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Dukes' Club Robotic Assisted Surgery Webinar 6: International experience of the Medtronic HUGO Robotic Assisted Surgery system

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Summary

This on-demand teaching session features medical professionals discussing the newest robotic surgical system, the Medtronic Hugo Robot. The webinar includes a comprehensive introduction to the Hugo system, covering functionalities of the system tower, system console, and arm parts, followed by an in-depth overview of the Hugo Ascend training pathway designed for the entire theater team. Additionally, the speakers delve into the potential of digital solutions in supporting robotic training, highlighting touch surgery simulations, VR content, annotated videos, live streaming, and more. The session also includes firsthand experiences in using the Hugo Robotic system and a discussion on new robotic platforms' potential to improve patient outcomes and increase cost efficiency.
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Learning objectives

1. Understand the features and components of the Medtronic Hugo robot and how it differs from other robotic systems. 2. Explore the Ascend training pathway for the Medtronic Hugo robot, including the blend of virtual and in person learning content. 3. Review the technical and procedural training components, and comprehend how the training is designed for the whole theater team, including surgeons, assistants and theater staff. 4. Gain insights into the Hugo task simulator and its potential for practicing specific robotic skills outside of the theater or before attending the training pathway. 5. Learn about the livestreaming tool and its capabilities for facilitating remote practice and learning, especially for proctoring.
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Computer generated transcript

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

Hi, everyone. Er, thank you for joining our final webinar in the series. Er, hopefully we'll save the best till last. Um, we're joined by some fantastic speakers today to talk to you about um, the Medtronic Hugo robot. So it's the newest one on the scene. Um And first we'll be handing over to Arun, who's the senior medical liaison for Medtronic, who'll fill you in all about the robot. Thanks, Arun. All right. Thank you. Hi. Well, it's great to speak to you all and thank you for the invite from Dukes Club. Um, as I said, I'm a senior medical liaison and I lead for Colorectal surgery within the Digital Technologies Unit at Medtronic. And I'll be talking to you today about the Hugo Ascend trading pathway. I'd like to start by talking about the Hugo system and its components. First, we have the system tower, this houses the computing power for the system and it includes a ST vision system and a valley lab FT 10 unit. It has a display screen on top similar to a laps stack and it can also be used without the surgeon console to power the forearms as bedside assistance now desertion console. Unlike other systems, it's an open console with a large 3D display for which you use visors. And it has a smaller interactive touchscreen display to your right for you to control various settings for the instruments such as sensitivity or switching instruments. And you can also display images from other devices below. You can see it has foot pedals for clutching your instruments, switching to reposition the camera and for electrosurgery activation. And of course, we have the arm parts. So there are four, but you can also use three arm configurations as well. And each arm part is capable of using any robotic instrument. So for example, doing an LA if you're moving from spending flexure to the pelvis, you can always hot swap your endoscope for another instrument if you need to and adjust your configuration before I move on to the training pathway. What some of you may not know is I was a surgical trainee and as a trainee, I remember searching for training opportunities any chance I could get, I remember having to stay late when I was wanting to do vascular surgery just to try and do it below the amputation. And of course, CPOD kept getting pushed back and back and ended up be there till 1011 at night. I'm sure all of you have had similar experiences staying late or coming in on your off days to do extra lifts. We know the situation with obtaining adequate training is challenging with limited training opportunities, particularly time in theater and even more so for robotic surgery. And with that in mind, the ascend training pathway includes both technical and procedural training with a blend of virtual and in person learning content. It's been designed for the whole theater team including surgeons, assistants and theater staff. The technical training pathway combines virtual content with two days of in person training for the whole theater team to work together to all understand the components of the system, draping, docking instruments, procedure set up and tackling emergencies. The procedural training includes e-learning content and simulations via T surgery to understand more about Hugo including the surgeon console and procedural set of guides. The in person training is then about applying these new skills for a clinical setting and understanding patient positioning, set up and procedure specific steps using Q go with support from our expert surgeons. Our trainers, co specialists and proctors work closely with the surgeons to plan and prepare for their first case using pig or cadaveric models and especially for colorectal. This thing can include vessel control, managing bleeding stapling and anastomosis. The tuck surgery ecosystem is providing digital solutions to support your robotic training through simulations. VR content, annotated videos and virtual access to the theater through live streaming with T SE. You'll have access to surgical video and simulations to learn from as well as technical training modules. The Hugo task simulator allows you to become more familiar with the surgeon console and have time to practice specific robotic skills outside of the theater or before attending the training pathway. OK. And using livestream, we can accommodate remote practice and learning, which I'll come on to a bit later here. We can see some examples of our simulation content. On the left, we have a video based simulation which combines surgical video with CGI or computed generated elements to highlight certain structures or operative steps. As you can see here with the cystic artery on the right, you can see a fully CGI animated simulation which can be used for anatomy or device training. And you can access these simulations using your phone or tablet on the T surgery app. So for example, maybe before a the theater list or the night before you may want to brush up on anatomy or specific operative steps, you can do this using the app. Here on the left. We have our immersive VR training which is really useful to practice certain tasks and become more familiar with using Hugo. You can also practice patient emergencies within the virtual learning environment which can be done solo or in a group to practice these scenarios with your team. The VR environment provides a safe place to practice these scenarios multiple times which can be difficult to recreate with a patient model or without causing damage to the system. On the right. You can see an annotated video here we use surgical video with annotations to describe the full workflow for a procedure to help understand exactly what the surgeon is doing and what they're looking for. Again, these annotated videos can be accessed via the app or through touch surgery videos online. And this is useful when you're learning a new procedure or a technique. Or if you're working with a new consultant maybe and want to understand their specific workflow before you scrub in with them. We're also expanding our library of both video and animated CGI content. We've produced animated simulations which allow theater teams to learn how to set up Hugo for particular procedures, showing how to follow, follow the set of guides we provide and arrange the arm cars as needed. And we've also learned from the experts, the importance of the setup and the understanding what's happening outside of the patient and building content for bedside assistants and theater staff specifically, I mentioned livestream and partnership earlier. Proctoring is an extremely important part of the training pathway. So are linked with a dedicated pro to support them during their training right through to when they start performing cases of their own in hospital. Livestream is our streaming tool which is a mobile touch stream which connects wirelessly to our DS one computer. It lives on a wireless trolley, so you can move it around theater to either see the surgeon at the console and see what they're doing or wheel it to the patient. If you wanted to see the poor pace, poor, poor placement and patient set up or what the assistant is doing. Using this, a surgeon can receive partnership remotely if they need support or it can be used to train a group of surgeons who can't all get into theater. And this dashboard gives you an idea of how the live stream platform works. You can see and speak to other viewers or to the surgeon. You also have the option of annotating on the screen using the draw function. Here, you can highlight different structures, for example, a dissection plane or um part of the vascular anatomy. If you're fracturing someone or for example, the surgeon themselves may want to highlight something for their audience. If they're teaching trainees, you also have the ability to share a screen, say if you wanted to pull up the CT scan for a patient, we're always looking to add content to our touch surgery app, which includes both technical and procedural content for Hugo. And we work with surgeons to develop additional content. So feel free to scan the code and take a look at the library. I'll be available for questions at the end and thank you for your time. That was great. Thanks so much Aaron and I'm, I'm a big fan of the er touch Surgery app. I use it myself when I'm getting ready for cases. So I think it's, it's fantastic. Great. Um So I'm Andrew, I'm the Duke's Club secretary. Um and it's my pleasure to introduce our next speaker, um which is, er, Professor Van Ki Moan. He's a consultant colorectal and robotic surgeon at the Apollo Hospitals in Chennai. Um and he's also um the national lead er for the robotic Colorectal surgery program um for all of the Apollo hospitals across India. So I will play his video for us now. Hi, I'm professor consultant Colorectal robotic Surgeon at the Institute of Colorectal Surgery at the Poor Hospital Chennai. Today we're here to present our first clinical experience in colorectal surgery using the Hugo robotic system. Look at evidence, sorry, I think we may be having some technical difficulties in that. Um Andrew if you want to just maybe exit and then rejoin. Oh, right. Yeah, no problem, apologies for this. In the meantime, I can um introduce our next speaker um who is uh prof Nikr Isan from India, um otherwise known as Wey. Uh unfortunately, he sends his apologies. He couldn't join us this evening, er, because it's er Indian Times plus four, it would have been sort of half past midnight. Um but he will be presenting his prerecorded er presentation um about his experience in India. So, Andrea, if you reat attempt type five, I'm professor of an consultant Colorectal robotic Surgeon at the Institute of Colorectal Surgery at the hospital Chennai. Today we're here to present our first clinical experience in Colorectal surgery using the Hugo Grass robotic System flu for robotic rectal cancer surgery. Uh We've seen that with robotic surgery for colorectal cancer, particular rectal cancer. We have a long operative time, similar oncological outcomes, shorter length of stay low risk of conversion to open higher cost in our own program at a hospital. And I, we initiated the Prootic program in 2016, we've used the SI and, and the I in the last 6 to 7 years, completed 550 robotic colorectal resections. To date. A robotic program is built on subspecialisation, multidisciplinary colorectal cancer management. We standardize the technique and also found cost efficient sustainable patient outcomes. Using these important factors. Cost has always been a challenge for robotic surgery in particularly our healthcare system. But having standardized our technique and our outcomes over the last decade, we looked at the cost analyst of 300 patients who undergone robotic cancer and found that the cost is around $5100 which is 1/4 the cost of a robotic re cancer section in the US. Now there are several new robotic systems which are being introduced across the world. And the next question to answer is will newer robotic platforms improve patient outcomes and be more cost efficient. The system is a new robotic system which has been introduced the last couple of years. Uh It is a modular system which is flexible immersive with an open console. It has a masters concept, but with an open console system the Hugo Rass footprint is a slightly different footprint compared to the existing robotic systems. It is a larger footprint because of the modular way the system is designed the arm also for longer compared to what we've seen. Uh But it has got several advantages. You can mix a member of arms assist arms which are required for the procedure. Simple procedure may require only two robotic assistance compared to a complex procedure, may 3 arms. So if you have two camera systems or to, you can mix and match uh two arms or three arms and you can you between two different looking at the arms itself. These are modular arms. The one thing to notice is that they are longer. And so you need to do that when you're planning your uh theater and also training your staff because these are slightly different uh as far as they would extend uh within the uh environment where it is uh placed. Uh but it is very mobile, you can quickly deploy it. Uh and, and uh in having individual arms changes the way we've been used to robotics, the open console system gives you high definition 3d vision without sacrifice and situation awareness. In the operating room. You have easy group controllers, you are highly ergonomic and then you have a control part on the side which shows all the instruments which are being used. Also the direction which the camera is uh facing. You have several filters. Which you can apply so that you can get better clarity of the pictures you're seeing the Humera system vision card is fabulous. It has an interactive display. It's got an advanced visualization system using the car stores, image 1 3D system. Uh It has advanced energy platform, the value lab FT 10 energy platform which delivers consistent performance across all uh energy based devices. You also have the uh touch surgery video and analytics Platform Incorporated. We'll talk about it in the next few slides. Uh This is very useful because you surgical videos recorded and uploaded onto the cloud uh where they can be stored or shared. Uh You can get ideas about the search the times and workflows, surgical performance. Uh As you could see the DS one computer records all the all the uh procedure. Uh And more importantly, these are seamlessly uploaded to the surgeon's private library where you can annotate these videos uh mark them and share it with your colleagues for uh for uh learning purposes or also for critique the systems comes with uh excellent ergonomic and instrument settings. The most important one which we find useful are the motion scaling uh feature which allows the user to just distance that the instrument that moves. When the surgery hand controller, the rotation multiplier allows the user to just how far the instrument wrist flexes when the surgeon's hand controller is rotated. This is very useful when you're doing suturing, for example. So looking at the major advantages of the Hugo system, we have modular arms for universal independent arm cars with multi access with easy do and its use in multiple departments and surgeries. It's collapsible and portable can be more to different or s it's an open console design. So a communication between the or staff and the surgeon is better. It's called multiquadrant access system towers equipped with endoscope system. Uh It has advanced instrumentation uh using the legs and tr technologies. You have the 10 energy source and you have the rotation multiplier which helps with fast filtering. There are several training pathways which has been established for which train the or staff and the and the surgeons can go through training, the support of the uh medtronic training pathway. There is technical training for and or nurses, there's procedural training for surgeons uh and of course coaching for surgeons for sustained uh improvement in their uh surgical skill sets. The Hugo as in virtual training solution also supports the surgeons. Uh One is the touch surgery enterprise which we've already discussed. Then there is computer based training where it is procedural e learning. We also have a simulator attached to the system console where with uh simulator with objective skills assessment can be done. But of course, remotes coaching with proctorship or trainee site uh with video reviews and assessment feedback forms from Proctor, presenting our experience with the Hugo as robotic system for rectal cancer surgery uh the Hugo system was installed in a Polar main hospital in Chennai in um 2021 it was uh part of a clinical trial, first patient clinical trial for colorectal surgery. The first general surgery procedures in Asia and the first lower section procedure in the world was performed on 15th of December 2021 with the men under the mentorship of doctor has from UI Chicago. As you can see the console open is set up in such a way that uh you know, it is away from the uh left side and you can see the robot in place and this is a set up for right neomy, but you can see the arms are long, but you can see the vision part over there which has got the views for the support team. We need to give you an idea of how the the open system works. As you can see, you, you get excellent pictures uh using the carto uh camera system. Uh it's a very stable platform uh instrument, the instrumentation is very effective the picture quality and I have to comment that it's been excellent. And I said there are several filters which are available for the surgery. You can change the filters which suits you to get better clarity of the pictures. Setting up the robotic arm is uh important and there are four important steps. One is the column scale height, tilt angle, laser alignment and do angle. So the first thing to do is to adjust the col column to her height to about 70 centimeters between 6080 which is what I'm doing now, which can be flip with a switch. Once you have that, you press them red pedal to sort of block the to. And then you said the full angle is a minus 30. Use a laser alignment tool which is a blue switch there, pointing the head in towards the patient head. And then you can use the dock angle to do the arm itself. And that shows in which which angle the uh um talks to the patient do. The arms itself is very straightforward. We have a little video which shows how it's done. The arms are draped and then the the uh pulse, a caring physician. They put the line to the angle of the port and simple click to close the doors. The humera set up for the low intersection is shown on the slide. And we can see that the the height of the column is set at 70 patients are on the low head down so that we have an empty pelvis. It also shows a dark angle in which the arms come in uh do with the patient. This is how the robot is set up. It looks very busy because of the modular where the arm the the robot is designed. And you can see that the arms are modular and they are long and it's important for the clean, assist him to understand that and to train them as well so that you don't uh sustain any injury because of these long and n here, uh we have an example of a robotic TME a total melex for rectal cancer using the platform as you can see deep in the pelvis to uh doing a total me, you can see that we have a very stable uh you get great pictures. Uh The instrument articulation is brilliant. Uh The picture quality is excellent. You can see how clearly the tissues are demonstrated. The traction countertraction using the system is fabulous of showing the anterior dissection. This is a simple technique which we use to hike up the pelvic peritoneum so that we can do the anterior dissection. You can see the interaction between the instruments, the articulation, you can use all the three arms or we we use standard laparoscopic instruments, do some retraction. What you might notice sometimes is that because of the modular where these arms are set up and each arm is individual. In the early part of the learning curve, you might see that there is some vibration at the end of the instrument tip uh when you start out your program, but you'll get used to it. And you know, it's just a way because these arms are long. Uh the moments need to be fine tune. And I think once you've done that these vibrations uh settle down very nicely. So I'm gonna uh show this little clip of left colon mobilization. As you can see again, the pictures are very good sta stable platform quality of pictures as uh uh brilliant uh very pre the articulation of the instrument is very good. So slide uh this is our experience using the system. We have done 11 low resections, uh three abdominal resections, 12 right hemicolectomy operations, three left hemicolectomy and six ventral mesh recopies. Looking at our outcomes, the docking time has averaged out over 23 minutes but uh procedure time is about 300 minutes. Consult time is 100 and 70 minutes. It's not very different from our initial experience with the I uh initial first time because we had similar uh procedure and consult time. So what it shows is that when you adopt a new system, uh you might slow down a bit because you're adopting uh to a newer platform and newer way the instruments work. Uh But once I think you build up on your personal experience, I think the procedure and the consult time goes down to your usual average uh complete tm basically demonstrates that we had a complete resection of the rectal tumor which has been done 100% of the time. There's no convergence in our in this subset of patients. Uh I'm looking at the cost because that, that's what is different compared to because all the other outcomes are more or less similar. But the cost is 25 to 30% cheaper compared to existing platform or the market leader. Yes, there were initial challenges to adoption of the new technology which is uh software issues because of several newer system and an open console. But all of them have been addressed hardware issues. But there with uh a diathermy and, and the way the instruments uh work. But all these again were uh addressed during the study time with feedback to the manufacturer, the modular systems uh with the molar system, there are vibrations on the instrumental but it reduces the experience because of long arms in which uh you use them. Uh And the assistants have to be aware uh of the long arms as well. The camera is not integrated with the instrument, uh uh has a housing which attaches to the arm. So, uh you know, you may have feel that you may not reach the deep end of the pelvis, but we've never had a problem with it. And uh it, it just being aware of it and improves with learning curve. So in the future, there is uh gonna be integration of ligature and staplers into the robot that is making uh clickline C instruments compatible with the system, thereby reducing the procedure cost for it. Because if you have a housing to attach the clickline instrument, which are not risk, but you know, you can use them to, to track, you don't need the articulation, articulated instruments for everything which you use for the robotic procedure. So that will reduce the cost. And the ICG is being planned for addition to the robotic system, uh newer indications thoracic and he and head and neck indications are being uh looked at. And again, new additional instruments will be introduced. So in HS is a stable and safe robotic system for use for surgical procedures. Thank you very much. Ok. Many thanks to um Profen for taking the time to give us his excellent presentation. Um Next up, I'd like to introduce Carlo Revi, who's a consultant neurologist in Northampton at the moment. However, he's previously done uh fellowship at the Marsden and was also at the prestigious or Academy in Belgium. Um He'll be taking us through the experience that they've had um with PBP, which is proficiency based progression and without further a do I like to hand it over to Carly? All right. Thank you, Tyler. Um I first of all apologize for um a colleague, uh Doctor Pati who was supposed to be here with us tonight, but um for some clinical duties he was able to. So the first part of my talk through the PBP methodology um will be part of his original talk. First of all, let me um thank uh the Duke Club for this kind in, in uh invitation. Uh It's a true pleasure to be here tonight. And uh uh I, I'll, I will go through uh with you to um this um our international experience, what um I I've been doing during my experience uh in Belgium and Dose Academy. And also I will be um ii apologize. I mean, um it might be uh slightly urology focused as a talk. Um But this is uh what we have been doing, but I also I will also touch on uh what happened with other specialties. So uh about proficiency based progression PBP is short. Um I have some introductory slides on uh what were the needs for a more structured and uh a safer uh basically um surgical method methodology. Uh This um we all came from a need of training uh surgeons outside the or so in a safe environment with simulation models. But the thing is simulation model is not enough sometimes cause of course, we need something more structured than simply um giving them a simulator and let them play with it. So the two main needs for uh an efficient uh training, a surgical uh training program is that this training is standardized and to be standardized, we need some measurement um Metrix to um measure uh the performance and to assess and to grade and to give feedback to these trainees. So to translate to a effective training. So these are uh in a nutshell. Uh The, let's say this is the rationale behind proficiency based progression so that the progression through training might be based on a certain level of proficiency that each time at each step on the procedure um needs to be um reached. And it's important to stress this particular um this particular um reason behind it cause uh you will see why and how will come into practice with the introduction of UAs. So this is basically the a recap of P EP methodology where a new skill is characterized and the metrics are defined metrics are, let's say um the, the, the a specific task is broken down into specific and a dedicated step. A very specific one that they kind of need to go down to a yes or no question. And so these uh metrics are then validated by experts. And the mean performance of experts is defined as a, a proficiency benchmark. So a certain trainee to progress through, through training needs to match that mean performance to to proceed through the training pathway. So this is characterization and validation of metrics of a clinical procedure. So basically, the metrics are implemented in training program. But the main, uh the main thing about PBP is that can be applied to every task basically. So uh we're talking about surgery but uh you can apply PDP to every uh specific task you might uh mm envision in your mind. So we started with robotic prostatectomy, which is uh let's say the the most popular uh procedure in uh uh robotic urology. And was the first uh everything started with robotic prostatectomy is the one that is most uh performed worldwide. So this is the first, the first publication a few years ago where the procedure uh which is likely a one hour, half, two hours procedure is broken down into 12 phases and each phase is uh like split into uh more steps. Um And this is the final publication and uh the same thing was done with basic skills training. So let's say taking a step back for a trainee trainee wants to train a robotic prostatectomy. So um certain basic skills training um are uh inspired to specific task of the operation. Uh And you see uh the video below are the real thing while there is the above is a chicken model and in a way they kind of uh resemble one another. So it might be useful to um to, to practice in a safer environment outside the they are. So both basic skill training and procedural training. So the real thing are um let's say uh open to a metrics based training. So to be a, a PBP based curricula can be implemented in both in both in basic skills and in um in clinic, in procedural training. So in the real operation, the real surgery, our PP is changing surgical training. Uh uh This is just a recap of main um the most popular um scientific publication publication on uh different different procedures. I talk about radical prostatectomy, a partial nephrectomy, but also low anterior resection and other kind of uh procedure that have been uh implemented with PBP methodology to give it a more standardized approach. So now what's up with the UAs? So PVP um is kind of um I would say while the, while the UAs came into like into play, um the PPP was there and it was this kind of joint uh a shared objective uh to develop uh a, a standardized training pathway. And basically this conversation between um Metronic and uh or the academy was really effective as uh there, there was a methodology that needs something to be applied. And a a new robot that had like uh all the interest in, you know, doing things right the first time. So to start with the, with the right uh with the right approach, I would say the basic skills training with the yoga is the same as with other platform. The procedural training can be basically applied in uh the same way because the procedure did not change with a different platform. But the advantage of telling of starting from scratch here is that um is on a more technical uh field, meaning that basic skills and procedural training are the same while the technical training can focus and ca and I have uh let's say more advanced and more standardized and I would say safer, but at least um in a way structure program uh that can also uh be bidirectional meaning. Um It's not just II think this is the main novelty about this. Uh It's not just the manufacturer saying yes, you do things this way. It's just a conversation since um clinical and a doctors are involved, experts on the clinical side are involved. So this translates into a structure for you that have also uh uh one of uh like both the manufacturer and the clinical user. Um So I think this is the main advantage of UAs and is integration with PBP methodology. And so um uh this can be specifically focused on emergency scenarios, platform related or patient related. And uh just to recap here is uh a, a study commissioned by Medronic where uh you see in the, in the, in the picture down there, um a group of experts uh at or academy where uh they, they met and they discussed through and going through the PVP methodology with Delphi consensus as, as you see, stop by the system rate, arm and cards, prepare instruments, play sports and do arms. These are all the steps the procedure uh like in this particular case, the technical training for yas is broken down. So a, a thing as basic as a technical training. Uh meaning this, this button means something. Uh the other one means something else can be standardized, can be trained uh in a standardized manner or uh with PBP methodology. So this is uh my last slide and I'm happy to uh take questions and discuss about PBP while uh now with my uh next presentation. Oh no, m sorry, I'll discuss what basically was the international experience and specifically uh what we have been through uh using the PPP methodology, not only from, let's say uh a technical training po point of view, but in practice in the real world, what what happened when the, the, the Metronic Uber came and receive approval. So in a way we the the community at a certain goal and uh to deliver the first clinical case. Uh So um everything started in June 2021 when the first procedure in the ward was uh performed uh in Chile. Um Of course, that kind of um started the clock for all other approvals to uh to get there and see Mark arrive in um September octo, I would say October 2021. Um I remember I was at Dorsey Academy, which is one of the main um training centers uh in the ward. So basically we medtronic um set foot and wanted to implement the new robot. So they will bring the machines, they will bring it personal. So uh one C Mark was approved uh was after the pandemic. Um So it was kind of uh an important like excitement around it. And uh we were marching towards uh the first case uh on human man in Europe, of course, um This went through like a lot of steps in between. It wa it wasn't just that uh OK, we bring a new robot in, we just do what we used to do. Uh But what that was not the case even though um uh Professor Mori, the like to academy is I would say one of the most experienced robotic surgery in the world, but still we had to went to go through uh different training, dry, wet labs at or c and uh more specifically, we had to optimize the or setting. I think this is um something that goes back to what I mentioned earlier about the, the conversation between the manufacturer and the users. Meaning that you see on the left, the user guy says you have two arms, two armed cards on the right, two armed cards on the left. So this is how you should use the platform on the, on the right. You see how we use the platform uh in Belgium. All these is the hospital where the first procedure were, was, was performed. So we moved 11 instrument on the right on the left side. Uh Meaning that basically um there was no need for leg support because um the, the, the arm you see here is like parallel to the patient and that usually goes in between legs and uh like leg support are usually used for, for, for uh for Uber us. While this configuration like squeeze three arms on the left and allowed for uh no leg supports in the, in the or of course, it's not mandatory, but it's something that I think is really valuable um just for a matter factor to be open to this kind of feedback. Same thing happened with uh Gemelli. Gemelli is um important hospital in Rome. Uh They have a really important um uh G unit. And so they were kind of invited and they were leading the development and implementation of Uber us with respect to a Gyne surgery. We see here two configuration, a compa and a butterfly configuration uh translated here like um uh in the icon uh drawing uh where you see left hand and endoscope on one side, the right hand and four. So arm on the other side, of course, um I'm not the best person to go through specifics of these different configuration and what are the advantages and the ava these advantages. But I believe um I think this is one of the main uh advantages of you go to be flexible and so to allow for different configuration based on what you have to do. So this is still uh late 2021 while we were implementing uh basic surgical skills and different uh or setups uh to allow for different uh let's say configurations based on the specific surgery you have to do. Uh I remember um we also add uh a team from uh like abdominal wall uh robotic surgery, which is something might be more interest for about for our audience today. And as well. They have a totally different and I would say upside down approach. So they were uh trying, they, they, they were developing and uh like uh um experimenting and uh trying different configuration to that, that might suit them best proficiency. This progression was part of this thing. As I mentioned, exercises by step errors, time limits the metrics validated by performance units where a performance unit is the main performance of experts, the average performance of experts. So that's AAA benchmark, a proficiency benchmark. Because what happens with other methodology is that basically the inventors or the one that propose the methodology, they just say yes, we base our training on this proficiency benchmark who decide that benchmark. Nobody knows. So basically is uh I would say less uh standardized approach. Now we reach February 2022 1st case in Europe. Uh you see on the left, Mr Mori uh I was part of the surgical team. I was assisting in that day and we did two, a radical prost. Uh This was all summarized in a publication that went to our flagship journal and also II put er of March, the first gyne case performed in Europe uh by uh the gel hospital in Rome um where they have one of the the the the largest um casistic of um of gyne gynecological uh surgery, main cancer surgery. And then I first done our surgery case performed in India. Uh I don't wanna uh like say the wrong date, probably professor from Apollo Hospital that send out his presentation was more precise, but I would say it was uh end of 2021 beginning on 2022. So where, um, everything started and, and all uh like say the, the, the experience with us, um, was started just a word untouched surgery, of course, was mentioned before. Um, I think is, um, from a trainee perspective, a really important and um uh like uh handy uh plug in, I would say to this system, not that um is not, is not there for other other um robots. Uh I believe no surgical platform can you know, exist without a, a recording system or at least uh a way to, you know, collect data and this kind of data. But I think it, that it is not just about recording what you're doing is, is, is also and mainly how inactive of what you're doing. Uh with that surgery, you can do that, do that quite easily. You have all your gallery and you have your um operations um broken down in uh phases. You can annotate, you can talk, review, see what happened. And it, I wouldn't say it's live because of course, it's not like uh five seconds after you finish. But is it all comes and it's all useful for you to learn to have everything there? Cause uh for example, uh I remember um I have loads of videos uh that I kind of manually collected. And uh but of course, right there while I was collecting them saying, oh yes, I took this video because it's really interesting and blah, blah, blah, then reviewing it, let's say one month afterwards I say, oh, why did I take this video? I don't remember. So II have loads of this video that I like hours long and II, I'm, I'm supposed to, you know, get through all, all of the to understand why I took it in the first place. While here you kind of add, add steps, you can tag and understand and just make a note of it so that you, you know what, what and why uh you, you took, you took the video in the first place. So this I think is a really uh useful feature that it might always be there. So in conclusion, the introduction of your robot uh requires standardized training. Uh We touch on the PPP and I think this is a particularly important as um kind of the PPP on a standardized training requires experienced surgeons to be involved. So it's not just uh a machine that is given to clinicians but is a completely uh let's say final product of training that is developed altogether at the same time. Uh This relies on communication. The conversation between manufacturer and clinical user is a a key determinant of successful clinical experience. So there's no um I think that's the only way to implement a new platform. And so if you tell me, uh if you ask me what's my experience with, from a trainee perspective with you? Go? Uh I II can I can uh let's say uh I witnessed how this conversation was successful and how um the platform was implemented in clinical practice really safely and with uh an open minded approach, this is my um last slide. I'm more than happy to take que to take questions. Thank you. Brilliant. Thanks so much. Er, Doctor Bra. That was a, a wonderful talk. Um So, uh as, as I've written in the chat, please do feel free to, to put any questions um in the chat and we'll, we'll ask them to our speakers. Um just while we're waiting for some to come through, I'll, I'll start with a question. Um So it's fantastic to hear about um all of the PVP methodology and, and it's great that we've got procedures in colorectal. We've got um anterior resection that's been worked on and obviously as, as um we've just had so brilliantly explained to us. Um prostatectomy is, is much further along as well. Um Doctor Rob, how long does it take to um complete a PBP sort of generation cycle for a, for a procedure? And, and how long can we expect to be waiting for all of our other procedures to sort of go through that process? Yeah. Um It's estimated around six months to one year I would say one year um because it takes um I mean, it, it looks kind of straightforward and simple, which it is. But the problem is that of course, we are not always all together in the same room. It's just OK, we need to do this meeting when like gathering, you know, 20 people availability is always challenging. So it's like you, you have different phases. The first ones are probably uh the most time consuming where you have to define the metrics. And uh I would say you start testing the metrics not earlier than four or 56 months and then you test the metrics. And also that's really uh a a really time consuming bit because usually you take videos and you have the metrics that are approved, approved, I mean, uh tested by the the experts and then you take the videos and you score the videos with these metrics. But of course, there are like two or three hours videos. So you have to do it again and again and again, II would say one year, great. Thank you. I I've got a question actually um kind of links in with what profen was, was saying earlier. Um where he mentioned that the cost of the, the robot was sort of 25% cheaper and and maybe Aaron, you could fill us in on this as well from a sort of sales point of view. Um But sort of the reasoning behind the, the cost savings, is it because it's a modular car? Is it a consumables? Like the, the sort of reasoning behind the um uh cost benefit of this robot? Uh I don't know if Carlos wanted to comment on that, but I mean, from what I've heard or from speaking to colorectal surgeons who use Yugo, I think it is, yeah, it is more related I believe to the instruments and the use of the instruments. Um How many instruments you might use during a procedure compared to other systems, for example, and the lifespan of instruments. Um and then the that consumable cost. Yeah. OK, thanks. And yeah, honestly, um I, I'm not familiar with this side of thing uh is just, you know, uh like uh like elev conversation with different people and I've always been told uh first of all that it like it, it, it depends on where, where in which nation you buy the, the, the robot and in some nation which state you buy the robot and um cause there are different regulations. So probably somewhere you can get some, let's say tax uh discounts or something else. And uh but the main, the main point of interest are instruments and uh I uh I'm not sure if this is implemented already, but electronic is looking at um let's say uh give value to every minute of the instrument, meaning if you plug the instrument is not one life, but let's say um the instrument has, I don't know, 100 minutes. Uh, it's not that each life is 10 minutes. So, if you plug it, it is 10 minutes gone. Even if you use it for one minute. But if you plug it for one minute just and, and then the procedure ends, you're still at 99. So, especially for instrument that you use less often, let's say during a proce, not the cure that you like, you start and finish with it. Probably a clip applier or uh I don't know, something else that might um save some costs. Mm Yeah. No, that's, that's really helpful. And that kind of ties into to a follow up question which is um you've spoken a lot about European um market and experience in Rome, et cetera. Why do you think it's not being used in the UK as much? Um If you've got any experience on that? I think only guys and Tommy, I think is has it for urology in the, in the country. But um are we, are we seeing, gonna see it any time soon as, as colorectal trainees in the UK? Um Probably, yes, I II would say yes, I think it's a AAA matter uh of, let's say market, market strategy. Uh What I can tell you is uh I have to Proctor next month uh near London. So some hospitals are getting in uh I think they are kind of uh getting there soon. Probably what I thought is that maybe CMR is more, uh let's say eradicated here since it's local. Uh So that, that kind of, that n niche uh was already occupied by someone else. So they kind of prioritized some other, some other markets. II think they will uh they will metron will uh will um let's say, um approach more and more hospitals in the UK soon. Great. I have a quick question for Aaron if, if that's ok. Um, so it's fantastic to sort of see how, how capable the, the touch surgery app is. Um, I think as sort of junior, um, surgeons with limited robotic experience and, and sort of looking to make those first steps. Um, a, a big part of it is getting time on the stimulator. And I think one of the, the things that, um, is difficult about tracking our progress on simulators that are currently sort of more commonly available is, um, that we're not really able to, um, see a progression through our scores on, on the various activities that you can do. Um, unless we're sort of writing them down ourselves and keeping sort of like a, a manual logbook of them. I just wondered if there's any sort of, um, connectivity between the Hugo Simulator and, and the Touch Surgery app or if that was sort of in the works or anything. Um Yeah. No, it's a good question. We, at the moment the, because obviously, well, Hugo was developed by Medtronic for obviously um many, many many years, I'm sure before it was um released and obviously received the Ce Mark and Tug surgery was or and DS one from digital surgery was being developed sort of separately outside of Medtronic. So there isn't that integration as yet, but that's definitely more and more integration is definitely on the cards. I mean, obviously, we looked at livestream and the streaming side of things and how we can integrate more features with the Hugo. Um So I think there'll definitely be more integration to come. For sure. Brilliant. Thank you. Right. So it doesn't look like there's any further questions in the chart. Um So, and we're coming up just on eight o'clock. So I'd like to um thank thank our speakers again from tonight and thank all our, our viewers and, and everyone who's logged in throughout the series. Thanks for joining us. We really hope you had some um you've enjoyed the program we've put together and, and enjoyed the speakers that we've got from all over the world. And uh hopefully, this has inspired everyone to go and be robotic colorectal surgeons. Um Just a small plug um from RN Andrews, put the um dates of the er Dukes Club weekend this year, um which is gonna be in leeds on the 13th to 15th of September um and also a link to our um colonoscopy training feedback survey. Um So, without further ado, I'd like to close the session and thanks everyone. Thanks again, special, shout out to Andrew Lilian and Charlotte too for guiding us through the webinar series and thanks to Carlo and I for tonight. So thank you everyone. Thank you. It's a pleasure. Thanks very much and shout out to you as well. Thanks a lot. See you guys. Bye.