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Dukes' Club Robotic Assisted Surgery Webinar 5: Robotic Assisted Emergency General Surgery



Join us for an engaging on-demand teaching session where world-renowned speakers, including pioneer Robotic Colorectal Surgeon, Professor Jim K, will explore the utilization of robotic assisted surgery in emergency general surgery. The session will delve into the challenges and advantages of robotic surgery for diverticular disease, a growing pandemic, particularly among young people. With a focus on improving patient's quality of life, Professor Jim K will reveal how robotics can overcome the technical limitations of traditional laparoscopy and discuss the results of various case studies and systematic reviews comparing laparoscopic and robotic approaches. The content of this session will be valuable to any medical professional interested in the advancements in robotic-assisted surgery.
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Session 5: Robotic Assisted Emergency General Surgery

Learning objectives

1. Understand and recognize the increasing prevalence and complexity of diverticular disease in a younger population and its impact on emergency general surgery. 2. Identify the distinctive challenges and complications associated with surgical treatment of diverticular disease, including loss of tissue plane, bulky mesentery, and higher risk of intraoperative complications. 3. Gain knowledge on the advantages of using robotic-assisted surgery in managing perforated sigmoid diverticular disease, including lower conversion rates, lower complication rates, and quicker recovery times. 4. Understand and critically review the current literature on the use of robotic-assisted surgery for diverticular disease, specifically focusing on the outcomes, advantages, and limitations. 5. Discuss and evaluate the role of enhanced technologies in robotic-assisted surgery in improving surgical outcomes for patients with diverticular disease - particularly considering operating time variations with experience.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Right. So, hello everyone. Thanks for joining us. This is our penultimate um robotic webinar session. Um And this one is on the use of robotic assisted surgery in emergency general surgery. And I'm thrilled to say that we got some world renowned speakers today. Um And it's my pleasure to introduce our, our first speaker who is uh professor Jim K. I mean, he, he essentially needs, needs no introduction, but um he's one of the pioneers of robotic colorectal surgery is offered counseling courses and fellowships and, and tonight, we're, we're pleased to be hearing from him about er robotic surgery and emergency perforator, diverticular disease. So, pro over to you. Thank you Tanner. I hope you can hear me. Ok. And uh thank you for a very kind introduction. I appreciate that it's an absolute player to, to be with you tonight. Um I think uh Dukes has done amazing job with the uh series of webinars uh that have been conducted so far. And this one is a real cracker Jacker with uh pushing it to the limits now, with robotics in the emergency setup. I'm just trying to share uh my screen and let me see if you can, please confirm that you can see my slides. Yeah. All good. Yes. Yeah, good, good. Thank you. So, yes. So I've got 2025 minutes to talk about uh a particular role of robotics in perforated sigmoid diverticular disease. Um and I have to do, try to do some justice and um I'm gonna be followed up by Alan Naval who's got a significant experience in this domain as well. So it would be great to, to share some experience from her as well in terms of managing this. Um These are my disclosures. What I've tried to cover is about role of robotics in diverticular disease management. Try to summarize some of the published literature which sadly is limited. Um and maybe uh the application of enhanced technologies in robotics. And how does it help us to do the job well in diverticular disease surgery? And there is some data from um uh our center's experience. So s sigmoid diverticular, you can look at it. It is a continuum of variety of presentations ranging from uncomplicated diverticulitis to complicated diverticular disease which could present with abscesses, fist, stricturing with bowel obstruction and often leading to an emergency admission with either a perforation or a large bowel obstruction. Now, I don't want to bore you with epidemiology of diverticular disease, but it is a changing landscape. And I think when I, when I was studying, I was taught that it's a disease that happened in the seventies and the eighties and a lot of people have it but don't get complications or symptoms and that's not true anymore. A lot of people are in the age of 30 to 50. Um I often see a lot of young people coming in with more advanced and more complicated diverticular disease and it's a real pandemic, in my opinion, especially on the emergencies. Um because these young people often neglect their symptoms and come in quite late thinking that this may be IBS and it may be that there is an overlap between IBS and diverticular disease, but it is increasing in prevalence, especially in young people. We have some guidelines from A CPG B and such coloproctology mainly suggesting that we have been historically, very conservative in treating diverticular disease. And we only get involved as a surgeon if there are complications, if there are um rec recurrent admission with diverticulitis, leading to either uh uh fetal peritonitis with H three or four peritonitis or, or, or failure of conservative treatment. Um or eventually somebody presenting with bowel obstruction, um elective surgery for uncomplicated diverticulitis is still rare. And the reason we do this is that there are consensus guidelines from quite few national international societies about why you want to do surgery. It is done to improve the quality of life because divert disease can still happen in the remaining colon and cause ongoing symptoms. But you want to prevent complications in the future. And improve someone's quality of life. Now, as surgeons, we need to understand that there are particular challenges here. When you're dealing with diverticular disease, there is a loss of tissue plane due to inflammatory reaction around the colon and the mesocolon which cause sticky planes and it is not as nice and clean as you see in cancer patients. The me entry gets bulky, distended, stretched and is difficult to handle. It's friable, it bleeds because of chronic inflammation. It is a much challenging dissection, especially when you're trying to identify key structures such as ureter and canal vessels. And then all of that can translate into higher incidence of intraoperative complications. Um especially if there is a less experienced operating surgeon involved. Um multiple papers from around the world show a higher conversion rate uh in this particular group of patients as opposed to cancer patients. Now, elective surgery um has been shown with um better outcomes, short term, laparoscopically done, you get better results, but there is a significantly high conversion rate in this group of patients so much so that when any training program started around the world and laparoscopy or robotics, we often say don't try to do divertic colitis or complicated diverticular disease patients on your learning curve because that's where the experience was not that great. We published some data, excuse me from uh my unit, looking at the trends of emergency laparoscopy uh intervention in colorectal patients. It's a seven year study and Portsmouth have been very heavily laparoscopically focused, um, center even for emergencies. And you can see all comers here with perforated diverticular disease or bowel obstruction get laparoscopy as a default. And if you look at the conversion rate still, there is a decent conversion rate, especially for colectomy 26%. So one and four gets converted, um, and same for the right time is a bit less uh, um, total colectomy 17%. So there is a healthy conversion rate. But again, you can give some leeway here that you're doing it for all comers and you're putting a scope in doing a diagnostic assessment and then converting early if there is no space. But some of these conversions can be avoided because the technical challenges of laparoscopy in these patients are way more than sometimes the robot offers you to do. So. If you're gonna get involved with robotic surgery for these patients, then again, the the goals are the same to remove the disease area and preferably rejoin the bowel back with an anastomosis. And the challenges remain the same that the adherence with the side wall, with the bladder, with the vagina or the fistula, you have to be able to dissect and perform it. Elys, take down the fist and uh recorrect the anatomy. And of course, the robot offers advantage. In my opinion, it's been supplemented by many of these meta analysis and reviews that you overcome the technical limitations of laparoscopy with the robot, often the sigmoid flag one which is in the way of you reaching the sidewall is a problem with the straight, straight, straight stick instruments. But robotically, you can go over it and you can also perform a lateral to medial mobilization of the mass, identifying key structures, preserving ureter and gonadal. So, decreasing your c and size pain, improving your recovery and reducing your length of stay is a a win win situation for this group of patients. So there are two meta analysis uh recently published um uh looking at significant number of diverticular patients and they all agreed, I'll show you some more detail in a minute that they showed decreased conversion rate, decreased complication rate, decreased length of stay, but at the cost of increased operating time and I will dissect that in a minute. So there's a, there's a paper from Debbie Kaller and uh Elizabeth Raskind from the US. They looked at about 1000 patients in each group compared robot lab and open sigmoidectomy, but they included both complicated and uncomplicated a articular disease. So it's a quite a wide range of heterogeneous group. But again, they showed the same thing, short length of stay, less complication, less conversion, but takes more time. Following on. There was a study published in 2020. So the previous one was 2019. That was the early reports of uh robotics in emergency setting from the US in 2020. There was a paper from Italy looking at the feasibility of doing um robotics, single cancer, single case study from a center, 77 patients. Um So 80 patients, 77 were reas and with a pretty decent outcomes, you look at those outcomes and say yeah, fine. That looks really good for diverticular disease patients, less conversion rate, less complication rate, six days length of stay pretty acceptable. And two year um two years ago, we had a systematic review uh by Helen Mohan and her colleagues and they looked at 15 articles, half of them were case series. But you, you have a decent number of robotic resection in this group over 3700. And again, the same method is coming out longer operating time, but less conversion, less complications. Um So sorry, they didn't show a significant difference in grade three and more complication maybe in the grade one and two complications were less. Uh but there's no data on the quality of life and functional outcomes. This is the last one which has been published and I'll be glad to know that there's not a lot of literature on this. This is the last review I could find and I think this is pretty recent 2023 frontier of robotics. Uh five studies have been picked up in this. Um It's a systematic review mostly from the US as you can see, one from Italy and one from Turkey. But if you look at the number of patients in these arms, the robotic group has very small number of cases uh as opposed to uh the previous studies I mentioned and their messages were very clear, it took longer. Of course, the operation times are longer in robotics. Uh It has less blood loss in robotic surgery. No surprise there reduced conversion, same theme and lower complication rate. So in summary, most data points towards the decreased rate of conversion. If that's the big hard core point that we're gonna take as a, as a mark, we did an analysis and that is accepted by International Journal of Colorectal Disease just uh last week. Um It is comparing uh left Colectomy for diverticular disease and and and reviewing robotic versus laparoscopic approach. Um in the setting 644 study were identified. But in the end, uh we were able to compare uh only eight studies which qualified um the criteria and again, very similar trends that yes, it um the conversion is absolutely statistically significantly less in robotic hands. Um The stroma race, there is no difference between lab and robot uh operative times are longer in the robotic group. Um And then the hospital stay is the trend is to where a reduced hospital stay in the robot group. Um But this is important um morbidity rates with endo grade three and four complications are less in the robotic approach to Left Colectomy for diverticular disease. In this review not operating time is an interesting one. It's a mixed bag and it comes with experience. If you're doing a lot of operative surgery with the robot, you're gonna get quicker and slicker at this and then your operating time are gonna go down. But if you look at this, some of the studies, earlier studies with surgeons still on the learning curve, you have 30 minutes more on the robot as opposed to laparoscopy. And that could be the draping time, the port placement, the docking times that eventually reduce with experience. And if you look in the lower half of this uh table, you eventually find that actually there are some studies where they're not finding any difference between lab and robot re remember that these are complicated patients which even laparoscopically will take longer. So the operative times play around depending on the strength of the team, their, their performance and their experience and the difference is not huge, even not talking of hours and hours of difference. It, it's about 30 to 40 minutes max. We have another study which has been been submitted for publication looking at diverticular disease, uh robotics versus laparoscopic. But we are picking up complicated vertically. This is the group we are talking about which has flat mo perforation, sepsis, strictures and fist. And then you're comparing um the patients between that versus uh versus laparoscopy. Um As you can see here, we had a decent spread between the, the two groups, we reduce the stroma rate in these patients. You can do primary anastomosis, uh reduce the need for ureteric stents because you can identify ureter better. With the robotic approach. You have less blood loss and absolutely no conversion to open surgery and there is one day less uh hospital stay. And that's the same theme that we saw earlier. The rest of the comparative complication rates are very comparable between lab and robot. So a little bit about the technical side of it, what you're trying to do as an emergency, the setup is gonna be as here no different from your left side or an resections. You know, make sure that you have access to, to the, to the to the anus or anal canal and you can uh um perform uh uh endoscopy interoperatively if you need um single docking. Um The key advantages of a robot in this setting is the adhesiolysis. The first part of the operation always gonna be adhesiolysis and the robot helps you to do that safely. The 3D view, the access to the various parts of the abdomen to do adhesiolysis, take the small bowel loops off or take the chic loops off from the omentum that all can be done quite safely. Then you can take down the fist, which is could be called vaginal clo vasal. You can deal with fragile tissues much better because you're not putting much traction on these tissues. So, hence, there should be less bleeding. The advantages of robotic platform are also because of better vision and that vision allows you to see key structures better. So, uh ureter is the key, the left ureter is the key in these operations and often a headache for the surgeons because of the fibrosis, the scarring on the pelvic side wall, you can't see that very well and you're working over a flag mo and then trying to identify these structures, especially with these patients can be really problematic. And that's often is the cause of conversion in these patients. Um But all of this with a robotic approach allows you to, to see things better and hence the conversion rates remain low. So I'll give you a couple of examples of identification or injuries here on the left hand side, it's one of my friends gave me this video that there is this. Uh it's a, it's, it's a laparoscopic mobilization of the right colon. As you can see the right side sacral pro tree you are dissecting, it's quite inflamed scar tissues, it's not very nice tissue planes that you can see. You are happily mobilizing it immediately. And this is a horror moment when you see that, ok, you're almost now doing the measle colic transection or was a rectal transection in order to staple off the rectum. Um But here you have something in your hand which has an open end. Um And you're looking, oh, what happened there? Where does this one go, of course, if you, if you've identified it, you can do something to fix it, but there's also a way to identify them. This is the ICG in the ureter that you can see on the right hand screen, there's ICG in the ureters that you can use to identify. And that is sometimes very helpful when you're transecting the mis rectum, you see this ureter and you don't go near it and you can um be sure that you are away, but often if it is a lot of fibrosis and scarring and flag it, it can be impossible sometimes to even see the translumination of that dye through. And when you have patients like this who have got bowel obstruction with stricture, all that dilated bowel is gonna be in the way. Um and access is gonna be limited and the injury to the bowel is gonna cause um perforation and contamination. You see big patients high BM I central obesity, perforated diverticular disease with abscess. That's a recipe for disaster. It's a nightmare patient to operate for anybody who is gonna be delving into these patients. Um But there are ways that you can use the technology to help you to to improve these outcomes. One of the key problem in these patients is anastomosis as well. So once you've done the resection, how do you perform the anastomosis in a bowel which has been inflamed, thick walled and circular staples on its own may not be enough to hold the pressure that will be generated. So that, that's why, what very often we end up doing a heart man with an colostomy but improvements in stapling, choosing the right cartridge um and then enhanced technology such as the ability to suture on the pelvic floor. Or is this is not gonna be on the pelvic floor? Often you are crossing in front of the S one or S two. So you have a rectal stump available for you to work on, but you can reinforce that staple line which may be going through the uh inflamed tissues or in or, or thick wall rectum in that area. So choosing the right cartridge to staple using minimum firings of the stapler and then reinforcing that staple line uh with the with sutures can allow you to do better in these patients. ICG assessment definitely helps. And these are the techniques that we have been using with the key enhancement of the anastomosis where you reinforce the um staple line with interrupted sutures, you then perform the anastomosis and then you for that. And I'll show you that in the next clip in a, in a wee bit better. Let's skip this and you have advanced energy which is really important when you're dealing with these patients who have friable, fragile tissue. So, syncro sele or vessel sealer, which is a technology that is offered with robotic uh in platforms. Now, especially with intuitive, we have that others also have similar solutions. Um On the way you will be able to deal with most of these vessels in a, in a bipolar advanced energy fashion uh with the instruments which are of the right profile and shape to allow you to dissect safely in these areas. So this is just one example of what an instrument like synchro, for example would look like, looks a bit like harmonic, it's not a harmonic, it's a bipolar instrument, it does not have a blade in it. And you can dissect tissues and use the traction with your hand to cut the tissue. As you can see here, you're holding it with a bit of tension and traction. Um The tissues are dedicated with bipolar and then just divide it. So for, for small quick uh dissection without dealing with any major vessel, this can be pretty good when the tissues are inflamed that they're gonna ooze when you use monopolar ar. I mean, this could be a really good instrument to use. This is another instrument which not many surgeons are aware of. It's the robotic sucker, the endo wrist instrument, which is available for suction. So I often use it in my left hand when I'm dealing with abscesses and fluids and fist in the lower pelvis, your assistant cannot reach in that target area, they cannot show you space and the position that you want to see. So having this in my left hand is a blunt instrument, I can push with it. I control the section with my left foot paddle. So I'm swapping my feet between right paddle, left paddle, couple of cuts, a couple of sections and I can see the next point to dissect or divide. So it gives you a perfect clear view right at the area where you want to see deep down in the Pelvis or the flag mo in the side wall. So it it it it's a really great tool to operate when you have a very moist tissues at the back or on the side wall or if you're dealing with abscesses. So don't be afraid of, of using that as an extra tool to help you to keep a very clear view because the vision is the key. If you cannot see properly, you will be dissecting in the wrong areas. I'm gonna show you a couple of clips before we finish off this this concept of dissection. But there are gonna be parts of the operation in these patients which are gonna be very safe, simple and easy to do. And you must finish those before diving into the complex part of the operation where the abscess and perforation is. So, for example, in this patient, we are starting immediately um and that's trying to find the superior rectal artery as we normally do. Small bowel is kind of move medially, the patient is placed in the right position as we normally have 15 degree head down and 15 degree tilt. And these planes are reasonably clean. There's not much of a hassle here. There is a word of caution that these planes can be inflamed and you can get some more oozing from the tissues. So you have to be mindful. Um But with patients and gen gentle dissection, you get into the right place. Sometimes there is more inflammation around the region of I can be quite thick balled because chronic scarring and chronic inflammation. So you just have to be confident that you're on the right plane. You have got the gerota's fascia dropped down. So you're not pulling or playing with the ureter, you're confident, then you get onto the vessel and the vessel, as I said before can be very thick ball. So you have to keep dissecting it to get onto the actual target vessel. Now, here, as I say, this bleed is because of the neovascularization and the inflammation in that area. You can see the left colic going up over the surgeon's left hand and this whole thing looks quite big and very often surgeons are then afraid of dissecting this and you have to then use a stapler to cut across this. You can dissect them with control and the actual vessel is still quite thin and inside, but covered with a lot of fibrosis and connective tissue around it. So if you can dissect like this, you can then put hemo blocks on it. But if you are worried about bleeding or you can't progress, you can then take the whole vessel as it was before with a vascular stapler. But word of caution here, if you do that, make sure you drop the ureter, the left ureter in the background because the stale is quite big and the jaws can catch um that structure and and cause more damage. So you need to ensure that you have dropped this dissection, which just was just done here before you uh use the vascular stapler. The IV mobilization is quite straightforward. Often these patients require full splenic flexure mobilization. So don't be um hesitant in doing that because the sigmoid is contracted and thick walled. So you have to do a flexion mobilization, whichever approach you use, you go sub colonic and over the pancreas or you come from the top with the gastrocolic omentum down, but you need to have a plan of mobilizing a flexion. I think for the sake of time, I'll probably skip that because that's no different from what you do in your um standard um cancer operation. But we're gonna go back to the pelvis now in a minute just to delve into the area which is problematic and there's an abscess as well. So we know that and this is a flag mo sitting on the side wall. So you do a bit of lateral mobilization and in these cases, you don't persist with 100% medial to lateral mobilization. The free mobilization is achieved by doing a combination of lateral to medial and medial to lateral. Here. The tissue planes are more edematous because of the recent sepsis. Um This was an emergency admission with perforation. So you're gonna find some abscess and some juice in there and you have to control this. The contamination uh is always a worry and I did them laparoscopically and always found that I was unable to stay in the normal plane with a straight harmonic or, or, or even the scissors because you end up either going into the colon, having a sizable hole and more contamination or you end up having a sizable hole in the bladder if there's a fistula with the back of the uterus or, or the bladder. Now, here we are turning over the left pelvic brim, as you can see the gonadal vessels are underneath. Um and the tissues are again quite fragile and, and edematous. Uh but the clues that you're looking for is this yellow fat, which is the extra uh chronic fat. And once you see that you get into the right plane, so this ability to then stay into the right plane guided by those little clues is quite unique to robotics because of the 3D view and the ENDOS instrument access. Now, I'm just gonna forward this a little bit more just for the sake of time. Oh, what happened there? Sorry, apologies. No, there. So we are now looking at the pelvic brim uh um and the bladder and the uterus at the front just going down in there. So you see how much fibrosis is there and it is stuck. So a good suction working with you to help to control that is, is of paramount importance and the suction is provided now by the assistant because I've got my bipolar instrument. I need that to control any oozing and any bleeding here. The, the, the there's a pus there underneath, there was a bit more pus earlier on the pelvic side wall that was drained. Now, this is the key here, which is a big issue for us when you're doing this laparoscopically, you see the left ureter on the pelvic side wall and this flag one is stuck on the pelvic sidewall. Here you identify the line of the ureter gonadal are there. And then you're gonna work around this flag m medially in a plane that is developed from the back. And this is a pinch point of that pelvic sidewall that will be released once you go through this fibrotic scar tissue and once that last bit is lifted up, the rest of it will be pretty straightforward. Hopefully. Well, it's better than, than what it would be. Otherwise, these cases are never straightforward because the, the ideal clean tissue plane that you're looking for are just not there. And you have to work with that edema and the fluid that is coming through. So now it's almost straighter, you have to do the same dissection from the medial end. And as I said before, it's a combination of working from lateral to medial, medial to lateral. The importance is to have a good assistant who gives you the view and a surgeon who can uh operate with that to dissect and make progress. So the challenges of this kind of work, I think you especially out of hours work are gonna be the lack of availability of a trained staff. If you're doing it on the weekends or evenings, you're gonna struggle to do these procedures because you need team with, you can do docking board placement, set up with. You, assist in the bedside and troubleshoot the instrument malfunctions. Um You need to have access to the platform in the weekdays, your platform will be used. So you might struggle to even do a procedure uh during 9 to 5 working hours. The perception that the longer operating times or in fact, there may be still longer operating times to begin with may be a hindrance of doing this kind of work on the emergency list because people will say you're gonna block the emergency theater for a longer time and we have too much demand of cases to go through. You could you argue that you are taking away a robot, uh a laparoscopic training operation from a trainee when they could be doing a laparoscopic heart meds on these patients. And now it's becoming a robotic anti resection or sigmoid resection, which is done by a consultant and perhaps less for the trainee or the fellow to do. Um That's an argument and also lack of the perceived benefits to the patient. What are we trying to achieve by it? Just because we can do this, we must not do this, but we have to have a reason of why we're doing this. The solutions I can offer the last second, last slide, you have to work flexibly. I think in an innovative fashion, if you don't do this, you're not progressing and moving on with time. I think we have to use elective robotic teams as the on call team to begin with. And that allows the teams that are on call to be trained. So we did this by having an on call team that will come in for these major out of hour robotic procedures and those team were then training the present team uh on how to set up the robot, how to troubleshoot and how to do these cases well, operate together as two consultants or trainees and fellows. And that's a great learning opportunity. Uh And I think there are definitely benefits for the patient for sure. From my personal experience, I think the data is still quickly coming through. So over the next two or three years, we will see more. So I think I'll probably amount of time, I should stop by saying that robotic has a role in surgical management of diabetic disease. The key benefits are identification of tissue planes, minimizing collateral damage to normal tissues and a better anastomosis. Uh and hence reducing the need for stoma formation in these patients. Um And it can lead to improved outcomes in these patients which are complex. If you talk about emergency robotic surgery, I think it's feasible using a robotic platform. The increased use of mis for high morbid co morbid sick patients definitely translates into better advantages on those patients. The level and limited as I said, there are only three or four papers that I could quote. Um And we need to work together to generate that evidence for the future. Thank you very much for your attention. Thank you prov, that was an excellent talk and thank you for the fabulous videos. Um We'll, we'll wait to the end to ask you some questions. But next, I'd like to introduce Doctor Ellen Van. It, he is a colorectal surgeon. She's based over in Brussels, Belgium. Uh She's also a proctor and she's gonna talk us through setting up the E GS service in robotics. So over to you. Hello, good evening everyone. And um, first of all, thank you for having me here. Um It's really an honor to be able to talk to you. Um, and I'm gonna pick up where Jim left, uh, with a question mark. How do you do it putting up an emergency robotic surgery program. Um I had a lesson on how to share. So, is this ok? Yeah, that's perfect. Thank you. Ok, thank you. Thank you. So I'm going to talk about how to set up a robotic uh emergency surgery service or the way to it. Uh because I don't think that we in our hospital are there just yet. So for those who don't know me, I work in Belgium in Brussels in a small University hospital where we started back in 2016. So way after uh Jim's experience uh on the XI system, but in the beginning, we wanted to focus on rectal cancer surgery. That was the goal of my boss. And we just introduced our colonic work as a training purposes. Not because it was the end goal of our robotic program, our robotic recal program at that time. But during the learning curve, we saw that the robotic platform had benefits in terms of exposure of the operative field, the precision of dissection, especially in confined and difficult spaces. So that was not only for rectal cancer, but actually for all surgical resections and also all patients. And what we learned was the tougher, it gets the more clear the benefit of the robot becomes, it's not in those easy slim patients with an early stage cancer. It's in obese patients extensive prior abdominal surgery. And also as Jim said, frail patients, you know, that cannot support Trendelenburg that cannot support uh uh uh traditional peritoneum of 12 to 15 millimeters of mercury. Those are the patients where you see where you can go to the next level using robotic platform. And this is reflected in what we are doing in our practice today. We are actually covering the whole variety of colorectal surgery, being oncological resections with all the different types of uh surgery, TME CME combined resections, also IBD surgery, functional surgery with rectopexy, um and also diverticular disease, which is still uh one of uh the pieces cornerstones of a traditional colorectal uh practice. And then lastly, we introduced the emergency surgery. Now, why should we explore in um emergency uh surgery with the robotic platform? Well, actually, in when we're talking about emergency surgery, what we want is we want to offer the same benefits as that we do to our elective patients. So we want a minimal invasive approach. But actually, in reality, it's often a laparotomy that is necessary either because the patient cannot support the, the the perioperative conditionings or because we get into trouble because it's technically too difficult to get the job done leading to a conversion. And this is further confirmed by some evidence in literature. It is scarce uh all of this literature, but there was a survey held by the World Society of Emergency Surgery back in 2022 asking surgeons, what are you doing in your everyday practice? And what was uh astonishing is that less than 30% of responders use laparoscopy in over half of their cases. So that means they do most of it in, in an open way. And when they do laparoscopy, it's mainly appendectomy and cholecystectomy. We're talking about general practice. We're not talking about hyper specialized centers where they can do a lot of laparoscopic work for complex procedures because what they, they also saw in their survey is that the level of complexity that he could tackle minimally invasive is related to, of course, surgeons. And I would say hospital experience with the use of laparoscopy in the elective setting. And so there was also a propensity, uh scored uh analysis uh comparing laparoscopic and open abdominal surgery. So, not specifically uh colorectal. And so what they saw it's from the UK. Uh they saw that when uh applied to the laparoscopic approach resulted in lower mortality, blood loss and length of stay, which is in trend with uh the evidence Jim showed us uh and which is of course, the logic thing when extrapolating it from the elective work. And we see that less than 15% of emergency cases are actually performed laparoscopically and of those almost half is converted. So if we think in reality, laparoscopic surgery in the emergency setting, it is actually for the happy few because technically challenging difficult patients, difficult circumstances and so a high risk of conversion, that's what it is. So what can robotic surgery offer us Well, it's minimal invasive surgery on the next level. So when we're talking about elective surgery, comparing laparoscopic and robotic, we're always talking about marginal gains and looking where it's difficult to see the, the real benefit. But I think when we will gain more evidence, I feel fairly confident that we will see a huge difference because we're comparing in the elective setting, laparoscopy to robotic procedures. While we uh when we're talking about emergency surgery, we're going to be comparing in the future, we're not there yet, but you can always dream more open surgery to robotic surgery. And I think there the difference and the games will be a whole lot bigger more compared to urology from open to robotics. So I think emergency surgery, there is some music in there. Now, what's the road to success then? Well, we don't operate alone. You have the surgeon, you have the team and you have the machine. So the robotic platform as was shown by the beautiful videos of gyms. Um It has some features that you do not find with a straight uh stick uh surgery. You have the 3d view, the third arm and the articulating instruments that make you feel like a fish in the water when they're going get stuff. So in confined spaces, you can expose yourself and you can do a precise dissection which is not always feasible with the traditional laparoscopic approach. There's also the surgeon, there are some things you have to have some qualities you need to have. And it's just actually having passed the learning curve when you want to talk about colorectal uh emergency surgery, you should not do it in your early experience because the exposure is already difficult when doing uh procedures robotically led along doing it when the bowel is dilated where you have the ileus, where the patient might not support 20 or 25 degrees. Trendelenburg. So in those circumstances, in the emergency setting, it's even more difficult than in the elective setting. So you as a surgeon, you need to be trained before tackling robotic emergency, uh colorectal surgery, but we do not fly solo. We are part of a team and we are only as strong or as good as every team member. So you need a fully trained or team, everyone needs to be ready. Scrub nurse, first assist, needs to be able to expose to get that aspirator down to the abscess. They need to be able to really assist you where in an elective setting, robotic surgery tends to be more of a solo procedure. That's not the case in the emergency setting. And also your anesthetist needs to feel confident when putting patients under anesthesia in an emergency setting. We always talk with each other in terms of Trendelenburg, pmo Peritoneum operating at a low level pressures of 6 to 8 millimeters of mercury with a reduced Trendelenburg to keep the patient stable enough to be able to subs stand the procedure all the way to the end and last, but not least you need access to the robotic platform. It's not um of course, during the night and in the weekend, the robot is available, but you also need the material if you start doing procedures at night and in the weekend, you need to have the logistics team, the um um sterilization team ready even after office hours. Because if you start doing it after hours, you might compromise the elective program. And then there's still the active uh the access during daytime. What are you gonna do if you need to have access to the robot when the day uh program is running? So access is a real big hurdle uh to take. Now we started uh experiencing or, or having some, some uh cases uh in an emergency setting in more or less 2019 where one day we had a perforated diverticulitis and the robot was available and we thought, why not? It was a high BM I patient for BMI of 46 with uh an abscess uh and some diffuse um um pus. So not as uh fes all the way, but mainly uh pus in the lower pelvis. And we thought, why not give it a go? Let's, let's see how far we can go because we felt pretty sure that we would not be able to do it laparoscopically. So we were like, we've got nothing to lose. And what we saw was first an eye opener, the postoperative recovery because we had some uh laparotomy patients as well in the ward and the difference in recovery in terms of wound infection, length of stay and morbidity associated with laparotomy. That was really an eye opener for us and pushed us to even further um embark on the uh emergency surgery. So for now, because of axis reasons, we mainly do colorectal indications, but actually, we could use the robot or we want to use the robot for all emergencies, eligible for minimal invasive surgery where we feel the need to have the advantage of the robotic platform. And so we have broadened our indications. We have done some anastomotic revisions, some incarcerated hernias, even a peripheral gastric ulcer in a highly morbid patient who was hemodynamically unstable where we could not give chemo peritoneum up until 12 and she was really highly obese. She also had a lot of other medical problems, won't go into detail. But there we saw the benefit, let's just do it robotically and that was a good decision. So we really try to select the patients where we feel the robot will help us to push further main limitations in our hospital. Yes, there is a cost. But if you look at the overall picture, shorter hospital stay, less morbidity, less anastomatic leakage, et cetera. It's not really the cost. That is the main hurdle. It's the availability and the So I am not too scared to admit that we do not have a true robotic emergency service yet because there are limitations of the availability and access of the platform having only one robotic system at our avail available to us. So what do we do? Uh our um um uh what we like to keep in mind is why reduce the quality of care in the emergency setting. So what we would typically do if we have a perforated diverticular case, for instance, the thing I chose here as a video to run, um is we just start laparoscopically and we do a laparoscopic exploration to see if the patient can support a bit of hemoperitoneum. We do a lavage and then if the patient is stable during that time or stable enough, we will then drape and do the system not to waste any material or drapes when the patient is really too unstable to even support and when it has to go fast, we will still do a laparotomy, of course. And then typically, what we do is work our way around the problem. So as Jim said, you don't want, do not want to go directly to the pelvis or to the abscess or to the perforated zone, but you want to go in a circular movement away from the problem like in warfare uh to tackle it uh in the end. And so here we had to do a splenic flexure immobilization because the perforation was very high up to the proximal sigmoid. So you go work your way around the problem. We use the air seal for two reasons. You can do the low pressure to reduce the, the pressure needed, uh which is uh in favor for an anesthetist. And also because you can aspirate while maintaining the pressure. And when you have a perforated disease, it's very important that you can aspirate without the ceiling falling on your head every time. Uh You, you, you suck uh with aspiration device as was shown by Jim. The ICG is really helpful to help you with the vascularization. Um We just check if the rectal stump is of good quality, which we check if the proximal bowel end is of good quality. And if the patient is hemodynamic relative stable, we will just join up uh both uh bowel ends without uh any problem. We like to use swabs. Um And this is our um take on how to tackle uh colorectal emergency surgery. Now how to set up a true robotic emergency service or what I think or what can I give you as pointers? Well, I think the training is the same what whatever your end goal is, you need to be trained on the platform, you need to follow the structure training pathway. It doesn't matter what type of surgery you want to do because as II try to prepare a bit for this presentation. So I learned that in the UK, you really have dedicated emergency surgery teams, which is not the case in Belgium. So that was new for me. So if that's your goal, if you work in an emergency department and you want to do emergency surgery, you just have to undergo the training like every other surgeon. And I think it's important to set goals, uh define the indications. What do we want to operate in the end once we have an established program and what are the indications we are going to use to get there. So you need to think about those things because you cannot tackle the difficult cases in the beginning. So you need to have a plan and you need to track your outcomes. You need to capture what you are doing to keep on convincing your board to further investigate in your uh program. And then the team, it was already set by Jim. This is a very big hurdle in a lot of hospitals, big hospitals, big uh emergency um on call staff, not always properly trained on the robotic platform. And I think if you want to set up nowadays in 2024 an emergency service robotic uh team, you have to have a dedicated team that can progress relatively smoothly through the uh learning curve and then expand the team to new team members, one after another to keep the level uh of experience relatively high. And you have to have access if you don't have access. You don't have a program and you should not bother. You should really insist on that how to get to the learning curve. Same as for, uh, elective, uh, surgery. Start slow and easy and you will end up being first. So, start with easy cases. And I thought about it. Why not? Simple cholecystectomies a very early, uh, uh, acute, uh, cholecystitis, you know, one day where you just have the edema, simple appendectomies, maybe elective taps or rectopexy if that is possible. So simple cases. So that's what you should talk about before starting your uh program, choose your patients wisely so that everyone can get trained onto the system and everyone can get fluent with the system before really diving into those complex cases. So build up the complexity, keep the flow going, choose your patients in the beginning, stay away of those patients where you will see the benefit in the end obese patients or extensive prior abdominal surgery, stay away of them and then bowel dilatation. I think doing obs obstructive uh cases in the beginning. And even nowadays, those remain a big um difficult uh indications. So stay away of them in the beginning and have access regularly to build up your experience. And then after the learning curve, who knows because we're not there yet, it's still an exploratory field. We are still in the early days of the adoption. And so the sky for the moment is actually the limit but we should always keep a balance between cost and potential benefit. That's why I think when exploring new possibilities, always keep that balance. What are we doing? Is it making sense? Should we keep on doing these patients or should we refer them for laparoscopy after the learning curfew? So you should constantly weigh cost and potential benefit by analyzing your data reader targeting your program, setting your goals. And for me, for now, the main limiting factor if access is not an issue and your team is trained, it's mainly those ill patients. If you have big ileus with big large bowel extension and hemodynamic unstable patients. While I get not all patients will be or are as we speak, fit for a minimal invasive approach. So we'll never reach 100% and that maybe should not even be the goal. But if we can go from 15% with 50% of conversion rate to maybe 50 or 70% minimal invasive with a conversion rate of maybe 30 to 40%. A lot of patients will have benefits from the robotic approach. So, in my opinion, uh the robotic emergency surgery is feasible and safe if used wisely, it allows for more minimal invasive surgery in the emergency setting. With a low conversion rate. You should think about when to implement it or when you really want to implement it as such, you should do it in a well designed learning curve pathway. You have to have your team backing you up 24 7 and you have to have the access 24 7. Thank you for your attention. Oh, thank you doctor uh E GS service in um in robotics. So obviously Procar and you've done it down in Portsmouth and whenever I talk about E GS and Robotics, everyone says, oh, don't be so ridiculous. So, how long do you think, or roughly how long does it take for, for your team to be set up and proficient in running an ES service or being able to deliver eeg S cases? Um Thanks Charlotte. I mean, that's just a very difficult one to answer because it's just no one size fit. All depends on your hospital logistics and what kind of uh uh an emergency service you run and what is the attitude towards even laparoscopy? We, we heard from Alan's presentation that across the country there is a huge number of centers who don't think that even laparoscopy in the emergency setting is the right thing to do. Um And they're doing very small number of those cases. Um but they are the sick patients who really want to benefit. And we as a unit run a very specialized service in emergency. So we have a specialist colorectal and a specialist upper gi emergency on call. So there are two specialists on call at any time of the day. Uh And we take relevant cases under our wings and you, we feel that if we are best placed to do elective cases in the most complex way, we should be the best people to deal with the more sicker patients who come through the emergency corridor in that setting. And hence, I think if you want to take it to the next level, then definitely robotics will be the next place from laparoscopy. But I could not emphasize any more than what Alan said earlier that it is not something to be considered on your learning curve. Um I was part of the world Emergency survey when we surveyed all units across Europe about their access to robotics. You will be amazed to hear that nobody had access to out of hours robotic platforms because they were used um uh in daytime by the elective specialty. So the eeg S teams cannot do anything and out of hours there was no team available to, to do those cases. So it's a chicken and egg situation. I would just highlight two points in this context and then we'll see what Alan um has to say about this. One is the team training. Um The nurses which do out of hours work, especially in the UK. There's a set pattern. There's a group of people who often do one in five or one in six or one in four nights on call and they're the same teams, they hardly do elective enough elective work to keep their skills set up to that level. Of what has happened with innovation and research and, and robotics was a complete kind of um put off for them to. So we don't know about robotics and we feel very uncomfortable dealing with it. But one thing with the nursing teams is that once they know what they're doing, they feel very confident and comfortable doing something. It's, it's just about the lack of knowledge or lack of familiarity with that set up. So what we did was we set up an emergency on call team which involved some key nurses and some advanced nurse practitioners and some interested surgeons. And we said, ok, these cases are not going to happen every night or every evening or every weekend. But in the 1st 3 to 6 months, can we just have an on call team who's happy to come in, do these cases? But in doing so train that team, which is on call at night or out of hours regularly as a part of their job. So they get trained and this is kind of learning by diffusion, you just teach them and actually you, I'm sure you that it is so easy once the robotic system is dogged and you know what you're doing, it's smooth sailing for the whole team for the next two or three hours. It's not as hectic or chaotic as a laparotomy or laparoscopy would be, for example. So they started enjoying it that actually once you know what you're doing and once you set it up, things get going very smoothly and then it's quite smooth sailing and not much of a hassle and the surgeons are comfortable doing it. So that's one point. Second is about the registrars training, we all know how sensitive that issue is. And then this is something that is again going to be for consultants to do who are already mastered the learning curve on the robot. So if you're going to bring robotics into the emergency or and take all those Harmans and sigmoid resection the right hemi out into the robot platform done by consultants. Again, I think the registrar's training is gonna suffer again a lot more. So we have to strike a balance where these two or three years are particularly challenging for the UK landscape, in particular for trainees where consultants are getting over that learning curve. So perhaps an emergency avenue is something that is available for trainees to get their laparoscopic skills. If we can put the robots in emergency theaters, then again, amazing. Yes, that will increase the exposure and and the because you can then do cholecystectomies, you can do appendicectomy, small bowel resections. It almost become second nature like any, some of the US centers would do that. You will talk the robot if you feel that you're comfortable to do it, but we are not quite there yet. So I think for the trainees, I would say don't worry too much about robotics in the emergency set up. It is something that will come with time. And I think my, my vision is that you will have platforms in robotic the, which would be purposefully built for emergency use only and, and, and hence you will have unrestricted access to robotic systems, but that may take 3 to 4 years or five years to come. But watch the Yeah, II do agree if I can uh continue on that same, uh, page, I think it's just too early. Um, to really say that a robotic surgery is ready to be implemented on a broad scale. We're not even there in the elective setting yet. I think if you watch the laparoscopic evolution and where, how long that took and before we started doing laparoscopic emergency surgery, it's the same thing when I was a trainee and II. Might I or I think I'm not that old yet. We could not do laparoscopic surgery in the emergency setting. I was trained to do a classic appendectomy through the burning incision during my training. And that is 20 years ago. So we, we have come a long way. Um, and I think robotic surgery will follow the same pathway. What I do think is that we need to learn from the mistakes and not to leave young surgeons out of the equation and take them into training from the beginning. And that's why. And I think Jim is the leading example, I think even though we are still exploring robotic surgery. What it can, we can still take you guys with us by giving parts of the operation to you guys. If you have done the training, if you know how to drive the console, why not let you do parts of the operation? No one says that you have to do a full rectal resection from the get go. And so in that, in that opinion, if the robotic platform becomes more available, this will also go into the uh uh emergency department uh by, by nature. But I think from the beginning, we should work together with groups like you, we also have a trainee society in Belgium and we have developed a structured training pathway with that society. So nationwide that all trainees can are offered and can follow for free and then we offer uh slots throughout uh Belgium. So that is something to take you guys because I heard in the beginning that that was a bit of a, a problem, the access and the training and it's getting the surgeons together and, and making a standardized curriculum available to everyone that can help us forward. Thank you so much for both your presentations that's really encouraging to hear as well. Um Particularly from a trainee point of view, I just wanted to come back towards um uh after you've done your, for example, perforated diverticular case. Um And do you have a flavor of how the second operation may be when you come back to reverse these patients. Is there any difference that you've noticed in, in terms of, I don't know, ease or, or techniques that you find um when you come back to reverse them, Alan, you want to go first, please. Yeah, I'll tell my thoughts. It's uh it's my experience if you do a robotic approach for the emergency part and you decide for what reason that you do not join them, you do a Hartman's, it's my experience that the um reversal is also technically less challenging because you tend to disturb and disrupt a bit less the anatomy when using the robotic platform than what you would do typically for us then open or laparoscopically. But maybe the difference with open surgery is even bigger. So I think you only have to gain for the second operation uh as well. If you can do the first, the index operation minimally invasive. I totally agree. Alan, I had the same experience obviously going back into some of these patients for reversal of heart men's. But also some of my cancer patients have lived long enough to have a second cancer or some other problems and you've gone back in and absolutely surprise, no adherence, no real scar tissue, no real challenge. Um Unless of course they had a big complication or abscess or sepsis that's different. But as a rule, they don't get scarring so much so that I I'm also wo more worried in robotics about closing um mesenteric defects because the, this is just a recipe for internal herniation. It's just so pretty smooth gliding that there is no real adherence. Parastomal hernias are a bit more common as well. There's hardly any scarring to the abdominal wall and they just glide through the fascial defects. So perhaps more attention to close those defects and, and, and close the internal rings. But you're right, if you do a robotic hearts, a robotic reversal seems uh are relatively easier. Um uh when you go back in and we try to do them the same way. We, we try to obviously immobilize the stoma, drop it in, put a wound protector and then dock the system and it's like laparoscopy when it came the initial papers and studies and recommendations. If you read um previous laparotomy used to be a contraindication for laparoscopy because people felt that ESIs was not possible laparoscopically. The same concept was there when I was training people. We were just saying the same thing don't take on patients who had previous laparotomy for your robotic learning curve because you might struggle. But hand on heart. If you ask me if I have a patient with laparotomy and adherence, I just want to talk the robot ASAP. And I, what I tried to do is forget about the port placement and, and, and, and if I II did a case recently and previous midline laparotomy burst abdomen, fist and stuck I just, we needed space to put three arms somewhere so I can get a camera and two hands in. And that was it. And then it was an hour or so of ESIs and the 3D view, the access to the abdominal wall, the less traction of the bowel. There was not a single small bowel injury and laparoscopically, I would have probably opened up two or three places and put some sutures in to repair it. Here, you have a beautiful 3d view and working around with the under wrist on the abdominal wall, taking all those adhesions down. Similarly, in the pelvis, the biggest adhesions are the small bowel adherence to the rectal stump or to the bladder, which is your blind spot. When you're coming in with laparoscopy, you just don't see behind yourself. Here, you can go in and take it off the sacrum completely without causing any either to the rectal stump or to the small bowel and the bladder drops onto the rectum, you can separate it and lift it up. So there are potential advantages in lots of ways that translate into a better recovery for those patients, but it's essentially linked to your experience in robotic surgery. So, so that this is certainly not something that I would say that you should go into. But it's one point before I forget I could quickly make is about training for those scenarios. And if you look at the athletes, they train and if you have a marathon coming up, you might be training for long periods with extra weights. You, some, some athletes want to train at high altitudes to, to get used to that atmosphere. And this is the kind of thing that you can train yourself. As Alan said, the biggest issue is the lack of exposure or a view. So you're not gonna get a perfect exposure and a view of the small bowel being away and you have the I MA and I MB in front of you. But you can train by operating in your elective practice with low pressure pneumopar, drop it down to eight or even six. Just pretend that you have less or try to operate even without the assistant. Yes. Try to manage that small bowel with your robotic arms and just see if I can manage without having the assistant to, to give you the view. So you can simulate those kind of situations where you will be single handed and you will have less view or or try to use more than one port by the assistant in different places to see how would they give you a view? You will have less gravity because you won't be able to put them to head down because of hemodynamic instability. So there are things that if you're working in a fellowship program or mentoring by the right mentors, they can teach you to train yourself and prepare yourself for those scenarios. If the, when the, and when the time comes, you'll be able to deal with all of that. But even when you are in a training program, there are still parts of that operation that you can still do. And, and I think the mindset should be that it's a collaborative approach of two surgeons of various grades or skill set, working together to achieve that um case to completely finish that. And it's almost, I don't like the parallels with the airline industry, but you're going back to flying with the captain and the first officer and learning on the job. So there's gonna be a lot of job training on the job training, which is very different from when we were graduating that we use. We were supposed to be the finished article. By the time you finish your training and you hit the ground running while now with the trainees with so much innovation and developments happening, you will be kind of for the first few years pairing up with the right minded colleagues together and, and, and learning on the job as, as we grow together. Thank you. I've just got one more quick question before we wrap things up this looking towards the future. Really. Um some of the single port systems are, are coming. Do you think that will play a role um in the emergency setting? Maybe the total colectomy in a IBD patient, for example, um Just a couple of minutes before we wrap up. Thank you. Um There is some future in it, what the exact place of single port will be. I think it's still also exploratory because they don't have a stapler device yet. So it's always single port plus one if you want to staple if you want to use it. So I think you should, you should see what it can do, but I would be uh excited to see how far it can get us if we can get everything through, it's like CS, but then through the stoma side, if you can do that, why not, then you can, you do not have to do the plan still if you're going to put in your stoma. Uh anyway. Um So, uh yeah, looking forward to see that, but I don't know if we are there yet. Probably it will take a couple of years to be really um there where it should be a bit like the Da Vinci had several versions um before reaching the level that it has reached now with the fourth generation uh very quickly from my side as well. I think it's great potential with sales uh but the technology is not quite ready yet and may take a few more years and not only that, it has to be done cost effective in a way that it's affordable on a on a regular basis to be enrolled. Um for emergency procedures. I II think the debate will be very similar to what it was 10 years ago between single port versus multiport laparoscopy. And the difference was very small. It was very difficult to show a big difference between the two just because you can do. It doesn't mean that we have to do it. I think a multi port, uh robotic platform form with four or five ports is, is, is a very good set up now to do complex cases. And I think what we should be focusing on, we will never catch up with technology. It will always be advancing ahead of us. And rather than running blindly behind it, we should be accepting what is going to be the standard of the next five years and train people. Well, in that the rest of it will be building blocks that will come with time. But if you keep on going after the new gadget every six months, you will never progress to the state that you want to be at. Thank you. So thank you again to our, our wonderful speakers. I think that was a great session with some really good videos and, and talking points. Um Thank you to everyone logged on at home. Um Just a reminder, next week is our last session. Um We'll be focusing on the new medtronic robot. Um And we've got another international speaker, uh doctor, we who's gonna be logging on from India. So I hope you um appreciate time and effort and we've also got some speakers from the or C academy. So another really great session. Look to see, look forward to see you then. Thanks everyone. Thank you all. Have a nice evening. You too. Bye bye bye.