing and the bowel that needs mobilizing. So we've already heard about this already that ab I patients aren't obese often they're underweight and that brings challenges because they're not just often underweight. Now, they've often had elements of disease when they were younger when they were still growing. So they may have an incredibly narrow frame and that brings together challenges of patients who you can't put the ports all in a row. So what do you need to do instead or you need to often arc them. You can either do a diagonal incision or I prefer doing this kind of sort of frowny face um where you're pointing towards your pathology. So for example, this would be a pelvic set up. But I've got an example here, a patient having a right hemicolectomy who was very small. So I couldn't put the lowest port in a line. So I've curved it round. It's really important that you curve towards your operating field. Otherwise you're gonna have a lot of clashes, previous operations. So this is what we've talked about how you're gonna get in. Where are you planning to extract? And the adhesions are often centered under your previous incision. We don't really appreciate that doing. We do open surgery. We think the adhesions last forever. They often don't, they're often centered on your incision. So if you can get in somewhere else, then often you can relieve those adhesions much more easily robotically than ever doing laparoscopic adhesions which often drains your soul. Now, this is an example of extreme adhesions. So this isn't something again, I would recommend on your first day, this is a patient who I've managed to gain access into a small part of their abdomen, which I predicted wouldn't have adhesions, which they didn't. Unfortunately, the rest of their abdomen did. You can see how close I am to the instruments here? And that's because that is as much cavity as I could achieve. So this is a patient who actually ended up going a really extensive operation who had it done completely robotically, despite having had a previous open athesis and a previous open subtotal colectomy, this patient's small bowel was all plastered onto the anterior abdominal wall and it took over two hours just to do the athesis to get the rest of the robotic ports in. I'm using a laparoscopic instrument here and I'd recommend only do laparoscopic until you can get your ports in. Don't be tempted to start doing all the adhesiolysis together. Aim for where you need to put your ports in. Often your ports are away from your pathology, cos you need the distance and that might be where the adhesions are less. So, really think about what step is important. First step one is insufflation. Step two is adhesiolysis for your, for your port incision. And actually, it may take you a good couple of hours before you get to the traditional first time surgery of step zero. Identify pathology. Now, this, this is a very recent patient of mine and this really goes to prove a point of it's not always gonna be possible to do it all robotically, you know, and if that's the case, it doesn't mean they won't get benefit. I have done all of the patients adhesiolysis and bowel mobilization for this patient robotically. I'm now left with two welded enterocutaneous fistulae for recurrent fistulated Crohn's and you can see the whole mass just sort of moves on block. You can see a small bowel loop on that right side and everything moves together. This is a completely solid area of small bowel. There's actually an abscess cavity with a fistula leading into it and then the abscess cavity leading out through the abdominal wall, which you can now see in front of you. And in, for me, I knew I wasn't going to be able to do that part robotically. I also knew to get the specimen out. I was gonna need a certain extraction site and therefore I did everything. But this part, this patient had a much smaller incision, then they would have had it had, we said, well, we'll just do it all open and they had a safer in operation by not trying to do the part which I knew. Currently, I couldn't do that robotically, multivisceral fistulation. So these, I used to really shy away from probably for about the first year actually. Now this doesn't feel as bad. So we've got patients here who have either Coover cycle fistulas, entero cycle fistulas. Um Patients might be fistulated from the small bowel to the large bowel. And if you know that part of the bowels coming out, then it does give you more flexibility of when you're doing your dissection, often it's really vascular. Um and it's really hard to get into those correct planes. You can see we've got the bladder at the front and it's been dragged down into this inflammatory mass of the bowel below. But actually, once that's all taken off, often the fistula isn't that big, you can then repair it with your sort of more articulated hands than you would have laparoscopically. And it's quite simple then to perform a repair. But again, you want to take your time in building yourself up to these, it's not necessarily always about technical skill. It might also be about your mental faculties once you get to a really hard part of the operation and you may find you even want to operate in pairs. And certainly, if you're training, then if you said actually, it's the fistula, that would really be the best thing for me to do today. Can you do all of the other bits so that I'm as fresh as possible when I get to that part here, we've got a patient who's one of the few videos that I haven't edited down. So I'm sorry about that. Um So this is a patient with a really large enterocolic fistula and it was really hard, sort of getting access into the patient. We've done some adhesiolysis already. And now we're going to try and find this fistula to separate it out and you'll be able to see on the left, we're trying to just move the bowel around, it pulls all the small bowel up together, um, which you'll see in a moment and then on the right hand side, what you're going to see is you're then going to see actually the fistula coming apart. And at some point you've got to cut across a fistula. You know, we often get really worried about, I'm gonna go into the bowel. Of course, you're going to go into the bowel, it's open on both ends. At some point. You've got to remember that your positive pressure within the abdominal cavity is going to help keep all of that spillage to a minimum. You can see I've got a swab ready to catch any spillage. And I've got my surgical assistant ready to suction if necessary. And this fistula probably was about a centimeter and a half wide, which actually, then we ended up having to suture repair on the inside. We did a first layer and then a second layer on the colon side cos the colon one's an innocent bystander if you found this and you weren't yet up to the job of saying I could do all this robotically. You lose nothing from saying I'm going to leave that part. I'm going to mobilize all of the bowel as much as possible so that it's going to come out of an incision as easily as possible. I'm not going to then be having tension on the bowel and I will do this part on the outside because maybe next time you won't need to. Now this is a common thing that I find and this is what I found with my prox as they, and it's someone Abby works with very closely as they just kept telling me how awful the bowel was. And it's about what do you do if the mesentary keeps bleeding when you're trying to move it? And the bowel is edematous. So on the left, what you can see is you can see some terminal ileal Crohn's disease. You can see there how thicken the mesentary is and it's about two or three centimeters thick at that point, no energy device is going to take care of that. So one of your options is if you're not going to be able to either suture that Mery, if you don't want to take it extracorporeally to divide it, which you might do initially, what would happen if you actually just went higher up the vessels. So if you did a relatively higher tie, we're not saying about chasing the ileo colic artery up to the duodenum, this is just about reaching a part of the mesentary which has got more normal vasculature. So here I am just dividing the ileocolic pedicle. And you can see at this point, it is small enough that I can dissect out the vessels and I can actually hemolock the vessels individually. So even if the me and tree is very vascular, you can, if you want to go more proximal. And whilst that may feel harder because we always say, I'll go close to the bowel. It's easier to control actually robotically because you're already at the floor of the abdominal cavity. It can actually be easier. And then what to do if your bowel is really edematous. So here I'm just showing someone with limited eli eli cecal disease. So I'm gonna be lifting up the caecum and see how I'm holding the mes tree and then all of a sudden I'm gonna go, oh, I can't hold it. It's too thick and you can almost see me thinking I'm a bit slow. So you, and you can see suddenly I'm paddling it, you know. So instead now of holding onto the mesentary, I'm now going to imagine that it's just my hands and I'm just gently scooping it up. You can see how thickened and edematous that bowel is. If you start grabbing it, the bowels gonna either tear the Mesentary is gonna tear or it's just gonna slip out of your hands and you're gonna do the same step again and again until it does bleed or tear. So I think it's important to know what the bowel feels like on the outside so that you know what to do when you're handling the bowel on the inside. I found it so useful in my training when I was learning robotics to stop thinking of these as instruments and imagined it was my hands. And if I came across a really thickened piece of small bowel with a really thick edematous mesentary. I wouldn't try and pinch the Mes Andry to move it. I'd take my hand scoop it over the top and lift it all up together. Do exactly the same robotically. So I think that is just on time. Thank you so much. I will stop sharing and we can go to any questions. Thank you, Katie. I think that's it. That was an absolutely fantastic presentation. Um, very humbling as well to listen to. That was absolutely brilliant. There is one question from the Q and A it's from do actually and um either to yourself or to Abby and he's asking what energy device would you recommend using a a Crohn's Me Tree? Um So I think similar to what Kate has already said in her talk about the Mery, I think it wouldn't go where the Mery is really thickened. Um I tend to use a vessel sealer just because I find it easier to operate than the synchro seal. But you know, you could use the synchro seal equally as well. I just find the vessel sealer easier to dissect with. I don't know what Katie uses. Yeah, I must admit. And I'm sorry, II don't like the synchro, I don't, I don't like the act of having to put tension on tissue as a way to get hemostasis. So, so for me, if I'm using an energy device, I'll use a vessel sealer. Um and I'll use the vessel sealer until I may be doing, say three or four sealants on one side of the Me tree and then dividing it before I realize this is now too thick. Um, I still do a lot of individualized, um, vessel ligation with HumaLOG. Um I've done some with ties and I've sutured and over sown some when I feel it's particularly friable. Um, and when it's got particularly hairy. But yeah, as Abby says, you know, if, if you can sort of go even a fraction higher up the, the mesentery, often you'll find that that mesenteric inflammation settles and it's a lot easier. You've just got to keep in mind really being clear about where the feeding vessels are. Um, you have to keep checking and keep deciding, am I going in the right direction? You know, don't take too much entry. And I think certainly, initially I remember saying the phrase, I will never divide Crohn's mesentary on the inside. I now do regularly. But that very much was my journey of, you know, I was apprehensive in open surgery about Crohn's entry. How on earth would I manage to control it robotically? But actually, I think the technology helps you, the fact that you're not having to lift this Mery up out of the abdomen to control it immediately takes the tension off, immediately gives you a better plane. Um And actually I find it easier, you know, I convert less and less because as soon as I convert. I kind of, oh God, this is, it's much harder now. It's open and yes, it's the harder parts you are doing open. But yeah, vessel sealer. Absolutely fantastic talks. It's just so beautiful to see how um robotics can be used in IBD. Um And uh I think one of the things II was really asking myself is do you have, you have either of you um come across any resources at the moment that trainees can look up and maybe uh read and prepare for a career in IBD and robotic surgery or is it too early or is there, is that, is there a niche that we need to fill? I mean, I think by the time that, you know, even now, I would say it's not becoming niche, you know, this is becoming more and more common, you know, the whatsapp group that Abby and I started exploding. We've got people from throughout the UK who have joined there. Um You know, I'm sort of into my second year of having an IBD robotic fellow and we go through kind of the same steps again and again, I think Abby's the same, you know, where it has been a, a voyage of learning. Um And what's really important is that nobody should feel they've got to start that, that journey on their own. You know, the IBD principles are the same patient optimization, patient selection, good consenting close, working with your gastroenterology colleagues. Um you know, and all, all of this that go around our patients that help them get to the operating day and the exact same in theater, you know, I've got a surgical care practitioner and literally her and I kind of have safe words, you know. You know, like I'll go, have you got Hemo? She go. Yes. Have you got a hea, yes. And we'll say that about four times, you know. And so I think, yes, you may not get a lot of it during your regular training. But I think having a good fundamental understanding of what Chrome's and I and IBD in general is um what the challenges are, somebody having good robotic training can easily translate that with IBD knowledge into really effective IBD robotic skills. You know, there is nothing here that Abby and I do that are doing differently other than we're probably having to go more on the first principles. You know, we haven't been able to say where's, where's the sort of, you know, robotic device to guide, saying where these ports to go? I think I'd agree. I think that it's also important that it's not just focused on robotic surgery. I think it's actually the wider IBD principles. And I think that in terms of a training perspective, if you are wanting to be an IBD surgeon, you really want to have some time dedicated to learning about IBD practice. So it's not so much the technical side of it, it's about the decision making. It's about looking at the patient and sort of deciding what your strategy is going to be. It's about knowing that there are bailout options and planning an approach accordingly. So I think for the future trainees out there, I think you look for IBD fellowships if you have a genuine interest in developing IBD as your practice, because I think it will stand you in good stead to have that focused training. I do think things are changing. I remember my sort of standard surgical training, there were a few centers I worked in where I BD had been centralized to one or two surgeons. And if you work in a center like that, you will get much greater exposure to IBD as a subspecialty than if you work in a center where everybody does a little bit. So it's looking for opportunities in your regular training. But if you don't have access to those, it's going out and looking for those fellowships. And I think the robotic side of IBD, it is more challenging to train somebody on robotic IBD. But like Katie, I tend to break up the operation and I will get the trainee doing some of it. I will do some of it because like Katie says, it takes the mental burden off you. It's a long difficult operation if somebody can do some of it and you can do some of it and you can share and learn then I think that that's the way forward and increasingly you will troubleshoot with your fellow or trainee that's present. So they also are part of that conversation. So I think it's a two way process. But yeah, I do think that you should have dedicated time for IBD training, either in your normal training or outside of that in a fellowship. I think, I believe quite strongly in that. Thank you so much. I think um we'll end this webinar on uh on that note and that advice. Um So this was fantastic. I'm already getting lots of great feedback. Thank you so much to our speakers for taking the time out and uh going through such an impressive uh uh uh uh surgical technique and with such impressive videos. Thank you to uh Alison Rohan um for supporting us and to intuitive as as well for always supporting training. Um This episode ends our robotic uh series in February, but we will come back to you in March with a fantastic episode with uh a huge lineup of a great speak, including Professor Joel Tierney, uh Danila Moscovitz, Charlie, Evans, Alice Hartley Peter Von, and Justin Collins. So lots to look forward to. Um We don't end of February here though, on Wednesday, we have an MDT peritoneal malignancy session. Uh So please join us for that and um I think that's going to be fantastic as well. So, with that good evening. Thank you so much.